_pages/claims/verify-2.html
---
title: Healthcare Provider Verification
---
{% include head.html %}
<link href="{{site.baseurl}}/stylesheets/form.css" type="text/css" rel="stylesheet" />
<body class="no-js layout-claims layout-claims-verify-2">
<a class="a-skip-to-main" href="#main">Skip to main content</a>
{% include site-header.html %}
<main role="main" id="main" class="page">
<div class="wrapper">
<h1>Healthcare provider verification</h1>
<p>[Claimant name] has asked you to contribute information relevant to their forthcoming claim for paid family medical leave benefits. Please enter additional information to help us verify [patient name]’s claim.</p>
<form action="{{ site.baseurl }}/claims/verify-3/">
<fieldset class="fieldset fieldset-physician">
<legend>Physician</legend>
<fieldset class="fieldset fieldset-name">
<legend>Name</legend>
<div class="field field-name-first">
<label>
<span class="label-text">First</span>
<input type="text" name="">
</label>
</div>
<div class="field field-name-middle">
<label>
<span class="label-text">Middle</span>
<input type="text" name="">
</label>
</div>
<div class="field field-name-last">
<label>
<span class="label-text">Last</span>
<input type="text" name="">
</label>
</div>
</fieldset>
<fieldset class="fieldset fieldset-mailing-address">
<legend>Mailing address</legend>
<div class="field field-street">
<label>
<span class="label-text">Street address</span>
<input type="text">
</label>
</div>
<div class="field field-city-state-zip">
<div class="field field-city">
<label>
<span class="label-text">City</span>
<input type="text">
</label>
</div>
<div class="field field-state field-select">
<label>
<span class="label-text">State</span>
<select>
<option value="AL">Alabama</option>
<option value="AK">Alaska</option>
<option value="AZ">Arizona</option>
<option value="AR">Arkansas</option>
<option value="CA">California</option>
<option value="CO">Colorado</option>
<option value="CT">Connecticut</option>
<option value="DE">Delaware</option>
<option value="DC">District of Columbia</option>
<option value="FL">Florida</option>
<option value="GA">Georgia</option>
<option value="HI">Hawaii</option>
<option value="ID">Idaho</option>
<option value="IL">Illinois</option>
<option value="IN">Indiana</option>
<option value="IA">Iowa</option>
<option value="KS">Kansas</option>
<option value="KY">Kentucky</option>
<option value="LA">Louisiana</option>
<option value="ME">Maine</option>
<option value="MD">Maryland</option>
<option value="MA">Massachusetts</option>
<option value="MI">Michigan</option>
<option value="MN">Minnesota</option>
<option value="MS">Mississippi</option>
<option value="MO">Missouri</option>
<option value="MT">Montana</option>
<option value="NE">Nebraska</option>
<option value="NV">Nevada</option>
<option value="NH">New Hampshire</option>
<option value="NJ">New Jersey</option>
<option value="NM">New Mexico</option>
<option value="NY">New York</option>
<option value="NC">North Carolina</option>
<option value="ND">North Dakota</option>
<option value="OH">Ohio</option>
<option value="OK">Oklahoma</option>
<option value="OR">Oregon</option>
<option value="PA">Pennsylvania</option>
<option value="RI">Rhode Island</option>
<option value="SC">South Carolina</option>
<option value="SD">South Dakota</option>
<option value="TN">Tennessee</option>
<option value="TX">Texas</option>
<option value="UT">Utah</option>
<option value="VT">Vermont</option>
<option value="VA">Virginia</option>
<option value="WA">Washington</option>
<option value="WV">West Virginia</option>
<option value="WI">Wisconsin</option>
<option value="WY">Wyoming</option>
</select>
</label>
</div>
<div class="field field-zip">
<label>
<span class="label-text">Zip code</span>
<input type="text">
</label>
</div>
</div>
<div class="field field-select">
<label>
<span class="label-text">Country</span>
<select>
<option>United States</option>
<option>Others</option>
</select>
</label>
</div>
</fieldset>
<div class="field field-phone-number">
<label>
<span class="label-text">Phone number</span>
<input type="text">
</label>
</div>
<div class="field field-type">
<label>
<span class="label-text">Type or speciality (if any)</span>
<input type="text">
</label>
</div>
<fieldset class="fieldset fieldset-license">
<legend>License</legend>
<div class="field field-license-number">
<label>
<span class="label-text">License number</span>
<input type="text">
</label>
</div>
<div class="field field-license-number">
<label>
<span class="label-text">State or country where licensed</span>
<input type="text">
</label>
</div>
</fieldset>
</fieldset>
<fieldset class="fieldset fieldset-patient">
<legend>Patient</legend>
<div class="field field-diagnosis">
<label>
<span class="label-text">Diagnosis or statement of symptoms</span>
<textarea></textarea>
</label>
</div>
</fieldset>
<div class="field field-primary-icd">
<label>
<span class="label-text">Primary ICD code</span>
<input type="text">
</label>
</div>
<div class="field field-secondary-icd">
<label>
<span class="label-text">Secondary ICD code</span>
<input type="text">
</label>
</div>
<div class="field field-date">
<label>
<span class="label-text">First date care needed</span>
<input type="date">
</label>
</div>
<div class="field field-date">
<label>
<span class="label-text">Date you expect recovery</span>
<input type="date">
</label>
</div>
<div class="field field-date">
<label>
<span class="label-text">Date patient will no longer require care by [Claimant name] (if applicable)</span>
<input type="date">
</label>
</div>
<div class="field field-number">
<label>
<span class="label-text">Approximately how many hours per day will patient require claimant?</span>
<input type="number" max="24">
</label>
</div>
<div class="field field-checkbox">
<label>
<input type="checkbox" name="">
<span class="label-text">
I certify under penalty of perjury that this patient has a serious health condition and requires a care provider. I have performed a physical examination and/or treated the patient. I am authorized to certify a patient disability or serious health condition pursuant to [state] unemployment insurance code section 2708.</a>
</span>
</label>
</div>
</fieldset>
<button>Submit</button>
</form>
</div>
</main>
{% include site-footer.html %}
</body>
<script type="text/javascript" src="{{site.baseurl}}/javascripts/underscore.js"></script>
<script type="text/javascript" src="{{site.baseurl}}/javascripts/jsonform.js"></script>
<script>
$( document ).ready(function() {
// Get the JSON Schema and form definitions
var json_form = $.get("{{site.baseurl}}/javascripts/form.json");
var json_schema = $.get("{{site.baseurl}}/javascripts/schema.json");
// When the schema and form are available, render the form
$.when(json_schema, json_form).done(function() {
$('#claim').jsonForm({
"schema": json_schema.responseJSON,
"form": json_form.responseJSON,
onSubmit: function (errors, values) {
if (errors) {
$('.form-errors').html('<p>Please fix the below errors.</p>');
}
else {
// Set this to a valid endpoint to receive the JSON form contents.
$.post('https://example.gov/', values);
}
}
});
}).fail(function() {
console.log('JSON schema could not be retrieved');
});
});
</script>