_pages/claims/verify.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 layout-claims-verify-1">
<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 sign in</h1>
<form action="{{ site.baseurl }}/claims/verify-2/">
<div class="field">
<label>
<span class="label-text">Patient’s last name</span>
<input type="text">
</label>
</div>
<div class="field">
<label>
<span class="label-text">Verification code</span>
<input type="text">
</label>
</div>
<button>Sign In</button>
</form>
<p class="note">Not sure what this is? See <a href="{{site.baseurl}}/claims/how-it-works/">how claims work</a>.</p>
</div>
</main>
{% include site-footer.html %}
</body>
<script type="text/javascript" src="{{site.baseurl}}/javascripts/lib/underscore.js"></script>
<script type="text/javascript" src="{{site.baseurl}}/javascripts/lib/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>