{"id":778,"date":"2025-09-05T18:49:04","date_gmt":"2025-09-05T23:49:04","guid":{"rendered":"https:\/\/medicount.com\/?page_id=778"},"modified":"2026-02-20T15:57:57","modified_gmt":"2026-02-20T20:57:57","slug":"patient-transport-insurance-information-form","status":"publish","type":"page","link":"https:\/\/medicount.com\/es\/patient-transport-insurance-information-form\/","title":{"rendered":"Formulario de informaci\u00f3n sobre el seguro de transporte de pacientes"},"content":{"rendered":"<div class=\"wpb-content-wrapper\"><div class=\"vc_row wpb_row vc_row-fluid\"><div class=\"wpb_column vc_column_container vc_col-sm-12\"><div class=\"vc_column-inner\"><div class=\"wpb_wrapper\">\n\t<div class=\"wpb_text_column wpb_content_element\" >\n\t\t<div class=\"wpb_wrapper\">\n\t\t\t<h2>Servicios m\u00e9dicos de emergencia<\/h2>\n<p>Para procesar su reclamo, por favor complete el formulario a continuaci\u00f3n con la informaci\u00f3n de su seguro. Solo complete los campos que sean aplicables a su cobertura.<\/p>\n<p>\n<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_4' style='display:none'><form method='post' enctype='multipart\/form-data'  id='gform_4'  action='\/es\/wp-json\/wp\/v2\/pages\/778' data-formid='4' novalidate data-trp-original-action=\"\/es\/wp-json\/wp\/v2\/pages\/778\"> \r\n <input type='hidden' class='gforms-pum' value='{\"closepopup\":false,\"closedelay\":0,\"openpopup\":false,\"openpopup_id\":0}' \/>\n                        <div class='gform-body gform_body'><ul id='gform_fields_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_4_2\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Informaci\u00f3n sobre el EMS<\/h2><\/li><li id=\"field_4_4\" class=\"gfield gfield--type-text gfield--input-type-text gf_one_third gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_4'>N\u00famero de Cuenta:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_4_4' type='text' value='' class='medium'  aria-describedby=\"gfield_description_4_4\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_4_4'>  Si no conoce su n\u00famero de cuenta, ll\u00e1menos al (888-410-6986) o env\u00edenos un correo electr\u00f3nico a\nptrelations@medicountdev.com para que nos pongamos en contacto con usted.<\/div><\/li><li id=\"field_4_1\" class=\"gfield gfield--type-text gfield--input-type-text gf_middle_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_1'>Ciudad o Departamento de Servicios M\u00e9dicos de Emergencia:<\/label><div class='ginput_container ginput_container_text'><input name='input_1' id='input_4_1' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_3\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gf_right_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_3'>Fecha de Servicio:<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_3' id='input_4_3' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/aaaa' aria-describedby=\"input_4_3_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_4_3_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_3' class='gform_hidden' value='https:\/\/medicount.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_4_5\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Informaci\u00f3n para el paciente<\/h2><\/li><li id=\"field_4_6\" class=\"gfield gfield--type-text gfield--input-type-text gf_one_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_6'>Nombre:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_4_6' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_7\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gf_middle_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_7'>Fecha de Nacimiento:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_7' id='input_4_7' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/aaaa' aria-describedby=\"input_4_7_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_4_7_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_7' class='gform_hidden' value='https:\/\/medicount.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_4_8\" class=\"gfield gfield--type-text gfield--input-type-text gf_right_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_8'>Direcci\u00f3n postal:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_4_8' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_9\" class=\"gfield gfield--type-text gfield--input-type-text gf_one_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_9'>N\u00famero de Seguro Social:<\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_4_9' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_10\" class=\"gfield gfield--type-text gfield--input-type-text gf_middle_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_10'>Ciudad, Estado, C\u00f3digo Postal:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_4_10' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_11\" class=\"gfield gfield--type-phone gfield--input-type-phone gf_right_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_11'>N\u00famero de Tel\u00e9fono:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_11' id='input_4_11' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_12\" class=\"gfield gfield--type-email gfield--input-type-email gf_one_third gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_12'>Correo electr\u00f3nico<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_12' id='input_4_12' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_4_12\" \/>\n                        <\/div><div class='gfield_description' id='gfield_description_4_12'>Por favor provea al menos un m\u00e9todo de contacto.<\/div><\/li><li id=\"field_4_59\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_middle_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >\u00bfEl paciente es el titular de la p\u00f3liza?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_59'>\n\t\t\t<li class='gchoice gchoice_4_59_0'>\n\t\t\t\t<input name='input_59' type='radio' value='Yes'  id='choice_4_59_0'    \/>\n\t\t\t\t<label for='choice_4_59_0' id='label_4_59_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_59_1'>\n\t\t\t\t<input name='input_59' type='radio' value='No'  id='choice_4_59_1'    \/>\n\t\t\t\t<label for='choice_4_59_1' id='label_4_59_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_13\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Insured Information (if other than patient)<\/h2><\/li><li id=\"field_4_14\" class=\"gfield gfield--type-text gfield--input-type-text gf_one_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_14'>Nombre:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_4_14' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_15\" class=\"gfield gfield--type-phone gfield--input-type-phone gf_middle_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_15'>N\u00famero de Tel\u00e9fono:<\/label><div class='ginput_container ginput_container_phone'><input name='input_15' id='input_4_15' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_16\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Informaci\u00f3n del Garante (si aplica)<\/h2><\/li><li id=\"field_4_17\" class=\"gfield gfield--type-text gfield--input-type-text gf_one_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_17'>Nombre:<\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_4_17' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_18\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gf_middle_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_18'>Fecha de Nacimiento del Garante:<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_18' id='input_4_18' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/aaaa' aria-describedby=\"input_4_18_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_4_18_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_18' class='gform_hidden' value='https:\/\/medicount.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_4_77\" class=\"gfield gfield--type-email gfield--input-type-email gf_right_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_77'>Correo electr\u00f3nico<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_77' id='input_4_77' type='email' value='' class='medium'     aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_4_19\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Informaci\u00f3n sobre el seguro primario<\/h2><\/li><li id=\"field_4_20\" class=\"gfield gfield--type-text gfield--input-type-text gf_one_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_20'>Name of Insurance Provider:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_4_20' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_55\" class=\"gfield gfield--type-text gfield--input-type-text gf_middle_third gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_55'>N\u00famero de identificaci\u00f3n de miembro:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_55' id='input_4_55' type='text' value='' class='medium'  aria-describedby=\"gfield_description_4_55\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_4_55'>For traditional Medicare (red, white, and blue card) this will be an alphanumeric code. For traditional Medicaid, this is a 12-digit billing number on your card.<\/div><\/li><li id=\"field_4_27\" class=\"gfield gfield--type-text gfield--input-type-text gf_right_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_27'>N\u00famero de Grupo:<\/label><div class='ginput_container ginput_container_text'><input name='input_27' id='input_4_27' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_29\" class=\"gfield gfield--type-text gfield--input-type-text gf_one_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_29'>Direcci\u00f3n postal para reclamaciones:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_29' id='input_4_29' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_42\" class=\"gfield gfield--type-text gfield--input-type-text gf_middle_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_42'>Ciudad, Estado, C\u00f3digo Postal:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_42' id='input_4_42' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_57\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gf_right_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_57'>Subir tarjeta del seguro<\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='52428800' \/><input name='input_57' id='input_4_57' type='file' class='medium' aria-describedby=\"gfield_upload_rules_4_57\" onchange='javascript:gformValidateFileSize( this, 52428800 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_4_57'>Tama\u00f1o m\u00e1ximo de archivo: 50 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_4_57'><\/div> <\/div><\/li><li id=\"field_4_78\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >\u00bfEl paciente tiene seguro secundario?\nS\u00ed\/No<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_78'>\n\t\t\t<li class='gchoice gchoice_4_78_0'>\n\t\t\t\t<input name='input_78' type='radio' value='Yes'  id='choice_4_78_0'    \/>\n\t\t\t\t<label for='choice_4_78_0' id='label_4_78_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_78_1'>\n\t\t\t\t<input name='input_78' type='radio' value='No'  id='choice_4_78_1'    \/>\n\t\t\t\t<label for='choice_4_78_1' id='label_4_78_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_31\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Informaci\u00f3n sobre el seguro secundario<\/h2><\/li><li id=\"field_4_32\" class=\"gfield gfield--type-text gfield--input-type-text gf_one_third gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_32'>Nombre de la aseguradora:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_32' id='input_4_32' type='text' value='' class='medium'  aria-describedby=\"gfield_description_4_32\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_4_32'>If no secondary insurance please type N\/A in all required secondary fields.<\/div><\/li><li id=\"field_4_33\" class=\"gfield gfield--type-text gfield--input-type-text gf_middle_third gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_33'>Member ID Number:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_33' id='input_4_33' type='text' value='' class='medium'  aria-describedby=\"gfield_description_4_33\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_4_33'>Para el Medicare tradicional (tarjeta roja, blanca &amp; azul), suele ser su n\u00famero de la Seguridad Social, con una letra o una letra &amp; un n\u00famero al final. Para Medicaid, es el n\u00famero de facturaci\u00f3n de 12 d\u00edgitos que figura en su tarjeta.<\/div><\/li><li id=\"field_4_34\" class=\"gfield gfield--type-text gfield--input-type-text gf_right_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_34'>N\u00famero de Grupo:<\/label><div class='ginput_container ginput_container_text'><input name='input_34' id='input_4_34' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_41\" class=\"gfield gfield--type-text gfield--input-type-text gf_one_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_41'>Direcci\u00f3n postal para reclamaciones:<\/label><div class='ginput_container ginput_container_text'><input name='input_41' id='input_4_41' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_54\" class=\"gfield gfield--type-text gfield--input-type-text gf_middle_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_54'>Ciudad, Estado, C\u00f3digo Postal:<\/label><div class='ginput_container ginput_container_text'><input name='input_54' id='input_4_54' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_79\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gf_right_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_79'>Subir tarjeta del seguro<\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='52428800' \/><input name='input_79' id='input_4_79' type='file' class='medium' aria-describedby=\"gfield_upload_rules_4_79\" onchange='javascript:gformValidateFileSize( this, 52428800 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_4_79'>Tama\u00f1o m\u00e1ximo de archivo: 50 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_4_79'><\/div> <\/div><\/li><li id=\"field_4_88\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_4_86\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >\u00bfEl traslado se debi\u00f3 a un accidente automovil\u00edstico?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_86'>\n\t\t\t<li class='gchoice gchoice_4_86_0'>\n\t\t\t\t<input name='input_86' type='radio' value='Yes'  id='choice_4_86_0'    \/>\n\t\t\t\t<label for='choice_4_86_0' id='label_4_86_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_86_1'>\n\t\t\t\t<input name='input_86' type='radio' value='No'  id='choice_4_86_1'    \/>\n\t\t\t\t<label for='choice_4_86_1' id='label_4_86_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_87\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >\u00bfEste traslado se debi\u00f3 a un accidente laboral?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_87'>\n\t\t\t<li class='gchoice gchoice_4_87_0'>\n\t\t\t\t<input name='input_87' type='radio' value='Yes'  id='choice_4_87_0'    \/>\n\t\t\t\t<label for='choice_4_87_0' id='label_4_87_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_87_1'>\n\t\t\t\t<input name='input_87' type='radio' value='No'  id='choice_4_87_1'    \/>\n\t\t\t\t<label for='choice_4_87_1' id='label_4_87_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_43\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Informaci\u00f3n sobre el seguro de autom\u00f3vil o el seguro de compensaci\u00f3n laboral<\/h2><\/li><li id=\"field_4_44\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gf_one_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_44'>Nombre de la aseguradora:<\/label><div class='ginput_container ginput_container_text'><input name='input_44' id='input_4_44' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_45\" class=\"gfield gfield--type-text gfield--input-type-text gf_middle_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_45'>Claim Number:<\/label><div class='ginput_container ginput_container_text'><input name='input_45' id='input_4_45' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_47\" class=\"gfield gfield--type-text gfield--input-type-text gf_right_third field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_47'>Policy Number:<\/label><div class='ginput_container ginput_container_text'><input name='input_47' id='input_4_47' type='text' value='' class='medium'  aria-describedby=\"gfield_description_4_47\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_4_47'>Please only provide policy number IF you do not know your claim number...<\/div><\/li><li id=\"field_4_53\" class=\"gfield gfield--type-text gfield--input-type-text gf_one_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_53'>Direcci\u00f3n postal para reclamaciones:<\/label><div class='ginput_container ginput_container_text'><input name='input_53' id='input_4_53' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_30\" class=\"gfield gfield--type-text gfield--input-type-text gf_middle_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_30'>Ciudad, Estado, C\u00f3digo Postal:<\/label><div class='ginput_container ginput_container_text'><input name='input_30' id='input_4_30' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_62\" class=\"gfield gfield--type-section gfield--input-type-section gsection centertext field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">EL PACIENTE FIRMA ESTA SECCI\u00d3N<\/h2><div class='gsection_description' id='gfield_description_4_62'>El paciente debe firmar en la Secci\u00f3n 1 a menos que sea f\u00edsica o mentalmente incapaz de firmar (si es incapaz \u2013 vea la Secci\u00f3n 2)\n<\/div><\/li><li id=\"field_4_63\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Autorizo a (Nombre del Cliente) (el Proveedor) a presentar un reclamo a Medicare, Medicaid, u otro pagador por los servicios proporcionados a m\u00ed por (el Proveedor) ahora, en el pasado, o en el futuro hasta que revoque esta autorizaci\u00f3n por escrito. Entiendo que soy financieramente responsable por los servicios &amp; suministros proporcionados, independientemente de mi cobertura de seguro. En algunos casos, puedo ser responsable de un monto adicional al pagado por mi proveedor de seguro. Acepto remitir de inmediato al (Proveedor) cualquier pago que reciba directamente de mi seguro o de cualquier fuente por los servicios proporcionados, &amp; cedo todos los derechos a dichos pagos al (Proveedor). Autorizo al (Proveedor) a apelar rechazos de pago u otras decisiones adversas en mi nombre. Autorizo &amp; doy instrucciones para que cualquier poseedor de informaci\u00f3n m\u00e9dica, de seguro, de facturaci\u00f3n u otra relevante sobre m\u00ed, libere esa informaci\u00f3n al (Proveedor) &amp; a sus agentes de facturaci\u00f3n, los Centros de Servicios de Medicare &amp; Medicaid, y\/o cualquier otro beneficio pagadero por servicios proporcionados a m\u00ed ahora, en el pasado o en el futuro. Tambi\u00e9n autorizo al (Proveedor) a obtener informaci\u00f3n m\u00e9dica, de seguro, de facturaci\u00f3n &amp; otra relevante sobre m\u00ed de cualquier parte, base de datos u otra fuente que mantenga dicha informaci\u00f3n. <\/li><li id=\"field_4_84\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full signature-field gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_84'>Firma del Paciente:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_84' id='input_4_84' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_81\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gf_middle_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_81'>Fecha<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_81' id='input_4_81' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/aaaa' aria-describedby=\"input_4_81_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_4_81_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_81' class='gform_hidden' value='https:\/\/medicount.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_4_66\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">SI EL PACIENTE ES INCAPAZ DE FIRMAR<\/h2><\/li><li id=\"field_4_67\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_67'>Explique por qu\u00e9 no es pr\u00e1ctico que el paciente firme:<\/label><div class='ginput_container ginput_container_text'><input name='input_67' id='input_4_67' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_68\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Firmando en nombre del paciente, autorizo la presentaci\u00f3n de una reclamaci\u00f3n a Medicare. Medicaid o\ncualquier otro pagador por cualquier servicio prestado al paciente por (el proveedor) ahora. en el pasado o\nen el futuro. Al firmar a continuaci\u00f3n, reconozco que soy uno de los firmantes autorizados que figuran a\ncontinuaci\u00f3n. Mi firma no implica la aceptaci\u00f3n de la responsabilidad financiera por los servicios\nprestados.\n\n<\/li><li id=\"field_4_69\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Los representantes autorizados incluyen \u00daNICAMENTE a las siguientes personas. Indique su relaci\u00f3n con\nel paciente.<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_4_69'><li class='gchoice gchoice_4_69_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_69.1' type='checkbox'  value='Patient\u2019s Legal Guardian (If patient is a minor, parent signs in section 1)'  id='choice_4_69_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_69_1' id='label_4_69_1' class='gform-field-label gform-field-label--type-inline'>Patient\u2019s Legal Guardian (If patient is a minor, parent signs in section 1)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_69_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_69.2' type='checkbox'  value='A relative or other person who receives social security or other governmental benefits on behalf of the patient.'  id='choice_4_69_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_69_2' id='label_4_69_2' class='gform-field-label gform-field-label--type-inline'>Un familiar u otra persona que recibe prestaciones de la seguridad social u otras prestaciones\ngubernamentales en nombre del paciente.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_69_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_69.3' type='checkbox'  value='A relative or other person who arranges for the patient\u2019s treatment or exercises other responsibility for the patient\u2019s affairs.'  id='choice_4_69_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_69_3' id='label_4_69_3' class='gform-field-label gform-field-label--type-inline'>Un familiar u otra persona que se encarga del tratamiento del paciente o ejerce otra responsabilidad sobre\nlos asuntos del paciente.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_69_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_69.4' type='checkbox'  value='A representative of an agency or institution that did not furnish the ambulance services but furnished other care, services, or assistance to the patient.'  id='choice_4_69_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_69_4' id='label_4_69_4' class='gform-field-label gform-field-label--type-inline'>Un representante de una agencia o instituci\u00f3n que no prest\u00f3 los servicios de ambulancia, pero que\nproporcion\u00f3 otros cuidados, servicios o asistencia al paciente.<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_85\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full signature-field gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_85'>Firma<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_85' id='input_4_85' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_72\" class=\"gfield gfield--type-text gfield--input-type-text gf_middle_third gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_72'>Nombre impreso del representante:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_72' id='input_4_72' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_73\" class=\"gfield gfield--type-text gfield--input-type-text gf_right_third gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_73'>Relaci\u00f3n representativa con el paciente:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_73' id='input_4_73' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><\/ul><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_4' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Enviar'  \/> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_4' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_4' id='gform_theme_4' value='legacy' \/>\n            <input type='hidden' 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type=\"hidden\" name=\"trp-form-language\" value=\"es\"\/><\/form>\n                        <\/div><script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\n gform.initializeOnLoaded( function() {gformInitSpinner( 4, 'https:\/\/medicount.com\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery('#gform_ajax_frame_4').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_4');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_4').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! is_redirect && ! is_confirmation;var mt = parseInt(jQuery('html').css('margin-top'), 10) + parseInt(jQuery('body').css('margin-top'), 10) + 100;if(is_form){form_content.find('form').css('opacity', 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