Form Generator
Actions
{"submission":{"method":"get","action":"/cwbe/mail","redirect":false,"beforeSubmit":[{"statement":"model.loading = true;"}],"done":[{"statement":"model.loading = false; model.currentPage = 'confirmation';"}],"error":[{"statement":"model.loading = false; model.submissionError = true; window.scrollTo(0,0);"}]},"model":{"type":"object","properties":{"loading":{"type":"boolean","value":false,"omit":true},"currentPage":{"type":"string","value":"form","omit":true},"submissionError":{"type":"boolean","value":false,"omit":true},"dn":{"type":"string"},"au":{"type":"string","value":"/cwbl/ping"},"lu":{"type":"string"},"BG":{"type":"string","value":"sc"},"PROFILE":{"type":"string","value":"21bX1e3X1dcX1ffX1d5X1c7X214X299X230X229X214X1ffX1d5X26fX299X1d5X229X222X24cX1c7X1d5X24c"},"MAIL_FORMAT":{"type":"string","value":"text"},"filter_topics":{"type":"array","items":{"type":"string"},"omit":true,"value":["Medical policies","Member benefits","Member claims","Member authorizations","Other"]},"constituents":{"type":"array","items":{"type":"object"},"omit":true,"value":[{"value":"Provider","text":"Provider"},{"value":"Member","text":"Member"},{"value":"Benefit Coordinator","text":"Benefit Coordinator"},{"value":"Agent","text":"Agent"},{"value":"Guest","text":"Guest"}]},"subjects":{"type":"array","items":{"type":"object"},"omit":true,"value":[{"value":"Specific Policy Question","text":"Specific Policy Question"},{"value":"Can not Find a Policy","text":"Can not Find a Policy"}]},"i_am_asking_about":{"type":"string","omit":true,"enum":"filter_topics","validation":{"required":true}},"i_am_a_I":{"type":"string","enum":"constituents","validation":{"required":true}},"health_plan_I":{"type":"string","validation":{"required":true}},"first_name_I":{"type":"string","validation":{"required":true}},"last_name_I":{"type":"string","validation":{"required":true}},"practice_name_I":{"type":"string"},"email_I":{"type":"string","validation":{"required":true,"regex":{"value":"[^@]+@[^\\.]+\\..+","message":"Email format is invalid."}}},"confirm_email_I":{"type":"string","validation":{"required":true,"regex":{"value":"[^@]+@[^\\.]+\\..+","message":"Email format is invalid."},"condition":{"value":"model.email_I == model.confirm_email_I","message":"Email and Confirm Email must match."}}},"phone_I":{"type":"string","validation":{"required":true}},"policy_number_I":{"type":"string"},"subject_I":{"type":"string","enum":"subjects","validation":{"required":true}},"question_I":{"type":"string","validation":{"required":true}},"select_0":{"type":"string","enum":["Option 1","Option 2","Option 3"]}}},"form":[{"type":"page","name":"form","model":"currentPage","items":[{"type":"conditional","condition":"model.submissionError","items":[{"type":"alert","variant":"danger","items":["There was a problem when submitting the form. Please try again later."]}]},{"type":"paragraph","items":["The following form is intended to be used to submit questions about our Medical Policies. All other questions should be submitted through My Insurance Manager, our secure site."]},{"type":"select","title":"I am Asking About","model":"i_am_asking_about","width":"20"},{"type":"conditional","condition":"!model.i_am_asking_about || model.i_am_asking_about === 'Medical policies'","items":[{"type":"flex","items":[{"type":"select","title":"I am a","model":"i_am_a_I","width":"20"},{"type":"input","title":"Health Plan","model":"health_plan_I","width":"20"}]},{"type":"flex","items":[{"type":"input","title":"First Name","model":"first_name_I","width":"20"},{"type":"input","title":"Last Name","model":"last_name_I","width":"20"}]},{"type":"flex","items":[{"type":"input","title":"Practice/Group Name (if applicable)","model":"practice_name_I","width":"42"}]},{"type":"flex","items":[{"type":"input","title":"E-mail Address","model":"email_I","width":"20"},{"type":"input","title":"Confirm E-mail Address","model":"confirm_email_I","width":"20"}]},{"type":"flex","items":[{"type":"input","title":"Phone","model":"phone_I","width":"20"},{"type":"input","title":"Policy Number (optional)","model":"policy_number_I","width":"20"}]},{"type":"flex","items":[{"type":"select","title":"Subject","model":"subject_I","width":"20"}]},{"type":"flex","items":[{"type":"textarea","title":"Question","model":"question_I","width":"42"}]},{"type":"controls","items":[{"type":"button","title":"Send","submit":true,"loading":"loading","variant":"primary"}]}]},{"type":"conditional","condition":"model.i_am_asking_about && model.i_am_asking_about !== 'Medical policies'","items":[{"type":"alert","variant":"info","items":["Questions concerning member benefits, authorizations, claims or other member issues can be submitted through the secure ",{"type":"link","href":"https://provider.southcarolinablues.com/","items":["My Insurance Manager"]},". Once you've logged into My Insurance Manager, you can look up the member and submit questions through Ask Provider Services or Ask Healthcare Services. This helps keep protected health information secure."]}]}]},{"type":"page","name":"confirmation","model":"currentPage","items":[{"type":"alert","variant":"success","items":["Thank you! We have received your information and will respond within one business day."]}]}],"config":{"dndEditing":true}}