[{"name":"page_0", "elements": [{"type":"html","html":{"default":"The Medicare Prescription Payment Plan is a voluntary payment option that works with your current drug coverage to help you manage your out-of-pocket Medicare Part D drug costs by spreading them across the calendar year (January-December). This payment option may help you manage your expenses, but it doesn’t save you money or lower your drug costs.
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\r\nThis payment option might not be the best choice for you if you get help paying for your prescription drug costs through programs like Extra Help from Medicare or a State Pharmaceutical Assistance Program (SPAP). Call your plan for more information.
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\r\nComplete all fields unless marked optional\r\n
\r\n","es":"El Plan de Pago para Recetas Médicas de Medicare es una opción de pago voluntario que funciona con su\r\ncobertura de medicamentos actual para ayudarle a administrar sus gastos de bolsillo de medicamentos de la Medicare Parte D distribuyéndolos a lo largo del año calendario (enero-diciembre). Esta opción de pago puede ayudarle a administrar sus gastos, pero no le ahorrará dinero ni reducirá sus costos de medicamentos.

\r\nEsta opción de pago podría no ser la mejor opción para usted si recibe ayuda para pagar los costos de sus medicamentos con receta a través de programas como Ayuda Extra de Medicare o un Programa Estatal de Asistencia Farmacéutica (SPAP). Llame a su plan para obtener más información.\r\n

\r\nComplete todos los campos excepto aquellos indicados como opcionales"}},{"type":"text","name":"ApplicantFirstName","title":{"default":"First Name:","es":"Nombre:"},"isRequired":true},{"type":"text","name":"ApplicantLastName","title":{"default":"Last Name:","es":"Apellido:"},"isRequired":true,"startWithNewLine": "false"},{"type":"text","name":"ApplicantMiddleInitial","title":{"default":"Middle Initial (optional):","es":"Inicial del segundo nombre (opcional):"},"maxWidth": "20%","inputMask": "A", "inputFormat": "A","validators": [{"type": "text","maxLength": 1, "minLength":1 }]},{"type":"text","name":"ApplicantMBI","title":{"default":"Medicare Number:","es":"Número de Medicare:"},"isRequired":true,"maxWidth": "50%","validators": [ { "type": "regex", "text": "Invalid input. Medicare Number should be 11 characters and respect the official format.", "regex": "^[1-9][^SLOIBZsloibz0-9][^SLOIBZsloibz][0-9]-?[^SLOIBZsloibz0-9][^SLOIBZsloibz][0-9]-?[^SLOIBZsloibz0-9][^SLOIBZsloibz0-9][0-9][0-9]$" }, { "type": "expression", "text": "Please enter a valid MBI", "expression": "validateMBI()" } ]},{"type":"text","name":"ApplicantBirthDate","inputMask":"datetime","inputFormat": "mm/dd/yyyy","title":{"default":"Birth Date:","es":"Fecha de nacimiento:"},"isRequired":true,"startWithNewLine": "false", "validators": [ { "type": "expression", "text": "Please enter a valid date", "expression": "validateDateBeforeToday({ApplicantBirthDate})" } ]},{"type":"text","name":"ApplicantPhone","title":{"default":"Phone Number:","es":"Número telefónico:"},"isRequired":true,"inputMask": "phone", "inputFormat": "1-###-###-####"},{"type":"text","name":"ApplicantCellPhone","title":{"default":"Cell Number (either cell or email is required):","es":"Número de celular (se requiere celular o correo electrónico):"},"requiredIf":"{ApplicantEmailAddress} empty","inputMask": "phone", "inputFormat": "1-###-###-####"},{"type":"text","name":"ApplicantEmailAddress","title":{"default":"E-mail address (either cell or email is required):","es":"Correo electrónico (se requiere celular o correo electrónico):"},"requiredIf":"{ApplicantCellPhone} empty","maxWidth":"50%"},{"type":"panel","name":"panel_0","elements":[{"type":"text","name":"ApplicantAddress1","title":{"default":"Permanent Residence Street Address (don't enter a P.O. Box unless you're experiencing homelessness)","es":"Dirección de residencia permanente (no ingrese un apartado postal a menos que se encuentre sin hogar):"},"isRequired":true},{"type":"text","name":"ApplicantCity","title":{"default":"City:","es":"Ciudad:"},"isRequired":true,"validators": [{"type": "regex","text": "The city field should not contain numbers","regex":"^[^0-9]*$" }]},{"type":"text","name":"ApplicantCounty","title":{"default":"County (optional):","es":"Condado (opcional):"},"validators": [{"type": "regex","text": "The county field should not contain numbers","regex":"^[^0-9]*$" }]},{"type":"text","name":"ApplicantState","title":{"default":"State:","es":"Estado:"},"isRequired":true,"maxLength":2,"defaultValue":""},{"type":"text","name":"ApplicantZip","title":{"default":"ZIP code:","es":"Código postal:"},"isRequired":true,"startWithNewLine": "false","inputMask": "phone", "inputFormat": "#####"}]},{"type":"radio","name":"DifferentMailingAddress","title":{"default":"My mailing address is different than my permanent residence address:","es":"Mi dirección postal es distinta a mi dirección permanente:"},"choices":[{"value":"Yes","text":{"default":"Yes","es":"Si"}},{"value":"No","text":{"default":"No","es":"No"}}],"isRequired":true,"colCount":2},{"type":"panel","name":"panel_1","elements":[{"type":"text","name":"MailingAddress1","title":{"default":"Mailing address if different from your permanent residence address (P.O. Box allowed):","es":"Dirección postal si es diferente de su dirección permanente (se permite apartado postal):"},"isRequired":true,"visibleIf":"{DifferentMailingAddress} = Yes"},{"type":"text","name":"MailingCity","title":{"default":"City:","es":"Ciudad:"},"isRequired":true,"visibleIf":"{DifferentMailingAddress} = Yes","validators": [{"type": "regex","text": "The city field should not contain numbers","regex":"^[^0-9]*$" }]},{"type":"text","name":"MailingState","title":{"default":"State:","es":"Estado:"},"isRequired":true,"visibleIf":"{DifferentMailingAddress} = Yes","maxLength":2,"defaultValue":""},{"type":"text","name":"MailingZip","title":{"default":"ZIP code:","es":"Código postal:"},"isRequired":true,"visibleIf":"{DifferentMailingAddress} = Yes","startWithNewLine": "false","inputMask": "phone", "inputFormat": "#####"}]}]},{"name":"page_1", "elements": [{"type":"html","html":{"default":"

PLEASE READ AND SIGN BELOW:

","es":"

POR FAVOR, LEA Y FIRME ABAJO:

"}},{"type":"html","html":{"default":"

I understand this form is a request to participate in the Medicare Prescription Payment Plan. Aspire Health will\r\ncontact me if they need more information.
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I understand that signing this form means that I've read and understand the form and the attached terms and\r\nconditions.
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\r\n
Aspire Health will send me a notice to let me know when my participation in the Medicare Prescription\r\nPayment Plan is active. Until then, I understand that I'm not a participant in the Medicare Prescription\r\nPayment Plan.
\r\n

","es":"

Entiendo que este formulario es una solicitud para participar en el Plan de Pago para Recetas Médicas de Medicare. Aspire Health se comunicará conmigo si necesitan más información.

\r\n
\r\n

Entiendo que firmar este formulario significa que he leído y comprendido el formulario y los términos y condiciones adjuntos.

\r\n
\r\n

Aspire Health me enviará un aviso para informarme cuando mi participación en el Plan de Pago para Recetas Médicas de Medicare este activa. Hasta entonces, entiendo que no soy participante en el Plan de Pago para Recetas Médicas de Medicare.

"}},{"type":"text","name":"Signature","title":{"default":"Signature","es":"Firma:"},"requiredIf":"{digitalSignature} != 1"},{"type":"expression","name":"Signature_date","title":{"default":"Date:","es":"Fecha:"},"startWithNewLine": "false","readOnly":true,"defaultValueExpression": "todaysDate()"},{"type":"panel","name":"panel_2","elements":[{"type":"checkbox","name":"AuthorizedRepresentative","title":{"default":"","es":""},"titleLocation":"hidden","choices":[{"value":"1","text":{"default":"I am the representative authorized to complete this application","es":"Soy el representante autorizado para completar esta solicitud."}}]},{"type":"html","html":{"default":"If you're completing this form for someone else, complete the section below. Your signature certifies that you're authorized under State law to fill out this participation form and have documentation of this authority available if Medicare asks for it.","es":"Si usted está completando este formulario para otra persona, complete la siguiente sección. Su firma certifica que está autorizado según la ley del estado para completar este formulario de participación y que tiene documentación de esta autoridad disponible en caso de que Medicare la solicite."},"visibleIf":"{AuthorizedRepresentative} notempty"},{"type":"text","name":"AuthorizedRepName","title":{"default":"Name:","es":"Nombre:"},"isRequired":true,"visibleIf":"{AuthorizedRepresentative} notempty"},{"type":"text","name":"AuthorizedRepAddress","title":{"default":"Address:","es":"Dirección:"},"isRequired":true,"visibleIf":"{AuthorizedRepresentative} notempty"},{"type":"text","name":"AuthorizedRepCity","title":{"default":"City:","es":"Ciudad:"},"isRequired":true,"visibleIf":"{AuthorizedRepresentative} notempty","validators": [{"type": "regex","text": "The city field should not contain numbers","regex":"^[^0-9]*$" }],"startWithNewLine": "false"},{"type":"text","name":"AuthorizedRepState","title":{"default":"State:","es":"Estado:"},"isRequired":true,"visibleIf":"{AuthorizedRepresentative} notempty","maxLength":2,"defaultValue":""},{"type":"text","name":"AuthorizedRepZip","title":{"default":"ZIP Code:","es":"Código postal:"},"isRequired":true,"visibleIf":"{AuthorizedRepresentative} notempty","startWithNewLine": "false","inputMask": "phone", "inputFormat": "#####"},{"type":"text","name":"AuthorizedRepPhone","title":{"default":"Phone number:","es":"Número telefónico:"},"isRequired":true,"visibleIf":"{AuthorizedRepresentative} notempty","inputMask": "phone", "inputFormat": "1(###)###-####"},{"type":"text","name":"AuthorizedRepRelationship","title":{"default":"Relationship to participant:","es":"Relación con el participante:"},"isRequired":true,"visibleIf":"{AuthorizedRepresentative} notempty","startWithNewLine": "false"},{"type":"html","html":{"default":"Check this ONLY if you are completing the application on someone else's behalf","es":"Marque esto SÓLO si está completando la solicitud en nombre de otra persona"},"visibleIf":"{AuthorizedRepresentative} notempty"}]}]},{"name":"page_2", "elements": [{"type":"text","name":"submit_official_datetime","inputMask":"datetime","inputFormat": "mm/dd/yyyy","title":{"default":"Date Application Received:","es":"Fecha de recepción de la solicitud:"},"isRequired":true,"visibleIf":"1 == 2","readOnly":true,"startWithNewLine": "true","maxWidth": "50%"},{"type":"html","html":{"default":"We are open 8 a.m.–8 p.m. PT Monday through Friday from April 1 through September 30 and 8 a.m.–8 p.m. PT seven days a week from October 1 through March 31 (except certain holidays). Medicare beneficiaries may also enroll in Aspire Health Plan through the CMS Medicare Online Enrollment Center located at http://www.medicare.gov.","es":"Estamos abiertos de 8 a.m. a 8 p.m. hora del Pacífico, de lunes a viernes, del 1 de abril al 30 de septiembre; y de 8 a.m. a 8 p.m. hora del Pacífico, los siete días de la semana, del 1 de octubre al 31 de marzo (excepto ciertos días festivos). Los beneficiarios de Medicare también pueden inscribirse al Aspire Health Plan a través del Centro de Inscripciones de CMS Medicare en http://www.medicare.gov."},"visibleIf":"1 == 2"},{"type":"text","name":"esign_status","title":{"default":"","es":""},"visible":false},{"type":"text","name":"esign_email","title":{"default":"","es":""},"visible":false},{"type":"text","name":"esign_phone","title":{"default":"","es":""},"visible":false}]}]