'; InstaMed.launchInContext(); } else { Ext.isSecure = /^https/i.test(window.location.protocol);InstaMed.isNativeApplication = false;InstaMed.isConsumerApp = false;InstaMed.TitleBarMargins = '17 0 0 0';InstaMed.isMobile = true;InstaMed.isResponsive = true;InstaMed.isInContextMode = false;InstaMed.passedInMetaDataToken = '';InstaMed.isInAccessibilityMode = false;InstaMed.userAgentParameter = '';InstaMed.logoutPage = '../../Form/PaymentPortal/Logout?id=SILVERSCRIPT';InstaMed.isLightWeightMode = false;InstaMed.isReturnUrlUpdateParent = false;InstaMed.isClientSidePostData = false;InstaMed.isDesktop = false;InstaMed.isTablet = false;InstaMed.isDesktopOrTablet = false;InstaMed.isMobileOrTablet = true;InstaMed.isLoggedIn = false;InstaMed.useHistory = false;InstaMed.hasReturnUrl = false;InstaMed.hasCancelUrl = false;InstaMed.isNewRequiredFeild = true;InstaMed.browserTabID = '24260A5BF8594A248A34D5BA4DC33668';InstaMed.sessionTimeoutUrl = '../../Form/PaymentPortal/Logout?id=SILVERSCRIPT';InstaMed.page = 'Form/Payments/New';Ext.SSL_SECURE_URL = Ext.isSecure && Ext.isIE ? 'javascript:""' : 'about:blank';Ext.BLANK_IMAGE_URL = 'https://cdn.instamed.com/V_2024_May/Content/Images/General/BlankImage.gif';InstaMed.UniqueClientID = 'cd49c922b7fe425ea9a472e01fc06470';Ext.scopeResetCSS=true;InstaMed.contentUrl = 'https://cdn.instamed.com/V_2024_May/';var webPropertyId = 'UA-16010902-1';InstaMed.doIdleLogout = true;InstaMed.isSSO = false;InstaMed.isSelfService = false;LogoutTimer.init();var myMask = null;InstaMed.errorMessageSummaryTitle = 'Please correct the following errors';InstaMed.requiredErrorLabel = 'Required';Ext.ns('Ext.app.REMOTING_API');Ext.app.REMOTING_API = { "id": null, "url": "../../api/Payments/New", "type": "remoting", "namespace": null, "actions": { "PatientPortalLoginController": [ { "name": "checkSession", "len": 1 }, { "name": "changeLanguage", "len": 1 }, { "name": "showBiometricLogin", "len": 1 }, { "name": "authenticateBiometricInfo", "len": 1 }, { "name": "closeAppBanner", "len": 1 }, { "name": "verifyTextEnrollment", "len": 1 }, { "name": "navigateAfterLogin", "len": 1 }, { "name": "navigateFromEStatement", "len": 1 }, { "name": "forgotPassword", "len": 1 }, { "name": "submit", "len": 1 }, { "name": "deleteBiometricInfo", "len": 1 }, { "name": "navigateBackFromTwoFactor", "len": 1 }, { "name": "patientMatchSubmit", "len": 1 }, { "name": "skipTextEnrollment", "len": 1 }, { "name": "authenticateTwoFactor", "len": 1 }, { "name": "redirectToLogin", "len": 1 }, { "name": "getBackButtonOverride", "len": 1 }, { "name": "patientPortalNavigateBack", "len": 1 }, { "name": "saveEStatementPreference", "len": 1 }, { "name": "canUserResetPassword", "len": 3 }, { "name": "redirectToLoginEmailForm", "len": 1 }, { "name": "logout", "len": 1 }, { "name": "sendMobilePhoneNumberConfirmationCode", "len": 1 }, { "name": "navigateTo", "len": 1 }, { "name": "patientPortalHeaderBack", "len": 1 }, { "name": "registerUserBiometricInfo", "len": 1 }, { "name": "dualLogin", "len": 1 } ], "QuickPayOptimizedProviderLandingController": [ { "name": "navigatePayHereLink", "len": 1 }, { "name": "paymentPlanFlow", "len": 1 }, { "name": "submitPatient", "len": 1 }, { "name": "prepopulateDigitalPayoutQuickPayCode", "len": 1 }, { "name": "navigateCollectPaymentLink", "len": 1 }, { "name": "checkQuickPayCode", "len": 1 }, { "name": "payNow", "len": 1 }, { "name": "onPatientChange", "len": 1 }, { "name": "checkQuickPayCodeOnly", "len": 1 } ], "SessionlessQuickPayReviewAndConfirmController": [ { "name": "emailReceipt", "len": 1 }, { "name": "confirm", "len": 1 }, { "name": "viewReceipt", "len": 1 }, { "name": "initializeSession", "len": 1 } ], "QuickPayPaymentSummaryController": [ { "name": "redirectToSignUp", "len": 1 }, { "name": "redirectToLogin", "len": 1 }, { "name": "redirectToPatientProfile", "len": 1 } ], "SessionlessQuickPayPaymentInfoController": [ { "name": "submitPayment", "len": 1 }, { "name": "navigateBack", "len": 1 }, { "name": "updatePaymentMethod", "len": 1 } ], "PushNotificationController": [ { "name": "navigateByPushNotification", "len": 1 } ], "PreferencesController": [ { "name": "openWindowToUpdateEmailAddress", "len": 1 }, { "name": "get_MerchantStoreTerminalAlias", "len": 0 }, { "name": "openWindowToEnterMobilePhoneNumber", "len": 1 }, { "name": "openWindowToEnterMobilePhoneNumberConfirmationCode", "len": 1 }, { "name": "updateSecurityQuestions", "len": 1 }, { "name": "disableTwoFactorAuthFromPopUp", "len": 1 }, { "name": "verifyTextEnrollment", "len": 1 }, { "name": "confirmMobilePhoneNumber", "len": 1 }, { "name": "getUserMobilePhoneNumber", "len": 0 }, { "name": "navigateToTextMsgEnroll", "len": 1 }, { "name": "removeMobilePhoneNumber", "len": 1 }, { "name": "navigateToTextMsgEnrollTwoFAOnly", "len": 1 }, { "name": "enableTwoFactorAuth", "len": 1 }, { "name": "cancelTwoFAChangeFromPopup", "len": 1 }, { "name": "isUserRequireMobilePhoneNumberUpdate", "len": 0 }, { "name": "updateEmailAndPreference", "len": 1 }, { "name": "isUserRequireEmailAndPreferenceUpdate", "len": 0 }, { "name": "loadPatientData", "len": 0 }, { "name": "saveStatementPreferences", "len": 1 }, { "name": "updateMobilePhoneNumber", "len": 1 }, { "name": "loadPatientAccountPreferences", "len": 2 }, { "name": "deleteUserBiometricInfo", "len": 1 }, { "name": "sendNewMobilePhoneNumberConfirmationCode", "len": 1 }, { "name": "saveEmailPreferences", "len": 1 }, { "name": "updateCommunicationDeliverySettings", "len": 1 } ], "PaymentActionController": [ { "name": "selectLineItem", "len": 1 }, { "name": "viewTransaction", "len": 1 }, { "name": "getNextScheduledTransaction", "len": 1 }, { "name": "getSystemWideDefault", "len": 1 }, { "name": "displayPatientInformationMutliAccount", "len": 3 }, { "name": "getAuthorization", "len": 3 }, { "name": "getVirtualCardEntityID", "len": 1 }, { "name": "getPaymentPlanStatus", "len": 1 }, { "name": "getDisclaimer", "len": 1 }, { "name": "closeSSOReceipt", "len": 1 }, { "name": "voidTransactionFromHistory", "len": 1 }, { "name": "canReturnEcheck", "len": 1 }, { "name": "eCheckRefundTransactionFromHistory", "len": 1 }, { "name": "getBasePaymentTransaction", "len": 2 }, { "name": "returnToProfile", "len": 1 }, { "name": "viewReceiptByData", "len": 5 }, { "name": "canAdjustEcheck", "len": 1 }, { "name": "cancel", "len": 1 }, { "name": "doReturnEcheck", "len": 1 }, { "name": "getNumberOfPaymentsRemaining", "len": 1 }, { "name": "printAll", "len": 1 }, { "name": "emailReceipt", "len": 1 }, { "name": "getReceiptConfigurationList", "len": 1 }, { "name": "downloadReceipt", "len": 1 }, { "name": "downloadCheckImage", "len": 1 }, { "name": "cancelVirtualCard", "len": 1 }, { "name": "downloadCouponImage", "len": 1 }, { "name": "voidTransaction", "len": 1 }, { "name": "viewCheckImage", "len": 1 }, { "name": "eCheckReturn", "len": 1 }, { "name": "populateReceiptByData", "len": 5 }, { "name": "getPayeeName", "len": 3 }, { "name": "viewRefund", "len": 1 }, { "name": "creditCardRefundTransaction", "len": 2 }, { "name": "getPaymentPlan", "len": 1 }, { "name": "emailAllReceipts", "len": 1 }, { "name": "sendEmailReceipt", "len": 3 }, { "name": "canRefund", "len": 1 }, { "name": "eCheckRefundTransaction", "len": 2 }, { "name": "getBalanceRemaining", "len": 1 }, { "name": "collectNow", "len": 1 }, { "name": "eCheckAdjustment", "len": 1 }, { "name": "viewReceiptForTransaction", "len": 5 }, { "name": "viewVoid", "len": 1 }, { "name": "returnCodes", "len": 1 }, { "name": "canVoid", "len": 2 }, { "name": "populateReceipt", "len": 3 }, { "name": "displayMultiARLine", "len": 8 }, { "name": "copyPrimaryToSecondaryTransactionFieldsCommon", "len": 2 }, { "name": "creditCardRefundTransactionFromHistory", "len": 1 }, { "name": "doeCheckAdjustment", "len": 1 }, { "name": "viewReceipt", "len": 1 }, { "name": "getTransactionByData", "len": 2 }, { "name": "multiARRefundTransaction", "len": 1 }, { "name": "getTransaction", "len": 1 }, { "name": "getMultipleAccountReceiptText", "len": 3 } ], "GridController": [ { "name": "exportDataToFile", "len": 1 }, { "name": "saveColumnSortConfiguration", "len": 1 }, { "name": "saveColumnConfiguration", "len": 1 }, { "name": "updateCharts", "len": 1 }, { "name": "export", "formHandler": true, "len": 1 } ], "QuickPayLoginController": [ { "name": "login", "len": 1 }, { "name": "forgotPassword", "len": 1 }, { "name": "navigateToQuickPayLogin", "len": 1 }, { "name": "navigateBack", "len": 1 }, { "name": "navigateToQuickPaySignup", "len": 1 } ], "FileController": [ { "name": "saveHTML", "len": 1 } ], "QuickPayPaymentInfoController": [ { "name": "submitPayment", "len": 1 }, { "name": "navigateBack", "len": 1 }, { "name": "updatePaymentMethod", "len": 1 } ], "ManageAccountsController": [ { "name": "removeAccount", "len": 1 }, { "name": "saveAccountCustom", "len": 1 }, { "name": "getDigitalCard", "len": 1 }, { "name": "removePaymentMethodFromRadioSelector", "len": 1 }, { "name": "saveAccount", "len": 1 }, { "name": "editAccount", "len": 1 } ], "PayAnyDocController": [ { "name": "validateAddress", "len": 1 }, { "name": "selectAddress", "len": 1 }, { "name": "getFullAddressFromPPPTile", "len": 1 }, { "name": "updateHCBPInviteTracking", "len": 1 }, { "name": "navigateTo", "len": 1 }, { "name": "cleanUp", "len": 0 }, { "name": "verifyAddress", "len": 1 }, { "name": "confirmAddress", "len": 1 }, { "name": "isExactMatch", "len": 1 }, { "name": "formatAddress", "len": 6 }, { "name": "closeWindowNavigateTo", "len": 1 }, { "name": "isExactMatchAndCorrection", "len": 1 }, { "name": "forgotPassword", "len": 1 }, { "name": "isHealthcareBillPaymentsAmountValid", "len": 1 }, { "name": "incrementViews", "len": 1 }, { "name": "updateHCBPInviteCloseCount", "len": 1 }, { "name": "getNumberOfUserViews", "len": 0 }, { "name": "getAlias", "len": 0 }, { "name": "getSessionKey", "len": 1 } ], "IdleTimerController": [ { "name": "setRemainingIdleTime", "len": 0 }, { "name": "submit", "len": 1 }, { "name": "getRemainingIdleTime", "len": 1 } ], "PatientAuthenticationController": [ { "name": "verifyPatientAccountByQuickPayCode", "len": 1 }, { "name": "storeEStatementPreference", "len": 1 }, { "name": "skipAddPatient", "len": 1 }, { "name": "savePatientStatementAuthentication", "len": 1 }, { "name": "onStatementPatientChange", "len": 1 }, { "name": "verifyPatientAccount", "len": 1 }, { "name": "savePatientAuthenticationWithRegCode", "len": 1 }, { "name": "findPatientAuthLinkMatch", "len": 1 }, { "name": "updatePatientModule", "len": 2 }, { "name": "loadStatementData", "len": 1 }, { "name": "onPatientAuthPatientChange", "len": 1 }, { "name": "addPatient", "len": 1 }, { "name": "redirectToHome", "len": 0 }, { "name": "savePatientAuthentication", "len": 1 }, { "name": "associatePatientRecordWithUserAccount", "len": 2 } ], "MyAccountController": [ { "name": "removeProvider", "len": 1 }, { "name": "onHealthPlanChange", "len": 1 }, { "name": "hasAutoPay", "len": 1 }, { "name": "hasPaymentPlans", "len": 1 }, { "name": "loadMyProviderFeatures", "len": 0 }, { "name": "getTriggerUpdates", "len": 2 }, { "name": "removeOffNetworkPayee", "len": 1 }, { "name": "navigateToPayeeSearch", "len": 1 }, { "name": "navigateToEditAccount", "len": 1 }, { "name": "getCommunicationSettingsArray", "len": 1 }, { "name": "getCommunicationSettingsArrayInstaMedOnline", "len": 1 }, { "name": "shouldHideViewStatements", "len": 1 }, { "name": "navigateToStep", "len": 1 }, { "name": "addPayee", "len": 1 }, { "name": "shouldHideAutomaticPaymentsButton", "len": 1 }, { "name": "hasSMSEnabled", "len": 0 }, { "name": "navigateToWalletHealthPlan", "len": 1 }, { "name": "navigateToMyPreferences", "len": 1 } ], "SessionlessQuickPayGoGreenController": [ { "name": "storeEStatementPreference", "len": 1 } ], "SessionlessQuickPayPatientEntryController": [ { "name": "submitPatient", "len": 1 }, { "name": "navigateBack", "len": 1 }, { "name": "initializeSession", "len": 1 } ], "PaymentOptionsController": [ { "name": "editSelectedPaymentPlan", "len": 1 }, { "name": "submitPaymentPlan", "len": 1 }, { "name": "navigateToCustomPaymentPlan", "len": 1 }, { "name": "navigateBack", "len": 1 }, { "name": "getPaymentPlanPaymentsBreakdownWindowDetails", "len": 1 }, { "name": "navigateNext", "len": 1 }, { "name": "setSelectedOption", "len": 1 }, { "name": "navigateBackFromCustomPaymentPlan", "len": 1 }, { "name": "calculateOptions", "len": 1 } ], "PaymentHistoryController": [ { "name": "search", "len": 1 }, { "name": "cancelVirtualCards", "len": 1 }, { "name": "getSearchData", "len": 2 }, { "name": "cancelPaymentPlan", "len": 1 }, { "name": "getAdditionalColumns", "len": 0 }, { "name": "getData", "len": 1 }, { "name": "searchPayableTransactions", "len": 1 }, { "name": "getPaymentHistoryData", "len": 1 }, { "name": "searchHealthExpenses", "len": 1 }, { "name": "getScheduledPaymentData", "len": 2 }, { "name": "searchScheduledPayments", "len": 1 }, { "name": "getPayableTransactions", "len": 2 }, { "name": "viewPaymentReceipt", "len": 1 }, { "name": "quickPayViewAccountSummary", "len": 1 } ], "SessionlessQuickPayAccountSummaryController": [ { "name": "payOverTime", "len": 1 }, { "name": "navigateBack", "len": 1 }, { "name": "payNow", "len": 1 } ], "QuickPayGoGreenController": [ { "name": "storeEStatementPreference", "len": 1 } ], "QuickPayAccountSummaryController": [ { "name": "payOverTime", "len": 1 }, { "name": "navigateBack", "len": 1 }, { "name": "payNow", "len": 1 } ], "TextMessageEnrollmentController": [ { "name": "resendEnrollmentText", "len": 1 }, { "name": "updateMobilePhoneNumberFromPopUp", "len": 1 }, { "name": "updateMobilePhoneNumber", "len": 1 }, { "name": "verifyTextEnrollment", "len": 1 }, { "name": "enableTwoStepVerification", "len": 1 }, { "name": "updateUserTextCommPreference", "len": 1 }, { "name": "sendEnrollmentText", "len": 1 }, { "name": "skipTextEnrollment", "len": 1 } ], "SessionlessPaymentOptionsController": [ { "name": "editSelectedPaymentPlan", "len": 1 }, { "name": "submitPaymentPlan", "len": 1 }, { "name": "navigateToCustomPaymentPlan", "len": 1 }, { "name": "navigateBack", "len": 1 }, { "name": "getPaymentPlanPaymentsBreakdownWindowDetails", "len": 1 }, { "name": "navigateNext", "len": 1 }, { "name": "setSelectedOption", "len": 1 }, { "name": "navigateBackFromCustomPaymentPlan", "len": 1 }, { "name": "calculateOptions", "len": 1 } ], "QuickPayPatientEntryController": [ { "name": "addPatient", "len": 1 }, { "name": "submitPatient", "len": 1 }, { "name": "enterInformationManually", "len": 1 }, { "name": "navigateBack", "len": 1 }, { "name": "updatePatient", "len": 1 }, { "name": "editPatientInformation", "len": 1 } ], "SettingsController": [ { "name": "load", "len": 1 }, { "name": "save", "len": 1 } ], "ResetPasswordController": [ { "name": "changePassword", "len": 1 }, { "name": "navigateFromEnterCode", "len": 1 }, { "name": "requestPasswordReset", "len": 1 }, { "name": "validateAnswer", "len": 3 }, { "name": "isDualLoginSignUpFlow", "len": 0 }, { "name": "sendResetText", "len": 1 }, { "name": "submit", "len": 1 }, { "name": "resendPasswordResetCode", "len": 1 }, { "name": "getUserId", "len": 0 }, { "name": "sendEmail", "len": 2 }, { "name": "navigateFromSelectMethodForm", "len": 1 }, { "name": "getUserInitials", "len": 1 }, { "name": "pPPResetPassword", "len": 1 }, { "name": "generateResetCode", "len": 0 }, { "name": "sendResetEmail", "len": 1 }, { "name": "navigateFromForgotPassword", "len": 1 } ], "PatientPaymentController": [ { "name": "submitCreditCard", "len": 4 }, { "name": "confirm", "len": 1 }, { "name": "setCommonTransactionFields", "len": 1 }, { "name": "cancelNewCardInfo", "len": 1 }, { "name": "displayPatientBalance", "len": 1 }, { "name": "editProviderInformation", "len": 1 }, { "name": "setTransactionData", "len": 1 }, { "name": "onPatientChange", "len": 1 }, { "name": "submitNewCardInfo", "len": 1 }, { "name": "submitPatient", "len": 1 }, { "name": "cleanUp", "len": 0 }, { "name": "getSaveOnFilePaymentPlan", "len": 3 }, { "name": "submitPayment", "len": 1 }, { "name": "triggerPaymentEventTracking", "len": 1 }, { "name": "setPatientPaymentConfirmHeaderMessage", "len": 5 }, { "name": "preAuth", "len": 1 }, { "name": "cardAlreadySavedOnFile", "len": 1 }, { "name": "updateChargeLimit", "len": 1 }, { "name": "get_Transaction", "len": 0 }, { "name": "handleEpicPostBack", "len": 5 }, { "name": "updatePatient", "len": 1 }, { "name": "getLineItemTransactions", "len": 1 }, { "name": "redirectToLogin", "len": 1 }, { "name": "getPatientUniqueAlias", "len": 1 }, { "name": "addPatient", "len": 1 }, { "name": "editPatientInformation", "len": 1 }, { "name": "backToPayment", "len": 1 }, { "name": "getAPCEnrollmentUpdates", "len": 3 }, { "name": "setupAutomaicPayment", "len": 2 }, { "name": "set_Transaction", "len": 1 }, { "name": "clearPayAnyDocInformation", "len": 0 }, { "name": "submitECheck", "len": 3 }, { "name": "backToNewPaymentMethod", "len": 1 }, { "name": "getPreAuthUpdateFieldInfos", "len": 1 }, { "name": "getBankAccountInfoAlreadySavedOnFile", "len": 1 }, { "name": "handleDisbursem*nt", "len": 3 }, { "name": "savePaymentPlan", "len": 3 }, { "name": "getLineItemTransaction", "len": 1 }, { "name": "getCreditCardInfoAlreadySavedOnFile", "len": 1 } ], "PaymentPlanController": [ { "name": "setTransactionFields", "len": 2 }, { "name": "reCalculate", "len": 5 }, { "name": "backToPayment", "len": 1 }, { "name": "submitPayment", "len": 1 }, { "name": "onInstallmentAmountChange", "len": 1 }, { "name": "backToPaymentPlan", "len": 1 }, { "name": "onPatientChange", "len": 1 }, { "name": "submitPaymentPlan", "len": 1 }, { "name": "onTotalAmountChange", "len": 1 }, { "name": "onStartDateChange", "len": 1 }, { "name": "get_ScheduledTransactions", "len": 0 }, { "name": "submitPayments", "len": 1 }, { "name": "submitPatient", "len": 1 }, { "name": "get_EditPaymentPlan", "len": 0 }, { "name": "confirm", "len": 1 }, { "name": "emailReceipt", "len": 1 }, { "name": "onFrequencyChange", "len": 1 }, { "name": "onInitialAmountChange", "len": 1 }, { "name": "get_IsEditing", "len": 0 } ], "QuickPayReviewAndConfirmController": [ { "name": "emailReceipt", "len": 1 }, { "name": "confirm", "len": 1 }, { "name": "viewReceipt", "len": 1 } ], "CheckInPatientInformationController": [ { "name": "selectAddress", "len": 1 }, { "name": "onPatientChange", "len": 1 }, { "name": "next", "len": 1 }, { "name": "confirmAddress", "len": 1 } ], "MobilePayController": [ { "name": "getApplePayMerchantSession", "len": 1 } ], "SignUpController": [ { "name": "navigateFromSignUp", "len": 0 }, { "name": "completeSignUp", "len": 1 }, { "name": "redirectToSignUpForm", "len": 1 }, { "name": "redirectToSignUp", "len": 1 }, { "name": "sendAccountCreatedEvent", "len": 1 }, { "name": "signUp", "len": 1 }, { "name": "isEnterPayeeManuallyFlow", "len": 0 }, { "name": "verifyTextEnrollment", "len": 1 }, { "name": "dualSignUp", "len": 1 }, { "name": "isDigitalPayoutFlow", "len": 0 }, { "name": "skipTextEnrollment", "len": 1 }, { "name": "isPatientMatchFlow", "len": 0 } ], "FindProviderController": [ { "name": "search", "len": 1 }, { "name": "getManualPayeeBadge", "len": 1 }, { "name": "payNowRedirect", "len": 1 }, { "name": "clearPayAnyDocSession", "len": 1 }, { "name": "sessionSearch", "len": 1 }, { "name": "loadMyProviders", "len": 3 }, { "name": "getStore", "len": 2 }, { "name": "getVirtualCardTrustedPayeeInformation", "len": 1 }, { "name": "processStatementImage", "len": 1 }, { "name": "isIPBlocked", "len": 1 }, { "name": "updateHCBPUsageTracking", "len": 2 }, { "name": "goToAcceptPaymentRedirect", "len": 1 }, { "name": "getManualPayeeInformation", "len": 1 }, { "name": "scanStatement", "len": 1 }, { "name": "enterPayeeManually", "len": 1 }, { "name": "getPatients", "len": 3 }, { "name": "landingPageSearch", "len": 1 }, { "name": "set_ZipCodeService", "len": 1 }, { "name": "searchForProviders", "len": 1 }, { "name": "getProvidersAutoComplete", "len": 1 }, { "name": "goToRedirect", "len": 1 }, { "name": "get_ZipCodeService", "len": 0 }, { "name": "getManualPayeeText", "len": 0 } ], "QuickPaySignUpController": [ { "name": "signUp", "len": 1 }, { "name": "skip", "len": 1 } ] }, "descriptor": "Ext.app.REMOTING_API"};Ext.app.REMOTING_API.maxRetries = 0;Ext.app.REMOTING_API.timeout = 300 * 1000;Ext.app.REMOTING_API.enableBuffer = false;Ext.Direct.addProvider(Ext.app.REMOTING_API);Ext.app.REMOTING_API.requestKey = '3BD2CB18E23533848E194335696047B7D2B534E25089159C946C7FC7620C52AE';Ext.app.REMOTING_API.alias = 'SILVERSCRIPT';Ext.app.REMOTING_API.corporateID = '';Ext.app.REMOTING_API.token = '';function headerPatientPortalBack() { var nav = InstaMed.getNavigationView(); if(!Ext.Msg.isHidden()) { Ext.Msg.close(); } else if(nav.lastForm.length > 1) { nav.back(); } else { PerformAction({}, PatientPortalLoginController.patientPortalHeaderBack); } }Ext.define('MyApp.view.amountfield', { extend: 'Ext.field.Text', alias: 'widget.amountfield', config: { maxLength: 10, }, listeners: {blur: function(field, event, opts ){ field.doFormatAmount(field,event,opts); } }, doFormatAmount: function(field, event, opts ){ var s = new String(field.getValue()); if(s != null && s != '') { s = s.replace(/,/g,''); s = s.replace(/\$/g,''); field.setValue(Ext.util.Format.usMoney(s)); } }, getValue: function() { var val = new String(Ext.field.Number.superclass.getValue.call(this)); if(val == "null"){val = null;} return val; }, getSubmitValue: function() { var val = this.getValue(); if(val != null){ val = val.replace(/\$/g,''); } return val; }, transformOriginalValue: function(v) { if(v != undefined && v != null && v != '') { var s = new String(v); s = s.replace(/,/g,''); s = s.replace(/\$/g,''); var val = Ext.util.Format.usMoney(s); if(val == '$NaN.undefined') { val = ''; } return val; } return v; }, reset: function() { var me = this; Ext.field.Number.superclass.reset.call(this); me.enteredDigits = []; me.totalDigitsEntered = 0; }, setValue: function(v) { if(v==null || v==undefined || v==''){ this.enteredDigits = []; this.totalDigitsEntered = 0; } if(!this.hasFocus) { if (v == '$') { v = ''; } else { v = this.transformOriginalValue(v); } } v = new String(v).replace(/[^\$\d\.\,]/g,''); if(v.indexOf('.')!=-1 && v.indexOf('.') == v.length-4){ v = v.substring(0, v.indexOf('.') + 3); v = this.transformOriginalValue(v); } if(!this.KeyUpMode) { this.enteredDigits = []; this.totalDigitsEntered = 0; var count = 0; if(v) { var chars = v.split(''); for(var i = 0; i < chars.length; i++) { var c = chars[i]; if(c >= '0' && c <= '9') { this.enteredDigits.push(c); this.totalDigitsEntered++; } } } } Ext.field.Text.superclass.setValue.call(this,v); this.setInputValue(v); } });Ext.define('Ext.InstaMed.FormPanel',{extend: 'Ext.form.Panel',alias: 'widget.form',config: { defaultSubmitButton: null }});Ext.define('PatientPaymentPatientInfoMultiARDataViewModel', { extend: 'Ext.data.Model', config: { fields: [ { name: 'PaymentDate' },{ name: 'Amount' },{ name: 'PatientID' },{ name: 'PatientMedicalRecordNumber' },{ name: 'PatientFirstName' },{ name: 'PatientMiddleName' },{ name: 'PatientLastName' },{ name: 'PatientBirthDate' },{ name: 'PatientPhoneNumber' },{ name: 'AccountHolderEmail' },{ name: 'PatientInvoiceNumber' },{ name: 'PatientServiceBeginDate' },{ name: 'PatientServiceEndDate' },{ name: 'PatientAddress1' },{ name: 'PatientAddress2' },{ name: 'PatientCity' },{ name: 'PatientState' },{ name: 'PatientZip' },{ name: 'PatientCountry' },{ name: 'TransactionCode' },{ name: 'AdditionalCode1' },{ name: 'AdditionalCode2' },{ name: 'AdditionalCode3' },{ name: 'AdditionalCode4' },{ name: 'AdditionalCode5' },{ name: 'AdditionalCode6' },{ name: 'AdditionalInfo1' },{ name: 'AdditionalInfo2' },{ name: 'AdditionalInfo3' },{ name: 'AdditionalInfo4' },{ name: 'AdditionalInfo5' },{ name: 'AdditionalInfo6' },{ name: 'LineItemKey' } ] } }); Ext.create('Ext.data.Store', { id:'PatientPaymentPatientInfoMultiARDataViewstore', model: 'PatientPaymentPatientInfoMultiARDataViewModel', autoLoad: true, proxy: { type: 'memory', reader: { type: 'json' }, data: [] } }); function editLineItem(lineItemKey) { var store = InstaMed.get('PatientPaymentPatientInfoMultiARDataView').getStore(); var selIndex = store.find('LineItemKey', lineItemKey); if(selIndex >= 0) { var rec = store.getAt(selIndex); Ext.Array.each(InstaMed.getNavigationView().getCurrentItem().query('field'), function(f) { var val = rec.get(f.getName()); f.setValue(val && val.code ? val.code : val); }); } InstaMed.get('btnAddPatient').hide(); InstaMed.get('btnNext').hide(); var updatePatientButton = InstaMed.get('btnUpdatePatient'); InstaMed.get('btnCancelEditPatient').show(); var fullWidthButton = InstaMed.get('footerFullWidthButton'); if(fullWidthButton != undefined && fullWidthButton.isVisible()) { fullWidthButton.primaryButton = updatePatientButton; fullWidthButton.setText(fullWidthButton.primaryButton.getText()); fullWidthButton.forcePrimaryAction = true; } else { updatePatientButton.show(); } } function cancelEditLineItem() { InstaMed.get('btnAddPatient').show(); InstaMed.get('btnUpdatePatient').hide(); InstaMed.get('btnCancelEditPatient').hide(); InstaMed.resetForm(InstaMed.getNavigationView().getCurrentItem().query('form')[0]); var nextButton = InstaMed.get('btnNext'); var fullWidthButton = InstaMed.get('footerFullWidthButton'); if(fullWidthButton != undefined && fullWidthButton.isVisible()) { fullWidthButton.primaryButton = nextButton; fullWidthButton.setText(fullWidthButton.primaryButton.getText()); fullWidthButton.forcePrimaryAction = false; } else { nextButton.show(); } } function removeLineItem(lineItemKey) { var dataView = InstaMed.get('PatientPaymentPatientInfoMultiARDataView'); var store = dataView.getStore(); var selIndex = store.find('LineItemKey', lineItemKey); if(selIndex >= 0) { store.removeAt(selIndex); dataView.refresh(); } } function NavigateToPatientInformation(lineItemKey) { var form = InstaMed.getNavigationView(); form.push('NavPatientInformation'); if(lineItemKey) { editLineItem(lineItemKey); } PerformAction({}, PatientPaymentController.editPatientInformation); }function NavigateToQuickPayPatientEntry(lineItemKey) { var form = InstaMed.getNavigationView(); form.push('NavQuickPayPatientEntry'); if(lineItemKey) { editLineItem(lineItemKey); } javascript: PerformAction({}, QuickPayPatientEntryController.editPatientInformation,null); return false; }Ext.define('MyApp.model.CodeDescriptionPatientPaymentPatientInfoMultiARDataViewstore',{extend: 'Ext.data.Model',id: 'PatientPaymentPatientInfoMultiARDataViewstore',fields: [{name:'EntityID'},{name:'PatientFirstName'},{name:'PatientLastName'},{name:'PatientID'},{name:'Amount'},{name:'LineItemKey'},{name:'PaymentDate'},{name:'PatientMedicalRecordNumber'},{name:'PatientMiddleName'},{name:'PatientBirthDate'},{name:'PatientPhoneNumber'},{name:'AccountHolderEmail'},{name:'PatientInvoiceNumber'},{name:'PatientServiceBeginDate'},{name:'PatientServiceEndDate'},{name:'PatientAddress1'},{name:'PatientAddress2'},{name:'PatientCity'},{name:'PatientState'},{name:'PatientZip'},{name:'PatientCountry'},{name:'TransactionCode'},{name:'AdditionalCode1'},{name:'AdditionalCode2'},{name:'AdditionalCode3'},{name:'AdditionalCode4'},{name:'AdditionalCode5'},{name:'AdditionalCode6'},{name:'AdditionalInfo1'},{name:'AdditionalInfo2'},{name:'AdditionalInfo3'},{name:'AdditionalInfo4'},{name:'AdditionalInfo5'},{name:'AdditionalInfo6'},{name:'EmailAddress'}]});Ext.create('Ext.data.JsonStore',{ autoDestroy: false, proxy: { type: 'memory', reader: 'json', writer: 'json' }, storeId: 'PatientPaymentPatientInfoMultiARDataViewstore', fields: [{ name: 'EntityID', type: 'string'},{ name: 'PatientFirstName', type: 'string'},{ name: 'PatientLastName', type: 'string'},{ name: 'PatientID', type: 'string'},{ name: 'Amount', type: 'string'},{ name: 'LineItemKey', type: 'string'},{ name: 'PaymentDate', type: 'string'},{ name: 'PatientMedicalRecordNumber', type: 'string'},{ name: 'PatientMiddleName', type: 'string'},{ name: 'PatientBirthDate', type: 'string'},{ name: 'PatientPhoneNumber', type: 'string'},{ name: 'AccountHolderEmail', type: 'string'},{ name: 'PatientInvoiceNumber', type: 'string'},{ name: 'PatientServiceBeginDate', type: 'string'},{ name: 'PatientServiceEndDate', type: 'string'},{ name: 'PatientAddress1', type: 'string'},{ name: 'PatientAddress2', type: 'string'},{ name: 'PatientCity', type: 'string'},{ name: 'PatientState', type: 'string'},{ name: 'PatientZip', type: 'string'},{ name: 'PatientCountry', type: 'string'},{ name: 'TransactionCode', type: 'auto'},{ name: 'AdditionalCode1', type: 'auto'},{ name: 'AdditionalCode2', type: 'auto'},{ name: 'AdditionalCode3', type: 'auto'},{ name: 'AdditionalCode4', type: 'auto'},{ name: 'AdditionalCode5', type: 'auto'},{ name: 'AdditionalCode6', type: 'auto'},{ name: 'AdditionalInfo1', type: 'string'},{ name: 'AdditionalInfo2', type: 'string'},{ name: 'AdditionalInfo3', type: 'string'},{ name: 'AdditionalInfo4', type: 'string'},{ name: 'AdditionalInfo5', type: 'string'},{ name: 'AdditionalInfo6', type: 'string'},{ name: 'EmailAddress', type: 'string'}],data: []});function focusAmount(cmp){ if(cmp){ setTimeout(function(){ cmp.selectionStart = cmp.selectionEnd = 10000; }, 0); } }function setOtherAmounts(cmp){ if(cmp){ var amount = cmp.getValue(); if (amount == '') { cmp && cmp.setValue(null); cmp && cmp.setInputValue('$0.00'); }else { if(cmp){ var hasDollarSign = cmp.getInputValue().includes('$') if(hasDollarSign){ var amountVal = cmp.getInputValue().replace('$', ''); } } } } }function isNumeric(s) { return !isNaN(s - parseFloat(s)); }Ext.create('Ext.data.ArrayStore',{ type: 'json', autoDestroy: false, storeId: 'ApplicationStateComboboxStore', fields: [ { name: 'code', type: 'string' }, { name: 'description', type: 'string' } ], data: [['AK', 'Alaska'],['AL', 'Alabama'],['AR', 'Arkansas'],['AZ', 'Arizona'],['CA', 'California'],['CO', 'Colorado'],['CT', 'Connecticut'],['DC', 'District Of Columbia'],['DE', 'Delaware'],['FL', 'Florida'],['GA', 'Georgia'],['HI', 'Hawaii'],['IA', 'Iowa'],['ID', 'Idaho'],['IL', 'Illinois'],['IN', 'Indiana'],['KS', 'Kansas'],['KY', 'Kentucky'],['LA', 'Louisiana'],['MA', 'Massachusetts'],['MD', 'Maryland'],['ME', 'Maine'],['MI', 'Michigan'],['MN', 'Minnesota'],['MO', 'Missouri'],['MS', 'Mississippi'],['MT', 'Montana'],['NC', 'North Carolina'],['ND', 'North Dakota'],['NE', 'Nebraska'],['NH', 'New Hampshire'],['NJ', 'New Jersey'],['NM', 'New Mexico'],['NV', 'Nevada'],['NY', 'New York'],['OH', 'Ohio'],['OK', 'Oklahoma'],['OR', 'Oregon'],['PA', 'Pennsylvania'],['RI', 'Rhode Island'],['SC', 'South Carolina'],['SD', 'South Dakota'],['TN', 'Tennessee'],['TX', 'Texas'],['UT', 'Utah'],['VA', 'Virginia'],['VT', 'Vermont'],['WA', 'Washington'],['WI', 'Wisconsin'],['WV', 'West Virginia'],['WY', 'Wyoming'] ]})Ext.create('Ext.data.ArrayStore',{ type: 'json', autoDestroy: false, storeId: 'CountryStoreStore', fields: [ { name: 'code', type: 'string' }, { name: 'description', type: 'string' } ], data: [['AF', 'Afghanistan'],['AL', 'Albania'],['DZ', 'Algeria'],['AS', 'American Samoa'],['AD', 'Andorra'],['AO', 'Angola'],['AI', 'Anguilla'],['AQ', 'Antarctica'],['AG', 'Antigua And Barbuda'],['AR', 'Argentina'],['AM', 'Armenia'],['AW', 'Aruba'],['AU', 'Australia'],['AT', 'Austria'],['AZ', 'Azerbaijan'],['BS', 'Bahamas'],['BH', 'Bahrain'],['BD', 'Bangladesh'],['BB', 'Barbados'],['BY', 'Belarus'],['BE', 'Belgium'],['BZ', 'Belize'],['BJ', 'Benin'],['BM', 'Bermuda'],['BT', 'Bhutan'],['BO', 'Bolivia'],['BA', 'Bosnia And Herzegovina'],['BW', 'Botswana'],['BV', 'Bouvet Island'],['BR', 'Brazil'],['IO', 'British Indian Ocean Territory'],['BN', 'Brunei Darussalam'],['BG', 'Bulgaria'],['BF', 'Burkina Faso'],['BI', 'Burundi'],['KH', 'Cambodia'],['CM', 'Cameroon'],['CA', 'Canada'],['CV', 'Cape Verde'],['KY', 'Cayman Islands'],['CF', 'Central African Republic'],['TD', 'Chad'],['CL', 'Chile'],['CN', 'China'],['CX', 'Christmas Island'],['CC', 'Cocos (keeling) Islands'],['CO', 'Colombia'],['KM', 'Comoros'],['CK', 'Cook Islands'],['CR', 'Costa Rica'],['CI', 'Cote D\'ivoire (ivory Coast)'],['HR', 'Croatia (hrvatska)'],['CU', 'Cuba'],['CY', 'Cyprus'],['CZ', 'Czech Republic'],['KP', 'Democratic People\'s Republic of Korea (North)'],['CD', 'Democratic Republic Of The Congo'],['DK', 'Denmark'],['DJ', 'Djibouti'],['DM', 'Dominica'],['DO', 'Dominican Republic'],['TP', 'East Timor'],['EC', 'Ecuador'],['EG', 'Egypt'],['SV', 'El Salvador'],['GQ', 'Equatorial Guinea'],['ER', 'Eritrea'],['EE', 'Estonia'],['ET', 'Ethiopia'],['FK', 'Falkland Islands (malvinas)'],['FO', 'Faroe Islands'],['FM', 'Federated States Of Micronesia'],['FJ', 'Fiji'],['FI', 'Finland'],['FR', 'France'],['GF', 'French Guiana'],['PF', 'French Polynesia'],['TF', 'French Southern Territories'],['GA', 'Gabon'],['GM', 'Gambia'],['GE', 'Georgia'],['DE', 'Germany'],['GH', 'Ghana'],['GI', 'Gibraltar'],['GR', 'Greece'],['GL', 'Greenland'],['GD', 'Grenada'],['GP', 'Guadeloupe'],['GU', 'Guam'],['GT', 'Guatemala'],['GN', 'Guinea'],['GW', 'Guinea-bissau'],['GY', 'Guyana'],['HT', 'Haiti'],['HM', 'Heard Island And Mcdonald Islands'],['VA', 'Holy See (Vatican City State)'],['HN', 'Honduras'],['HK', 'Hong Kong'],['HU', 'Hungary'],['IS', 'Iceland'],['IN', 'India'],['ID', 'Indonesia'],['IR', 'Iran'],['IQ', 'Iraq'],['IE', 'Ireland'],['IL', 'Israel'],['IT', 'Italy'],['JM', 'Jamaica'],['JP', 'Japan'],['JO', 'Jordan'],['KZ', 'Kazakhstan'],['KE', 'Kenya'],['KI', 'Kiribati'],['KW', 'Kuwait'],['KG', 'Kyrgyzstan'],['LA', 'Lao People\'s Democratic Republic (Laos)'],['LV', 'Latvia'],['LB', 'Lebanon'],['LS', 'Lesotho'],['LR', 'Liberia'],['LY', 'Libya'],['LI', 'Liechtenstein'],['LT', 'Lithuania'],['LU', 'Luxembourg'],['MO', 'Macau (Macao)'],['MK', 'Macedonia'],['MG', 'Madagascar'],['MW', 'Malawi'],['MY', 'Malaysia'],['MV', 'Maldives'],['ML', 'Mali'],['MT', 'Malta'],['MH', 'Marshall Islands'],['MQ', 'Martinique'],['MR', 'Mauritania'],['MU', 'Mauritius'],['YT', 'Mayotte'],['MX', 'Mexico'],['FM', 'Micronesia (Federated States of)'],['MD', 'Moldova'],['MC', 'Monaco'],['MN', 'Mongolia'],['ME', 'Montenegro'],['MS', 'Montserrat'],['MA', 'Morocco'],['MZ', 'Mozambique'],['MM', 'Myanmar'],['NA', 'Namibia'],['NR', 'Nauru'],['NP', 'Nepal'],['NL', 'Netherlands'],['AN', 'Netherlands Antilles'],['NC', 'New Caledonia'],['NZ', 'New Zealand (aotearoa)'],['NI', 'Nicaragua'],['NE', 'Niger'],['NG', 'Nigeria'],['NU', 'Niue'],['NF', 'Norfolk Island'],['MP', 'Northern Mariana Islands'],['NO', 'Norway'],['OM', 'Oman'],['PK', 'Pakistan'],['PW', 'Palau'],['PS', 'Palestinian Territory'],['PA', 'Panama'],['PG', 'Papua New Guinea'],['PY', 'Paraguay'],['PE', 'Peru'],['PH', 'Philippines'],['PN', 'Pitcairn'],['PL', 'Poland'],['PT', 'Portugal'],['PR', 'Puerto Rico'],['QA', 'Qatar'],['KR', 'Republic of Korea (South)'],['RE', 'Reunion'],['RO', 'Romania'],['RU', 'Russian Federation'],['RW', 'Rwanda'],['SH', 'Saint Helena'],['KN', 'Saint Kitts And Nevis'],['LC', 'Saint Lucia'],['PM', 'Saint Pierre And Miquelon'],['VC', 'Saint Vincent And The Grenadines'],['WS', 'Samoa'],['SM', 'San Marino'],['ST', 'Sao Tome And Principe'],['SA', 'Saudi Arabia'],['SN', 'Senegal'],['CS', 'Serbia'],['SC', 'Seychelles'],['SL', 'Sierra Leone'],['SG', 'Singapore'],['SK', 'Slovakia'],['SI', 'Slovenia'],['SB', 'Solomon Islands'],['SO', 'Somalia'],['ZA', 'South Africa'],['ES', 'Spain'],['LK', 'Sri Lanka'],['SD', 'Sudan'],['SR', 'Suriname'],['SJ', 'Svalbard And Jan Mayen'],['SZ', 'Swaziland'],['SE', 'Sweden'],['CH', 'Switzerland'],['SY', 'Syrian Arab Republic'],['TW', 'Taiwan, Province of China'],['TJ', 'Tajikistan'],['TZ', 'Tanzania, United Republic of'],['TH', 'Thailand'],['TL', 'Timor-leste'],['TG', 'Togo'],['TK', 'Tokelau'],['TO', 'Tonga'],['TT', 'Trinidad And Tobago'],['TN', 'Tunisia'],['TR', 'Turkey'],['TM', 'Turkmenistan'],['TC', 'Turks And Caicos Islands'],['TV', 'Tuvalu'],['UG', 'Uganda'],['UA', 'Ukraine'],['AE', 'United Arab Emirates'],['UK', 'United Kingdom'],['US', 'United States'],['UM', 'United States Minor Outlying Islands'],['PU', 'United States Pacific Islands'],['VI', 'United States Virgin Islands'],['XK', 'Unmik (United Nations of Kosovo)'],['UY', 'Uruguay'],['UZ', 'Uzbekistan'],['VU', 'Vanuatu'],['VE', 'Venezuela'],['VN', 'Viet Nam'],['VG', 'Virgin Islands (British)'],['WF', 'Wallis and Futuna Islands'],['EH', 'Western Sahara'],['YE', 'Yemen'],['ZM', 'Zambia'],['ZW', 'Zimbabwe'] ]})Ext.define('MyApp.model.CodeDescriptionAccountSummaryPaymentInformationStore',{extend: 'Ext.data.Model',id: 'AccountSummaryPaymentInformationStore',fields: [{name:'Angle'},{name:'Label'},{name:'Color'},{name:'IsMaxAngle'}]});Ext.create('Ext.data.JsonStore',{ autoDestroy: false, proxy: { type: 'memory', reader: 'json', writer: 'json' }, storeId: 'AccountSummaryPaymentInformationStore', fields: [{ name: 'Angle', type: 'string'},{ name: 'Label', type: 'string'},{ name: 'Color', type: 'string'},{ name: 'IsMaxAngle', type: 'string'}],data: [{"Angle":"360","Label":"Total Balance","Color":"#005596","IsMaxAngle":true,"EntityID":null}]});Ext.define('Ext.chart.theme.instamed', { extend: 'Ext.chart.theme.Base', singleton: true, alias: 'chart.theme.instamed', config: { colors: ["#1976D2","#A5D6A7","#039BE5","#4A148C","#4CAF50","#9575CD","#C51162","#FB8C00","#880E4F","#E57373","#90A4AE"] } });function removeProvider(providerAlias) { var providerName = Ext.StoreManager.get('MyAccountProvidersList-init').findRecord('ProviderAlias', providerAlias).get('ProviderName');var payeeName = providerName;if(!payeeName){payeeName = 'This Payee'}if(InstaMed.isMobileOrTablet){Ext.Msg.show({title: '
Remove
',message: 'Remove ' + payeeName + ' ?',buttons: [{text: 'Cancel',ui: 'decline',itemId: 'no'}, {text: 'Remove',ui: 'confirm',itemId: 'yes'}],fn: function(btn) {if (btn === 'yes') {PerformAction({ProviderAlias: providerAlias, ProviderName: providerName}, MyAccountController.removeProvider); }}}); }else{ Ext.Msg.buttonText.cancel = Ext.util.Format.htmlEncode('Cancel'); Ext.Msg.buttonText.ok = Ext.util.Format.htmlEncode('Ok'); Ext.Msg.show({title: '
Please Confirm
',msg: 'Remove ' + payeeName + '?',icon: Ext.Msg.QUESTION,buttons: Ext.Msg.OKCANCEL,iconWidth:54,iconHeight:45,fn: function(btn) {if (btn === 'ok') {PerformAction({ProviderAlias: providerAlias, ProviderName: providerName}, MyAccountController.removeProvider);}} });} event && event.stopPropagation(); }function removeOffNetworkPayee(entityID, payeeName){ if(InstaMed.isMobileOrTablet){Ext.Msg.show({title: '
Remove
',message: 'Remove ' + payeeName + ' ?',buttons: [{text: 'Cancel',ui: 'decline',itemId: 'no'}, {text: 'Remove',ui: 'confirm',itemId: 'yes'}],fn: function(btn) {if (btn === 'yes') {PerformAction({EntityID: entityID, ProviderName: payeeName}, MyAccountController.removeOffNetworkPayee); }}}); }else{ Ext.Msg.buttonText.cancel = Ext.util.Format.htmlEncode('Cancel'); Ext.Msg.buttonText.ok = Ext.util.Format.htmlEncode('Ok'); Ext.Msg.show({title: '
Please Confirm
',msg: 'Remove ' + payeeName + '?',icon: Ext.Msg.QUESTION,buttons: Ext.Msg.OKCANCEL,iconWidth:54,iconHeight:45,fn: function(btn) {if (btn === 'ok') {PerformAction({EntityID: entityID, ProviderName: payeeName}, MyAccountController.removeOffNetworkPayee);}} });} event && event.stopPropagation();}function registerRemovePayeeTooltip(providerAlias) {Ext.tip.QuickTipManager.register({target: 'remove-payee-icon-' + providerAlias,text : 'Remove',showDelay: 125});}function registerAllRemovePayeeTooltips() { var store = Ext.StoreManager.get('MyAccountProvidersList-init'); if(store) {for(var i = 0; i < store.getTotalCount(); i++){var rec = store.getAt(i);registerRemovePayeeTooltip(rec.get('ProviderAlias')); } }} function EncodeApostropheAndURIComponent (str) { return InstaMed.encodeApostrophe(encodeURIComponent(str)); } function payeeTileRedirect(alias, visit, payment, add, select, pk, memberpay,trackingData, autoCompleteName, location) { var dataView = InstaMed.get('ProviderBadges'); if(dataView && dataView.lastStoreUpdate && (Math.floor(Date.now()) - dataView.lastStoreUpdate < 1000)){ return;}; var pageNum = 1; if(dataView) pageNum = dataView.getStore().currentPage; var navPage = Ext.get('NavFindProvider') var scrollLocation = 0; if (navPage && navPage.child) { var container = navPage.child('div', false); if(container && container.child) { var scroller = container.child('div[class*=x-scroller]', false); if(scroller && scroller.dom.scroll) { scrollLocation = scroller.dom.scrollTop; } } } PerformAction({ ProviderAlias: alias, isVisit: visit, isPayment: payment, isAdd: add, isSelect: select, isMemberPayment: memberpay, OffNetworkPK: pk,Origin:null, trackingData: trackingData, pageNumber: pageNum, scrollLocation: scrollLocation, autoCompleteName: autoCompleteName, location: location }, FindProviderController.enterPayeeManually); event && event.stopPropagation();}function handlePayNow(alias, pk) {PerformAction({ ProviderAlias: alias, OffNetworkPK: pk}, FindProviderController.payNowRedirect); event && event.stopPropagation();}function handleGoTo(alias, pk) {PerformAction({ ProviderAlias: alias, OffNetworkPK: pk}, FindProviderController.goToRedirect); event && event.stopPropagation();} function handleGoToAcceptPayment(alias) { PerformAction({ ProviderAlias: alias}, FindProviderController.goToAcceptPaymentRedirect); event && event.stopPropagation(); } function closem*nu(){ var dropdowns = document.getElementsByClassName("dropdown-content");var i;for (i = 0; i {PatientFirstName:htmlEncode} {PatientLastName:htmlEncode} ({PatientID:htmlEncode}) {PatientFirstName:htmlEncode} {PatientLastName:htmlEncode} ${Amount:htmlEncode} Edit Remove Total Balance {AutoLogo:htmlEncode}{ProviderName:htmlEncode} {AutoLogo:htmlEncode}{ProviderName:htmlEncode} {ProviderName:htmlEncode} {ProviderName:htmlEncode} {ProviderFormatedAddress:htmlEncode} {ProviderName:htmlEncode} {ProviderAddress1:htmlEncode} This provider offers automatic payments, paperless billing, and payment plans. {GroupName:htmlEncode} {ProviderInitials:htmlEncode}{OffNetworkProviderName:htmlEncode} {OffNetworkProviderName:htmlEncode} {OffNetworkProviderAddress1:htmlEncode} {OffNetworkProviderAddress2:htmlEncode}, {OffNetworkProviderCity:htmlEncode} {OffNetworkProviderState:htmlEncode} {OffNetworkProviderZip:htmlEncode} This provider offers automatic payments, paperless billing, and payment plans. Go Green! Enroll in Paperless Statements Automatic Payments is a feature that notifies you of future balances and automatically schedules a payment for your outstanding balance. Q: Which payment method will be used for the scheduled payment? Q: Can I edit my Automatic Payments enrollment after I sign up? Q: How will I be notified of future balances? ', ' ', '{PatientFirstName:htmlEncode} ', '{PatientLastName:htmlEncode} ', '({PatientID:htmlEncode})', ' ', ' ', ' ', ' ',' ', ' ', '{PatientFirstName:htmlEncode} ', '{PatientLastName:htmlEncode} ', ' ', ' ', ' ', ' ',' \t\t \t\tWe are required by law, regulation or agreement to give you certain information “in writing”. With your consent, we can provide this information to you by Electronic Delivery instead. We also need your general consent to use electronic records and signatures in our relationship with you. You agree that for all Communications for Services we may use Electronic Delivery and, at our discretion, terminate paper delivery of Communications to you unless and until you withdraw your consent to this Section 7 as described in Section 7(f) below. This Section 7 applies to all Communications relating to such Services. “Communications” include, but are not limited to, the following: Except as otherwise provided in this Section 7, physical delivery of Communications is not available for these Services. We reserve the right, but assume no obligation, to provide paper copies of any Communication that you have authorized us to provide via Electronic Delivery. To withdraw your consent to receive Communications by Electronic Delivery, you must follow the instructions set forth in the section titled “How to Withdraw Consent” in Section 7(f) below. Sometimes you are required to provide us with a written notice by law or under our agreement with you. Those notices must be provided to us on paper unless we tell you how to deliver the notice to us electronically. All Communications (including alerts that Communications have been provided or posted) that we provide to you electronically will be provided by one or more of the following methods: Communications delivered by e-mail will be sent to your e-mail address reflected in our records. You represent that any e-mail address you provide to us for Electronic Delivery purposes belongs to you or to a person who has authority for Services. You can update your email address on file with us by calling (866) 467-8263. You should print, download or otherwise retain a copy of this Section 7 and all other Communications provided by Electronic Delivery. In order to access, view, print and retain electronic Communications, you must have: By “Current Version,” we mean a version of the software that is currently being supported by its publisher. From time to time, we may offer services or features that require that your internet browser be configured in a particular way, such as permitting the use of cookies. If we detect that your Internet browser is not properly configured, we may provide you with a notice and advice on how to update your configuration. We reserve the right to discontinue support of a Current Version of software or an operating system if, in our sole opinion, it suffers from a security flaw or other flaw that makes it unsuitable for use. If our hardware or software requirements change, and that change would create a material risk that you would not be able to access or retain electronic Communications, we will give you notice of the revised hardware or software requirements. Continuing to use the Services after receiving notice of the change is reaffirmation of your consent with respect to other Communications. We will not impose any fee to process the withdrawal of your consent to receive Communications by Electronic Delivery. However, if you withdraw consent, your access to and use of the Services or certain features of the Services will be terminated. Any withdrawal of your consent to receive Communications by Electronic Delivery will be effective only after we have a reasonable period of time to process your withdrawal. At our option, we may treat the provision of an invalid e-mail address, or the subsequent malfunction of a previously valid e-mail address, as a withdrawal of your consent to receive Communications by Electronic Delivery. You may withdraw your consent to receive Electronic Delivery of Communications by calling us at (866) 467-8263. For Communications scheduled for Electronic Delivery, you should not expect to receive a paper copy of any Communication unless you request it. You can obtain a paper copy of an electronic Communication by printing it yourself or by requesting that we mail you a paper copy, provided that such request is made within a reasonable time after we first provided the Communication to you by Electronic Delivery. We may charge you a reasonable service charge, with prior notice of any such charge, for the delivery of paper copies of any Communication provided to you electronically pursuant to this Section 7. To request paper copies of electronic Communications, call us at (866) 467-8263. You acknowledge and agree that your consent to this Section 7 is provided in connection with a transaction affecting interstate commerce, that it is subject to the federal Electronic Signatures in Global and National Commerce Act (the “E-SIGN Act”), and that you and we both intend that the E-SIGN Act apply to the fullest extent permitted by law. We reserve the right, in our sole discretion, to discontinue providing you with electronic Communications, or to terminate or change the terms and conditions on which we provide electronic Communications. We will provide you with notice of any such termination or change as required by law. By consenting to this Section 7, you agree to the following statements: \r\n *To stop existing withholding orders by Social Security please call Customer Care.* By enrolling for automatic payments, I authorize my bank or financial institution to pay my monthly premium through automatic deductions from the account designated on this request; payable to my Medicare Part D Plan. The bank or financial institution will be fully protected in honoring these payments into subsequent plan years, until I provide notice to cancel this request. I understand that the charge or debit will be in an amount equal to my balance, up to $300 per month, to settle the current balance due. I understand that, once automatic payments go into effect, I will no longer receive a monthly invoice and my premium will be billed automatically to my preferred payment method between the 8th and the 10th of each month. I understand I will need to continue to pay my monthly premiums as long as I receive an invoice as it can take up to 3 days for my automatic payment option to take effect. \t\t \t\tWe are required by law, regulation or agreement to give you certain information “in writing”. With your consent, we can provide this information to you by Electronic Delivery instead. We also need your general consent to use electronic records and signatures in our relationship with you. You agree that for all Communications for Services we may use Electronic Delivery and, at our discretion, terminate paper delivery of Communications to you unless and until you withdraw your consent to this Section 7 as described in Section 7(f) below. This Section 7 applies to all Communications relating to such Services. “Communications” include, but are not limited to, the following: Except as otherwise provided in this Section 7, physical delivery of Communications is not available for these Services. We reserve the right, but assume no obligation, to provide paper copies of any Communication that you have authorized us to provide via Electronic Delivery. To withdraw your consent to receive Communications by Electronic Delivery, you must follow the instructions set forth in the section titled “How to Withdraw Consent” in Section 7(f) below. Sometimes you are required to provide us with a written notice by law or under our agreement with you. Those notices must be provided to us on paper unless we tell you how to deliver the notice to us electronically. All Communications (including alerts that Communications have been provided or posted) that we provide to you electronically will be provided by one or more of the following methods: Communications delivered by e-mail will be sent to your e-mail address reflected in our records. You represent that any e-mail address you provide to us for Electronic Delivery purposes belongs to you or to a person who has authority for Services. You should print, download or otherwise retain a copy of this Section 7 and all other Communications provided by Electronic Delivery. In order to access, view, print and retain electronic Communications, you must have: By “Current Version,” we mean a version of the software that is currently being supported by its publisher. From time to time, we may offer services or features that require that your internet browser be configured in a particular way, such as permitting the use of cookies. If we detect that your Internet browser is not properly configured, we may provide you with a notice and advice on how to update your configuration. We reserve the right to discontinue support of a Current Version of software or an operating system if, in our sole opinion, it suffers from a security flaw or other flaw that makes it unsuitable for use. If our hardware or software requirements change, and that change would create a material risk that you would not be able to access or retain electronic Communications, we will give you notice of the revised hardware or software requirements. Continuing to use the Services after receiving notice of the change is reaffirmation of your consent with respect to other Communications. We will not impose any fee to process the withdrawal of your consent to receive Communications by Electronic Delivery. However, if you withdraw consent, your access to and use of the Services or certain features of the Services will be terminated. Any withdrawal of your consent to receive Communications by Electronic Delivery will be effective only after we have a reasonable period of time to process your withdrawal. At our option, we may treat the provision of an invalid e-mail address, or the subsequent malfunction of a previously valid e-mail address, as a withdrawal of your consent to receive Communications by Electronic Delivery. You may withdraw your consent to receive Electronic Delivery of Communications by calling us at (866) 467-8263. For Communications scheduled for Electronic Delivery, you should not expect to receive a paper copy of any Communication unless you request it. You can obtain a paper copy of an electronic Communication by printing it yourself or by requesting that we mail you a paper copy, provided that such request is made within a reasonable time after we first provided the Communication to you by Electronic Delivery. We may charge you a reasonable service charge, with prior notice of any such charge, for the delivery of paper copies of any Communication provided to you electronically pursuant to this Section 7. To request paper copies of electronic Communications, call us at (866) 467-8263. You acknowledge and agree that your consent to this Section 7 is provided in connection with a transaction affecting interstate commerce, that it is subject to the federal Electronic Signatures in Global and National Commerce Act (the “E-SIGN Act”), and that you and we both intend that the E-SIGN Act apply to the fullest extent permitted by law. We reserve the right, in our sole discretion, to discontinue providing you with electronic Communications, or to terminate or change the terms and conditions on which we provide electronic Communications. We will provide you with notice of any such termination or change as required by law. By consenting to this Section 7, you agree to the following statements: Add Nickname
', 'Nickname', function (btn, value) { if(btn == 'ok') { setNickName(value)} },null,false,promptMessageValue,this); if (typeof(maxLength) == 'number') { var promptObj = window.message.getPrompt(); promptObj.setMaxLength(maxLength); promptObj.setInputAttribute('aria-label','Nickname'); promptObj.setInputAttribute('aria-required',true); } } }function setNickName(name) { if (!Ext.isEmpty(name)) { var accountType; var accountTypeCmp = InstaMed.get('AccountType'); if (accountTypeCmp) { accountType = accountTypeCmp.getValue(); } if (accountType == 'CreditCard') { var nickNameField = InstaMed.get('CardAccountNickName'); var nickNameLinkButton = Ext.getElementById('CardAccountNickNameLinkButton'); if (nickNameField) { nickNameField.setValue(name); nickNameLinkButton.textContent = name; nickNameLinkButton.setAttribute('aria-label','Edit '+name+' nickname'); } } else if (accountType == 'ECheck') { var nickNameField = InstaMed.get('CheckingAccountNickName'); var nickNameLinkButton = Ext.getElementById('CheckingAccountNickNameLinkButton'); if (nickNameField) { nickNameField.setValue(name); nickNameLinkButton.textContent = name; nickNameLinkButton.setAttribute('aria-label','Edit '+name+' nickname'); } } else { var nickNameField = InstaMed.get('BlindPaymentAccountNickName'); var nickNameLinkButton = Ext.getElementById('BlindPaymentAccountNickNameLinkButton'); if(nickNameField) { nickNameField.setValue(name); nickNameLinkButton.textContent = name; nickNameLinkButton.setAttribute('aria-label','Edit '+name+' nickname'); } } } } function setBlindPaymentNickName(value) { var nickNameLinkButton = Ext.getElementById('BlindPaymentAccountNickNameLinkButton'); if (nickNameLinkButton) { nickNameLinkButton.textContent = value; } } function apcVisibility(prefix, checkboxName){ var APcontrol = InstaMed.get('AutomaticPaymentContainer'); var APcheckbox = InstaMed.get('EnrollAutomaticPayment'); var APAuth = InstaMed.getValue('IsPatientAuthenticated'); var paymentMethodDisclaimer = InstaMed.get('prefixSavePaymentMethodDislaimer'); var whatIsAPC = document.getElementById('WhatIsAPC'); if(APcontrol !=null && APcheckbox!=null){ if(InstaMed.get(checkboxName)){ if(InstaMed.get(checkboxName).getChecked()) { if(APAuth == true) { APcontrol.show(); APcheckbox.enable(); APcontrol.removeCls('im-apc-container-disabled'); whatIsAPC && whatIsAPC.setAttribute('tabIndex','0'); APcheckbox.ariaEl.dom.tabIndex=0; } else { APcontrol.hide(); APcheckbox.setChecked && APcheckbox.setChecked(false); APcheckbox.setValue && APcheckbox.setValue(false); } if (paymentMethodDisclaimer) { paymentMethodDisclaimer.hide(); } } else { APcheckbox.disable(); APcontrol.addCls('im-apc-container-disabled'); whatIsAPC && whatIsAPC.setAttribute('tabIndex','-1'); APcheckbox.ariaEl.dom.tabIndex=-1; APcheckbox.setChecked && APcheckbox.setChecked(false); APcheckbox.setValue && APcheckbox.setValue(false); if (paymentMethodDisclaimer) { paymentMethodDisclaimer.show(); } } } } }function handleNickName(promptMessageValue) { var maxLength = 100; if (window.message) { var promptObj = window.message.getPrompt(); promptObj.setValue(promptMessageValue); window.message.show(); } else { Ext.Msg.setStandardButtons({ ok: { text: 'Ok', weight: Ext.platformTags.ios || Ext.platformTags.mac ? 120 : 10 }, abort: { text: 'Abort', weight: Ext.platformTags.ios || Ext.platformTags.mac ? 110 : 20 }, retry: { text: 'Retry', weight: Ext.platformTags.ios || Ext.platformTags.mac ? 100 : 30 }, ignore: { text: 'Ignore', weight: Ext.platformTags.ios || Ext.platformTags.mac ? 90 : 40 }, yes: { text: 'Yes', weight: Ext.platformTags.ios || Ext.platformTags.mac ? 80 : 50 }, no: { text: 'No', weight: Ext.platformTags.ios || Ext.platformTags.mac ? 70 : 60 }, cancel: { text: 'Cancel', weight: Ext.platformTags.ios || Ext.platformTags.mac ? 60 : 70 }, apply: { text: 'Apply', weight: Ext.platformTags.ios || Ext.platformTags.mac ? 50 : 80 }, save: { text: 'Save', weight: Ext.platformTags.ios || Ext.platformTags.mac ? 40 : 90 }, submit: { text: 'Submit', weight: Ext.platformTags.ios || Ext.platformTags.mac ? 30 : 100 }, help: { text: 'Help', weight: Ext.platformTags.ios || Ext.platformTags.mac ? 10 : 110 }, close: { text: 'Close', weight: Ext.platformTags.ios || Ext.platformTags.mac ? 20 : 120 }}); window.message = Ext.Msg.prompt('Add Nickname
', 'Nickname', function (btn, value) { if(btn == 'ok') { setNickName(value)} },null,false,promptMessageValue,this); if (typeof(maxLength) == 'number') { var promptObj = window.message.getPrompt(); promptObj.setMaxLength(maxLength); promptObj.setInputAttribute('aria-label','Nickname'); promptObj.setInputAttribute('aria-required',true); } } }function setNickName(name) { if (!Ext.isEmpty(name)) { var accountType; var accountTypeCmp = InstaMed.get('AccountType'); if (accountTypeCmp) { accountType = accountTypeCmp.getValue(); } if (accountType == 'CreditCard') { var nickNameField = InstaMed.get('CardAccountNickName'); var nickNameLinkButton = Ext.getElementById('CardAccountNickNameLinkButton'); if (nickNameField) { nickNameField.setValue(name); nickNameLinkButton.textContent = name; nickNameLinkButton.setAttribute('aria-label','Edit '+name+' nickname'); } } else if (accountType == 'ECheck') { var nickNameField = InstaMed.get('CheckingAccountNickName'); var nickNameLinkButton = Ext.getElementById('CheckingAccountNickNameLinkButton'); if (nickNameField) { nickNameField.setValue(name); nickNameLinkButton.textContent = name; nickNameLinkButton.setAttribute('aria-label','Edit '+name+' nickname'); } } else { var nickNameField = InstaMed.get('BlindPaymentAccountNickName'); var nickNameLinkButton = Ext.getElementById('BlindPaymentAccountNickNameLinkButton'); if(nickNameField) { nickNameField.setValue(name); nickNameLinkButton.textContent = name; nickNameLinkButton.setAttribute('aria-label','Edit '+name+' nickname'); } } } } function setBlindPaymentNickName(value) { var nickNameLinkButton = Ext.getElementById('BlindPaymentAccountNickNameLinkButton'); if (nickNameLinkButton) { nickNameLinkButton.textContent = value; } } function apcVisibility(prefix, checkboxName){ var APcontrol = InstaMed.get('AutomaticPaymentContainer'); var APcheckbox = InstaMed.get('EnrollAutomaticPayment'); var APAuth = InstaMed.getValue('IsPatientAuthenticated'); var paymentMethodDisclaimer = InstaMed.get('prefixSavePaymentMethodDislaimer'); var whatIsAPC = document.getElementById('WhatIsAPC'); if(APcontrol !=null && APcheckbox!=null){ if(InstaMed.get(checkboxName)){ if(InstaMed.get(checkboxName).getChecked()) { if(APAuth == true) { APcontrol.show(); APcheckbox.enable(); APcontrol.removeCls('im-apc-container-disabled'); whatIsAPC && whatIsAPC.setAttribute('tabIndex','0'); APcheckbox.ariaEl.dom.tabIndex=0; } else { APcontrol.hide(); APcheckbox.setChecked && APcheckbox.setChecked(false); APcheckbox.setValue && APcheckbox.setValue(false); } if (paymentMethodDisclaimer) { paymentMethodDisclaimer.hide(); } } else { APcheckbox.disable(); APcontrol.addCls('im-apc-container-disabled'); whatIsAPC && whatIsAPC.setAttribute('tabIndex','-1'); APcheckbox.ariaEl.dom.tabIndex=-1; APcheckbox.setChecked && APcheckbox.setChecked(false); APcheckbox.setValue && APcheckbox.setValue(false); if (paymentMethodDisclaimer) { paymentMethodDisclaimer.show(); } } } } } InstaMed.PopulatePaymentPlanPaymentsBreakdownDataViewComponentFromPaymentInformationReviewAndConfirmDataView = function(storeIndex){ var store = InstaMed.get("PaymentInformationReviewAndConfirmDataView").getStore(); var dataObj; if(storeIndex !== null){ dataObj = store.getAt(storeIndex-1); } else { if(store.queryRecords("IsSelected",true).length>0){ dataObj = store.queryRecords("IsSelected",true)[0]; }else{ dataObj = store.getAt(0); } } PerformAction({ Duration: dataObj.get("Duration"), EndDate: dataObj.get("EndDate"), Frequency: dataObj.get("Frequency"), InstallmentAmount: dataObj.get("InstallmentAmount"), IsRecommended: dataObj.get("IsRecommended"), IsSelected: dataObj.get("IsSelected"), StartDate: dataObj.get("StartDate"), TotalPlanAmount: dataObj.get("TotalPlanAmount").substr(1), InitialAmount: dataObj.get("InitialPayment").substr(1), }, PaymentOptionsController.getPaymentPlanPaymentsBreakdownWindowDetails ); };Ext.define('MyApp.view.NavigationView',{extend: 'InstaMed.navigation.View',alias: 'widget.mynavigationview',config: { name: 'NavigationView', useLogo: true, configInnerStates:[0], configActiveItem:0, configLastForm:[new Object()], mobilePrimaryActionButtonInTitleBar: false, mobileSecondaryActionButtonInTitleBar: false, navigationBar: false, items: [ {xtype: 'container', name: 'NavFindAndSearch', layout: {type: 'vbox', pack: 'start'}, showBackButton: true, scrollable: 'true', id: 'NavFindAndSearch', items: [ {xtype: 'container', docked: 'top', scrollable: null, id: 'NavFindAndSearch_container', items: [ {xtype: 'instamedNavigationBar', name: 'headerBar', layout: {type: 'hbox'}, hidden: false, cls: 'im-ignore-custom-colors im-ignore-background', scrollable: null, id: 'NavFindAndSearch_headerBar', items: [ {xtype: 'spacer', id: 'NavFindAndSearch_spacer', plugins: 'responsive', responsiveConfig: {'width > 1272':{flex : 1,},'width <= 1272':{flex :0,},} }, {xtype: 'titlebar', maxWidth: 1272, cls: 'largeTwelveColumn mediumTwelveColumn smallTwelveColumn xsmallTwelveColumn im-ignore-custom-colors im-ignore-background', scrollable: null, id: 'NavFindAndSearch_titlebar', plugins: 'responsive', responsiveConfig: {'width >= 1272':{title :'',},'width < 1272':{title : ' ',},}, items: [ {xtype: 'button', accessibleText: 'Back', iconCls: 'x-ma ma-arrow-back', align: 'left', name: 'TitleBarNavigationViewBack', margin: '', hidden: false, ariaRole: 'button', cls: 'x-button-icon-link-style white hiddenlg noprint', id: 'NavFindAndSearch_TitleBarNavigationViewBack', plugins: 'responsive', responsiveConfig: {'width > 1272':{iconCls :'',},'width <= 1272':{iconCls : 'x-ma ma-arrow-back',},}, listeners: {tap: function(){ headerPatientPortalBack(); }} }, {xtype: 'container', html: ' ', align: 'left', scrollable: null, id: 'NavFindAndSearch_container_1', plugins: 'responsive', responsiveConfig: {'width >= 1272':{hidden : false,},'width < 1272':{hidden :true,},} }, {xtype: 'button', name: 'HeaderTitlebarButton', ui: 'white', margin: '', hidden: true, ariaRole: 'button', cls: 'x-button-link-style im-center-header-button white noprint', id: 'NavFindAndSearch_HeaderTitlebarButton' }, {xtype: 'button', accessibleText: 'Log In or Sign Up', iconCls: 'x-ma ma-account-circle', align: 'right',menu:[{xtype: 'menuitem', text: 'Log In', handler: function() { PerformAction({}, PatientPortalLoginController.redirectToLogin,null); }, id: 'menuitem_LogIn'},{xtype: 'menuitem', text: 'Sign Up', handler: function() { PerformAction({}, SignUpController.redirectToSignUp,null); }, id: 'menuitem_SignUp'},], name: 'LoginOrSignUpProfileIcon', margin: '', ariaRole: 'button', cls: 'x-button-icon-link-style white noprint', id: 'NavFindAndSearch_button_LoginOrSignUpProfileIcon', plugins: 'responsive', responsiveConfig: {'!InstaMed.isLoggedIn & width > 960':{hidden: true,},'!InstaMed.isLoggedIn && width <= 960':{hidden: false,},}, listeners: {hiddenchange: function() { Ext.ComponentQuery.query('[name=LoginOrSignUpProfileIcon]')[0].getMenu().hide(); }} }, {xtype: 'button', text: '', align: 'right',menu:[{xtype: 'menuitem', text: 'Dashboard', handler: function(){ window.location.href='../../Form/PaymentPortal/Dashboard'; }, id: 'menuitem_Dashboard'},{xtype: 'menuitem', text: 'Help', handler: function() { window.open('https://help.instamed.com/patients/s/?dc_label=Patients')}, id: 'menuitem_Help'},{xtype: 'menuitem', text: 'Log Out', handler: function(){ window.location.href='../../Form/PaymentPortal/Logout?id=SILVERSCRIPT'; }, id: 'menuitem_LogOut'},], name: 'Profile', ui: 'white', margin: '', hidden: true, ariaRole: 'button', cls: 'x-button-link-style white noprint', id: 'NavFindAndSearch_button_Profile', plugins: 'responsive', responsiveConfig: {'InstaMed.isLoggedIn & width > 960':{hidden: false,},'InstaMed.isLoggedIn && width <= 960':{hidden: true,},}, listeners: {hiddenchange: function() { Ext.ComponentQuery.query('[name=Profile]')[0].getMenu().hide(); }} }, {xtype: 'container', align: 'right', name: 'LoginOrSignUpContainer', layout: {type: 'hbox'}, scrollable: null, id: 'NavFindAndSearch_LoginOrSignUpContainer', plugins: 'responsive', responsiveConfig: {'!InstaMed.isLoggedIn & width > 960':{hidden: false,},'!InstaMed.isLoggedIn && width <= 960':{hidden: true,},}, items: [ {xtype: 'button', text: 'Log In', align: 'right', name: 'LoginForDualLogin', ui: 'white', margin: '', hidden: false, ariaRole: 'button', cls: 'x-button-link-style hiddenxs hiddensm white noprint', id: 'NavFindAndSearch_button_LoginForDualLogin', listeners: {tap: function() { PerformAction({}, PatientPortalLoginController.redirectToLogin,null); }} }, {xtype: 'label', html: 'or', align: 'right', name: 'Or', ui: 'body1-white', cls: 'hiddenxs hiddensm body1-white', id: 'NavFindAndSearch_Or' }, {xtype: 'button', text: 'Sign Up', align: 'right', name: 'SignUpForDualLogin', ui: 'white', margin: '', ariaRole: 'button', cls: 'x-button-link-style hiddenxs hiddensm white noprint', id: 'NavFindAndSearch_button_SignUpForDualLogin', listeners: {tap: function() { PerformAction({}, SignUpController.redirectToSignUp,null); }} }] }, {xtype: 'button', accessibleText: 'Profile', iconCls: 'x-ma ma-account-circle', align: 'right',menu:[{xtype: 'menuitem', text: 'Dashboard', handler: function(){ window.location.href='../../Form/PaymentPortal/Dashboard'; }, id: 'menuitem_Dashboard_1'},{xtype: 'menuitem', text: 'Help', handler: function() { window.open('https://help.instamed.com/patients/s/?dc_label=Patients')}, id: 'menuitem_Help_1'},{xtype: 'menuitem', text: 'Log Out', handler: function(){ window.location.href='../../Form/PaymentPortal/Logout?id=SILVERSCRIPT'; }, id: 'menuitem_LogOut_1'},], name: 'ProfileIcon', margin: '', hidden: true, ariaRole: 'button', cls: 'x-button-icon-link-style white noprint', id: 'NavFindAndSearch_button_ProfileIcon', plugins: 'responsive', responsiveConfig: {'InstaMed.isLoggedIn & width > 960':{hidden: true,},'InstaMed.isLoggedIn && width <= 960':{hidden: false,},}, listeners: {hiddenchange: function() { Ext.ComponentQuery.query('[name=ProfileIcon]')[0].getMenu().hide(); }} }] }, {xtype: 'spacer', id: 'NavFindAndSearch_spacer_1', plugins: 'responsive', responsiveConfig: {'width > 1272':{flex : 1,},'width <= 1272':{flex :0,},} }] }] }, {xtype: 'container', layout: {type: 'hbox'}, cls: 'x-subheader-container', scrollable: null, id: 'NavFindAndSearch_container_2', items: [ {xtype: 'spacer', id: 'NavFindAndSearch_spacer_2', plugins: 'responsive', responsiveConfig: {'width > 1272':{flex : 1,},'width <= 1272':{flex :0,},} }, {xtype: 'container', maxWidth: 1272, layout: {type: 'hbox'}, cls: 'largeTwelveColumn mediumTwelveColumn smallTwelveColumn xsmallTwelveColumn x-subheader-panel ', scrollable: null, id: 'NavFindAndSearch_container_3', items: [ {xtype: 'image', src: '../../Forms/UtilForm/ContentHandler.aspx?URL=/Images/Database/D2D175C9-9D00-4559-A5AC-EB794B2023E3&id=SILVERSCRIPT&crop=true&maxWidth=150&maxHeight=64', hidden: true, cls: 'x-clickable x-button-provider-img', id: 'NavFindAndSearch_image', listeners: {painted: function() { var cmp = this; cmp.el.dom.setAttribute('aria-label', 'Aetna Medicare Prescription Drug Plan logo'); cmp.el.dom.setAttribute('role', 'img'); cmp.el.dom.setAttribute('title', ''); },tap: function(){ window.location.href='../../Form/PaymentPortal/Default?id=SILVERSCRIPT'; }} }, {xtype: 'container', layout: {type: 'vbox', pack: 'center', align: 'left'}, cls: 'im-provider-header-buttons', scrollable: null, id: 'NavFindAndSearch_container_4', items: [ {xtype: 'label', html: 'Aetna Medicare Prescription Drug Plan', name: 'SubheaderProviderName', ui: 'subheading-primary', cls: 'initial-caps font-400 im-bold-button subheading-primary', id: 'NavFindAndSearch_SubheaderProviderName' }, {xtype: 'container', layout: {type: 'hbox'}, scrollable: null, id: 'NavFindAndSearch_container_5', items: [ {xtype: 'container', html: '', hidden: true, cls: 'im-address-verification-icon', scrollable: null, id: 'NavFindAndSearch_container_6' }, {xtype: 'label', html: 'P.O. Box 504849, St Louis, MO 63150-4849', ui: 'body1-secondary', cls: 'line-height-20 body1-secondary', id: 'NavFindAndSearch_label' }] }, {xtype: 'container', layout: {type: 'hbox'}, hidden: false, scrollable: null, id: 'NavFindAndSearch_container_7', items: [ {xtype: 'label', html: '(855) 651-4856', ui: 'body1-primary', cls: 'body1-primary', id: 'NavFindAndSearch_label_1' }] }] }] }, {xtype: 'spacer', id: 'NavFindAndSearch_spacer_3', plugins: 'responsive', responsiveConfig: {'width > 1272':{flex : 1,},'width <= 1272':{flex :0,},} }] }, { xtype: 'panel', dock: 'top', frame: false, scrollable: 'true', id: 'panel', items: [ {xtype: 'container', maxWidth: 1272, layout: {type: 'hbox'}, cls: 'mainContent MainContentWithHeaerAndSubheader ', scrollable: null, id: 'container_1', items: [ {xtype: 'container', flex: 1, scrollable: null, id: 'container_2', items: [ { xtype: 'form', preventHeader: true, bodyCls: 'mypanel', api: { }, defaultSubmitButton: 'PayNow', name: 'formSearchPayment', itemId: 'formSearchPayment', cls: 'col-large-offSet-3 col-medium-offSet-3 col-small-offSet-1 smallTenColumn xsmallTwelveColumn mediumSixColumn largeSixColumn ', scrollable: null, id: 'formSearchPayment', items: [ {xtype: 'errorbox', name: 'ValidationSummary', ui: 'ErrorBox', hidden: true, cls: 'ErrorBox', id: 'ValidationSummary' }, {xtype: 'instamedHeading1', text: 'Make a Payment', id: 'formSearchPayment_instamedHeading1' }, {xtype: 'combobox', queryMode: 'local', triggerAction: 'all', typeAheadDelay: 300, itemId: 'Patient', displayField: 'description', store: Ext.create('Ext.data.ArrayStore',{ type: 'json', autoDestroy: false, storeId: 'PatientStore5', fields: [ { name: 'code', type: 'string' }, { name: 'description', type: 'string' } ], data: [['AB8FE4DC-3341-418D-AD03-A9A149595F4A', 'Add New'] ]}), valueField: 'code', forceSelection: true, picker: 'floated', clearable: true, editable: true, selectOnFocus: true, itemTpl: '{description}', displayTpl: '{description}', autoExpandOnFocus: true, validateOnBlank: false,listConfig: { id: 'formSearchPayment_Patient-boundlist', resizable: false }, fieldLabel: 'Select Member', label: 'Select Member', hidden: true, labelSeparator: ' ', placeholder: 'Select One', value: 'AB8FE4DC-3341-418D-AD03-A9A149595F4A', required: false, labelWrap: true, labelAlign: 'placeholder', errorTarget: 'under', clearable: false, requiredMessage: 'Select Member is required', autoComplete: 'off', name: 'Patient', margin: '', ariaRole: 'combobox', cls: 'x-trigger-field', id: 'formSearchPayment_Patient', listeners: {focus: function (cmp) { Ext.Function.defer(function (cmp) { if (!cmp.expanded && !cmp.readOnly && !cmp.isDisabled() && cmp.hasFocus) { cmp.onExpandTap(); } }, 250, this, [cmp]);},blur: function(cmp){if(cmp.validate){cmp.validate();}},select: function(cmp, newValue, oldValue, eOpts) {if (cmp.isRendered()) {myForm = InstaMed.findParentForm(cmp);PerformAction(myForm.getValues(),QuickPayOptimizedProviderLandingController.onPatientChange,cmp);}}} }, {xtype: 'container', name: 'PatientMatchFieldsContainer', scrollable: null, id: 'formSearchPayment_PatientMatchFieldsContainer', items: [ {xtype: 'textfield', allowBlank: false, allowOnlyWhitespace: false, maxLength: 200, maxLength: 200, enforceMaxLength: true, minLength: 1, selectOnFocus: true, autoCorrect: false, fieldLabel: 'Email', label: 'Email', component: {"type":"email","pattern":null}, inputType: 'email', hidden: false, labelSeparator: ' ', required: true, labelWrap: true, labelAlign: 'placeholder', errorTarget: 'under', clearable: false, requiredMessage: 'Email is required', autoComplete: 'on', name: 'EmailAddress', margin: '', id: 'formSearchPayment_EmailAddress', listeners: {action: submitOnEnter,blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'textfield', allowBlank: false, allowOnlyWhitespace: false, maxLength: 80, maxLength: 80, enforceMaxLength: true, minLength: 1, selectOnFocus: true, autoCorrect: false, fieldLabel: 'Payment ID', label: 'Payment ID', hidden: false, labelSeparator: ' ', required: true, labelWrap: true, labelAlign: 'placeholder', errorTarget: 'under', clearable: false, requiredMessage: 'Payment ID is required', autoComplete: 'on', name: 'QuickPayComboID', margin: '', dynamicToolTipText: 'Member\'s 9-digit Payment ID on Premium Coupon', id: 'formSearchPayment_QuickPayComboID', tooltip: {html:"Member\'s 9-digit Payment ID on Premium Coupon", trackMouse:"True"}, listeners: {action: submitOnEnter,blur: function() { var listenerArgs = arguments; Ext.Array.each([function(cmp){if(cmp.validate){cmp.validate();}},function() { PerformAction({QuickPayCode:InstaMed.get('QuickPayComboID').getValue(),ProviderAlias:InstaMed.get('ProviderAlias').getValue()}, QuickPayOptimizedProviderLandingController.checkQuickPayCode,null); }], function(func) { func.apply(this, listenerArgs); }); },change: function(cmp){ var value = cmp.getValue(); var queryLength = [7,8,9]; if(queryLength.indexOf(value.length)!=-1){ PerformAction({QuickPayCode:InstaMed.get('QuickPayComboID').getValue(),ProviderAlias:InstaMed.get('ProviderAlias').getValue()}, QuickPayOptimizedProviderLandingController.checkQuickPayCode,this,null,null,true,null,null,true); } }} }, {xtype: 'textfield', maxLength: 80, maxLength: 80, enforceMaxLength: true, minLength: 1, selectOnFocus: true, autoCorrect: false, fieldLabel: 'Medical Record Number', label: 'Medical Record Number', hidden: true, labelSeparator: ' ', required: false, labelWrap: true, labelAlign: 'placeholder', errorTarget: 'under', clearable: false, requiredMessage: 'Medical Record Number is required', autoComplete: 'on', name: 'PatientMedicalRecordNumber', margin: '', id: 'formSearchPayment_PatientMedicalRecordNumber', listeners: {action: submitOnEnter,blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'textfield', maxLength: 80, maxLength: 80, enforceMaxLength: true, minLength: 1, selectOnFocus: true, autoCorrect: false, fieldLabel: 'Parent Account ID', label: 'Parent Account ID', hidden: true, labelSeparator: ' ', required: false, labelWrap: true, labelAlign: 'placeholder', errorTarget: 'under', clearable: false, requiredMessage: 'Parent Account ID is required', autoComplete: 'on', name: 'GuarantorID', margin: '', id: 'formSearchPayment_GuarantorID', listeners: {action: submitOnEnter,blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'textfield', maxLength: 35, maxLength: 35, enforceMaxLength: true, minLength: 1, selectOnFocus: true, autoCorrect: false, fieldLabel: 'Parent Account First Name', label: 'Parent Account First Name', hidden: true, labelSeparator: ' ', required: false, labelWrap: true, labelAlign: 'placeholder', errorTarget: 'under', clearable: false, requiredMessage: 'Parent Account First Name is required', autoComplete: 'on', name: 'GuarantorFirstName', margin: '', id: 'formSearchPayment_GuarantorFirstName', listeners: {action: submitOnEnter,blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'textfield', maxLength: 60, maxLength: 60, enforceMaxLength: true, minLength: 1, selectOnFocus: true, autoCorrect: false, fieldLabel: 'Parent Account Last Name', label: 'Parent Account Last Name', hidden: true, labelSeparator: ' ', required: false, labelWrap: true, labelAlign: 'placeholder', errorTarget: 'under', clearable: false, requiredMessage: 'Parent Account Last Name is required', autoComplete: 'on', name: 'GuarantorLastName', margin: '', id: 'formSearchPayment_GuarantorLastName', listeners: {action: submitOnEnter,blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'textfield', maxLength: 35, maxLength: 35, enforceMaxLength: true, minLength: 1, selectOnFocus: true, autoCorrect: false, fieldLabel: 'First Name', label: 'First Name', hidden: true, labelSeparator: ' ', required: false, labelWrap: true, labelAlign: 'placeholder', errorTarget: 'under', clearable: false, requiredMessage: 'First Name is required', autoComplete: 'on', name: 'PatientFirstName', margin: '', id: 'formSearchPayment_PatientFirstName', listeners: {action: submitOnEnter,blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'textfield', maxLength: 60, maxLength: 60, enforceMaxLength: true, minLength: 1, selectOnFocus: true, autoCorrect: false, fieldLabel: 'Last Name', label: 'Last Name', hidden: true, labelSeparator: ' ', required: false, labelWrap: true, labelAlign: 'placeholder', errorTarget: 'under', clearable: false, requiredMessage: 'Last Name is required', autoComplete: 'on', name: 'PatientLastName', margin: '', id: 'formSearchPayment_PatientLastName', listeners: {action: submitOnEnter,blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'textfield', maxLength: 25, maxLength: 25, enforceMaxLength: true, minLength: 1, selectOnFocus: true, autoCorrect: false, fieldLabel: 'Middle', label: 'Middle', hidden: true, labelSeparator: ' ', required: false, labelWrap: true, labelAlign: 'placeholder', errorTarget: 'under', clearable: false, requiredMessage: 'Middle is required', autoComplete: 'on', name: 'PatientMiddleName', margin: '', id: 'formSearchPayment_PatientMiddleName', listeners: {action: submitOnEnter,blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'datepickerfield', picker: { cancelButton: false, toolbar : { items : [ { text : 'Clear', align : 'left', handler : function(btn) { var picker = btn.up('datepicker'); picker.fireEvent('change', picker, null); picker.setValue(picker.config.value); picker.hide(); } } ] } , value: new Date(), yearFrom: 1900, yearTo: 2030 }, floatedPicker: { xtype: 'datepanel', minDate: new Date('1/1/1900 12:00:00 AM'), maxDate: new Date('12/31/2030 12:00:00 AM'), yearPicker: { start: 1900, end: 2030, } }, minDate: new Date('1/1/1900 12:00:00 AM'), maxDate: new Date('12/31/2030 12:00:00 AM'), submitFormat: 'm/d/Y', showToday: true, badFormatMessage: 'Date of Birth format is MM/DD/YYYY', validateOnBlank: true, fieldLabel: 'Date of Birth', label: 'Date of Birth', hidden: false, labelSeparator: ' ', placeholder: 'MM/DD/YYYY', required: true, labelWrap: true, labelAlign: 'placeholder', errorTarget: 'under', clearable: false, requiredMessage: 'Date of Birth is required', autoComplete: 'on', name: 'PatientBirthDate', margin: '', dynamicToolTipText: 'Member\'s date of birth (MM/DD/YYYY).', id: 'formSearchPayment_PatientBirthDate', tooltip: {html:"Member\'s date of birth (MM/DD/YYYY).", trackMouse:"True"}, listeners: {blur: function() { var listenerArgs = arguments; Ext.Array.each([function(cmp){ var value = cmp.getValue(); if(value && typeof value == 'string') { value = new Date(value); } cmp.setValue(value); if(InstaMed.isResponsive){ cmp.setInputValue(value); } },function(cmp){if(cmp.validate){cmp.validate();}}], function(func) { func.apply(this, listenerArgs); }); }} }, {xtype: 'textfield', maxLength: 14, maxLength: 14, enforceMaxLength: true, minLength: 10, selectOnFocus: true, autoCorrect: false, fieldLabel: 'Phone Number', label: 'Phone Number', component: {"type":"tel","pattern":null}, inputType: 'tel', hidden: true, labelSeparator: ' ', placeholder: '(215) 555-5555', required: false, labelWrap: true, labelAlign: 'placeholder', errorTarget: 'under', clearable: false, requiredMessage: 'Phone Number is required', autoComplete: 'on', name: 'PatientPhoneNumber', margin: '', id: 'formSearchPayment_PatientPhoneNumber', listeners: {action: submitOnEnter,blur: function(cmp){if(cmp.validate){cmp.validate();}},change: function(field, event, opts ){ var s = new String(field.getValue()); if(s != null && s != '') { s = s.replace(/[-,()\s]/g,'');var newValue='(';newValue+=s.substring(0,3);if(s.length>3){newValue+=') ';}newValue+=s.substring(3,6);if(s.length>6){newValue+='-';}newValue+=s.substring(6,10); if(isNaN(parseInt(newValue.substring(1,3)))){ newValue = ''; } field.setValue(newValue); if(InstaMed.isResponsive){ field.setInputValue(newValue); } } }} }, {xtype: 'textfield', allowBlank: false, allowOnlyWhitespace: false, maxLength: 10, maxLength: 10, enforceMaxLength: true, minLength: 3, selectOnFocus: true, autoCorrect: false, fieldLabel: 'ZIP Code', label: 'ZIP Code', hidden: false, labelSeparator: ' ', required: true, labelWrap: true, labelAlign: 'placeholder', errorTarget: 'under', clearable: false, requiredMessage: 'ZIP Code is required', autoComplete: 'on', name: 'PatientZip', margin: '', dynamicToolTipText: '5 digit postal code of the mailing address.', id: 'formSearchPayment_PatientZip', tooltip: {html:"5 digit postal code of the mailing address.", trackMouse:"True"}, listeners: {action: submitOnEnter,blur: function(cmp){if(cmp.validate){cmp.validate();}},change: function(field, event, opts ){ var s = new String(field.getValue()); if(s != null && s != '') { s = s.replace(/[^0-9]/g,'');if(s.length>5){s = [s.slice(0,5),'-',s.slice(5,9)].join('');}field.setValue(s); if(InstaMed.isResponsive){ field.setInputValue(s); } } }} }, {xtype: 'textfield', maxLength: 100, maxLength: 100, enforceMaxLength: true, minLength: 0, selectOnFocus: true, autoCorrect: false, fieldLabel: 'Statement Number', label: 'Statement Number', hidden: true, labelSeparator: ' ', required: false, labelWrap: true, labelAlign: 'placeholder', errorTarget: 'under', clearable: false, requiredMessage: 'Statement Number is required', autoComplete: 'off', name: 'StatementNumber', margin: '', id: 'formSearchPayment_StatementNumber', listeners: {action: submitOnEnter,blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'datepickerfield', picker: { cancelButton: false, toolbar : { items : [ { text : 'Clear', align : 'left', handler : function(btn) { var picker = btn.up('datepicker'); picker.fireEvent('change', picker, null); picker.setValue(picker.config.value); picker.hide(); } } ] } , value: new Date(), yearFrom: 1900, yearTo: 2030 }, floatedPicker: { xtype: 'datepanel', minDate: new Date('1/1/1900 12:00:00 AM'), maxDate: new Date('12/31/2030 12:00:00 AM'), yearPicker: { start: 1900, end: 2030, } }, minDate: new Date('1/1/1900 12:00:00 AM'), maxDate: new Date('12/31/2030 12:00:00 AM'), submitFormat: 'm/d/Y', showToday: true, badFormatMessage: 'Statement Date format is MM/DD/YYYY', validateOnBlank: false, fieldLabel: 'Statement Date', label: 'Statement Date', hidden: true, labelSeparator: ' ', placeholder: 'MM/DD/YYYY', required: false, labelWrap: true, labelAlign: 'placeholder', errorTarget: 'under', clearable: false, requiredMessage: 'Statement Date is required', autoComplete: 'off', name: 'StatementDate', margin: '', id: 'formSearchPayment_StatementDate', listeners: {blur: function() { var listenerArgs = arguments; Ext.Array.each([function(cmp){ var value = cmp.getValue(); if(value && typeof value == 'string') { value = new Date(value); } cmp.setValue(value); if(InstaMed.isResponsive){ cmp.setInputValue(value); } },function(cmp){if(cmp.validate){cmp.validate();}}], function(func) { func.apply(this, listenerArgs); }); }} }, {xtype: 'amountfield', regex: /^[\$]?\d{1,3}(\,?\d{3,3})*(\.(\d|\d\d))?$/i, regexText: 'Please enter a valid dollar amount.', maxLength: 12, maxLength: 12, enforceMaxLength: true, minLength: 0, selectOnFocus: true, autoCorrect: false, maskRe: /[\$\d\.\,]/i, fieldLabel: 'Amount Due', label: 'Amount Due', hidden: true, labelSeparator: ' ', required: false, labelWrap: true, labelAlign: 'placeholder', errorTarget: 'under', clearable: false, requiredMessage: 'Amount Due is required', autoComplete: 'off', name: 'AmountDue', margin: '', id: 'formSearchPayment_AmountDue', listeners: {action: submitOnEnter,blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'textfield', maxLength: 100, maxLength: 100, enforceMaxLength: true, minLength: 0, selectOnFocus: true, autoCorrect: false, fieldLabel: 'Dynamic Field 1', label: 'Dynamic Field 1', hidden: true, labelSeparator: ' ', required: false, labelWrap: true, labelAlign: 'placeholder', errorTarget: 'under', clearable: false, requiredMessage: 'Dynamic Field 1 is required', autoComplete: 'off', name: 'DynamicField1', margin: '', id: 'formSearchPayment_DynamicField1', listeners: {action: submitOnEnter,blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'textfield', maxLength: 100, maxLength: 100, enforceMaxLength: true, minLength: 0, selectOnFocus: true, autoCorrect: false, fieldLabel: 'Dynamic Field 2', label: 'Dynamic Field 2', hidden: true, labelSeparator: ' ', required: false, labelWrap: true, labelAlign: 'placeholder', errorTarget: 'under', clearable: false, requiredMessage: 'Dynamic Field 2 is required', autoComplete: 'off', name: 'DynamicField2', margin: '', id: 'formSearchPayment_DynamicField2', listeners: {action: submitOnEnter,blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'textfield', maxLength: 100, maxLength: 100, enforceMaxLength: true, minLength: 0, selectOnFocus: true, autoCorrect: false, fieldLabel: 'Dynamic Field 3', label: 'Dynamic Field 3', hidden: true, labelSeparator: ' ', required: false, labelWrap: true, labelAlign: 'placeholder', errorTarget: 'under', clearable: false, requiredMessage: 'Dynamic Field 3 is required', autoComplete: 'off', name: 'DynamicField3', margin: '', id: 'formSearchPayment_DynamicField3', listeners: {action: submitOnEnter,blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'textfield', maxLength: 80, maxLength: 80, enforceMaxLength: true, minLength: 1, selectOnFocus: true, autoCorrect: false, fieldLabel: 'Dynamic Field 4', label: 'Dynamic Field 4', hidden: true, labelSeparator: ' ', required: false, labelWrap: true, labelAlign: 'placeholder', errorTarget: 'under', clearable: false, requiredMessage: 'Dynamic Field 4 is required', autoComplete: 'off', name: 'DynamicField4', margin: '', id: 'formSearchPayment_DynamicField4', listeners: {action: submitOnEnter,blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'hiddenfield', fieldLabel: 'ProviderAlias', label: 'ProviderAlias', labelSeparator: ' ', required: false, labelWrap: true, errorTarget: 'under', clearable: false, requiredMessage: 'ProviderAlias is required', autoComplete: 'on', name: 'ProviderAlias', margin: '', id: 'formSearchPayment_ProviderAlias', listeners: {blur: function(cmp){if(cmp.validate){cmp.validate();}}} }] }, {xtype: 'hiddenfield', fieldLabel: 'QuickPayFlowFromPaymentPage', label: 'QuickPayFlowFromPaymentPage', labelSeparator: ' ', value: true, required: false, labelWrap: true, errorTarget: 'under', clearable: false, requiredMessage: 'QuickPayFlowFromPaymentPage is required', autoComplete: 'on', name: 'QuickPayFlowFromPaymentPage', margin: '', id: 'formSearchPayment_QuickPayFlowFromPaymentPage', listeners: {blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'container', margin: '16 0 16 0', scrollable: null, id: 'formSearchPayment_container', items: [ {xtype: 'button', text: 'Pay Now', name: 'PayNow', ui: 'wide', margin: '', hidden: true, ariaRole: 'button', cls: 'x-button-action wide noprint', id: 'formSearchPayment_button_PayNow', listeners: {tap: function(cmp, newValue, oldValue, eOpts) { myForm = InstaMed.findParentForm(cmp); PerformAction(myForm.getValues(),QuickPayOptimizedProviderLandingController.payNow,cmp,undefined,undefined,undefined,undefined,undefined); }} }] }, {xtype: 'container', layout: {type: 'hbox', pack: 'start', align: 'bottom'}, cls: 'buttonContainer', scrollable: null, id: 'formSearchPayment_container_1', items: [ {xtype: 'spacer', id: 'formSearchPayment_spacer' }, {xtype: 'button', text: 'Next', ui: 'action', margin: '', ariaRole: 'button', cls: 'action noprint', id: 'formSearchPayment_button_Next', listeners: {tap: function(cmp, newValue, oldValue, eOpts) { myForm = InstaMed.findParentForm(cmp); PerformAction(myForm.getValues(),QuickPayOptimizedProviderLandingController.payNow,cmp,undefined,undefined,undefined,undefined,undefined); }} }] }] }] }] }] }, {xtype: 'spacer', flex: 1, id: 'spacer' }, {xtype: 'container', layout: {type: 'hbox'}, hidden: false, cls: 'x-panel-footer im-powered-by', scrollable: null, id: 'container_3', items: [ {xtype: 'spacer', id: 'spacer_1' }, {xtype: 'container', maxWidth: 1272, layout: {type: 'hbox'}, cls: 'largeTwelveColumn mediumTwelveColumn ', scrollable: null, id: 'NavFindAndSearch_container_8', items: [ {xtype: 'container', html: '', name: 'poweredbylogo', cls: 'hiddenxs hiddensm', scrollable: null, id: 'NavFindAndSearch_poweredbylogo' }, {xtype: 'container', cls: 'copyrightContainer hiddenxs hiddensm', scrollable: null, id: 'NavFindAndSearch_container_9', items: [ {xtype: 'spacer', cls: 'hiddenmd hiddenlg', id: 'NavFindAndSearch_spacer_4' }, {xtype: 'label', html: '© 2024 InstaMed. All Rights Reserved.', name: 'copyrightFooter', ui: 'body1-primary', cls: 'margin-bottom-10 body1-primary', id: 'NavFindAndSearch_copyrightFooter' }, {xtype: 'spacer', cls: 'hiddenmd hiddenlg', id: 'NavFindAndSearch_spacer_5' }] }, {xtype: 'spacer', cls: 'hiddenxs hiddensm', id: 'NavFindAndSearch_spacer_6' }, {xtype: 'container', cls: 'linkButtonContainer hiddenxs hiddensm', scrollable: null, id: 'NavFindAndSearch_container_10', items: [ {xtype: 'button', text: 'Security', iconCls: 'x-ma ma-lock-outline', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavFindAndSearch_button_Security', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/security/','open-window');}} }, {xtype: 'button', text: 'Privacy', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavFindAndSearch_button_Privacy', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/privacy-statement/','open-window');}} }, {xtype: 'button', text: 'Terms', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavFindAndSearch_button_Terms', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/terms-of-use/','open-window');}} }, {xtype: 'button', text: 'Help', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavFindAndSearch_button_Help', listeners: {tap: function() { InstaMed.popupNewWindow('../../Form/PaymentPortal/ContactUs?id=SILVERSCRIPT','open-window');}} }, {xtype: 'button', text: 'English', align: 'right',menu:[{xtype: 'menuitem', text: 'English', handler: function(cmp) { PerformAction({Language:'en'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'en', cls: 'hiddenxs hiddensm', id: 'menuitem_en'},{xtype: 'menuitem', text: 'Español', handler: function(cmp) { PerformAction({Language:'es'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'es', cls: 'hiddenxs hiddensm', id: 'menuitem_es'},{xtype: 'menuitem', text: 'Français', handler: function(cmp) { PerformAction({Language:'fr'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'fr', cls: 'hiddenxs hiddensm', id: 'menuitem_fr'},], name: 'ForeignLanguages', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavFindAndSearch_button_ForeignLanguages' }] }, {xtype: 'container', cls: 'hiddenmd hiddenlg', scrollable: null, id: 'NavFindAndSearch_container_11', items: [ {xtype: 'container', layout: {type: 'hbox', pack: 'center'}, cls: 'x-center-helper', scrollable: null, id: 'NavFindAndSearch_container_12', items: [ {xtype: 'spacer', id: 'NavFindAndSearch_spacer_7' }, {xtype: 'container', html: '
', name: 'poweredbylogo', scrollable: null, id: 'NavFindAndSearch_poweredbylogo_1' }, {xtype: 'spacer', id: 'NavFindAndSearch_spacer_8' }] }, {xtype: 'container', layout: {type: 'hbox', pack: 'center'}, cls: 'x-center-helper', scrollable: null, id: 'NavFindAndSearch_container_13', items: [ {xtype: 'spacer', id: 'NavFindAndSearch_spacer_9' }, {xtype: 'container', cls: 'copyrightContainer', scrollable: null, id: 'NavFindAndSearch_container_14', items: [ {xtype: 'spacer', cls: 'hiddenmd hiddenlg', id: 'NavFindAndSearch_spacer_10' }, {xtype: 'label', html: '© 2024 InstaMed. All Rights Reserved.', name: 'copyrightFooter', ui: 'body1-primary', cls: 'margin-bottom-10 body1-primary', id: 'NavFindAndSearch_copyrightFooter_1' }, {xtype: 'spacer', cls: 'hiddenmd hiddenlg', id: 'NavFindAndSearch_spacer_11' }] }, {xtype: 'spacer', id: 'NavFindAndSearch_spacer_12' }] }, {xtype: 'container', layout: {type: 'hbox', pack: 'center'}, cls: 'x-center-helper', scrollable: null, id: 'NavFindAndSearch_container_15', items: [ {xtype: 'spacer', id: 'NavFindAndSearch_spacer_13' }, {xtype: 'container', cls: 'linkButtonContainer ', scrollable: null, id: 'NavFindAndSearch_container_16', items: [ {xtype: 'button', text: 'Security', iconCls: 'x-ma ma-lock-outline', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavFindAndSearch_button_Security_1', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/security/','open-window');}} }, {xtype: 'button', text: 'Privacy', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavFindAndSearch_button_Privacy_1', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/privacy-statement/','open-window');}} }, {xtype: 'button', text: 'Terms', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavFindAndSearch_button_Terms_1', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/terms-of-use/','open-window');}} }, {xtype: 'button', text: 'Help', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavFindAndSearch_button_Help_1', listeners: {tap: function() { InstaMed.popupNewWindow('../../Form/PaymentPortal/ContactUs?id=SILVERSCRIPT','open-window');}} }] }, {xtype: 'spacer', id: 'NavFindAndSearch_spacer_14' }] }, {xtype: 'container', layout: {type: 'hbox', pack: 'center'}, cls: 'x-center-helper', scrollable: null, id: 'NavFindAndSearch_container_17', items: [ {xtype: 'spacer', id: 'NavFindAndSearch_spacer_15' }, {xtype: 'container', scrollable: null, id: 'NavFindAndSearch_container_18', items: [ {xtype: 'button', text: 'English', align: 'right',menu:[{xtype: 'menuitem', text: 'English', handler: function(cmp) { PerformAction({Language:'en'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'en', cls: 'hiddenmd hiddenlg', id: 'menuitem_en_1'},{xtype: 'menuitem', text: 'Español', handler: function(cmp) { PerformAction({Language:'es'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'es', cls: 'hiddenmd hiddenlg', id: 'menuitem_es_1'},{xtype: 'menuitem', text: 'Français', handler: function(cmp) { PerformAction({Language:'fr'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'fr', cls: 'hiddenmd hiddenlg', id: 'menuitem_fr_1'},], name: 'ForeignLanguages', ui: 'grey', margin: '', hidden: false, ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavFindAndSearch_button_ForeignLanguages_1' }] }, {xtype: 'spacer', id: 'NavFindAndSearch_spacer_16' }] }] }] }, {xtype: 'spacer', id: 'spacer_2' }] }] }, {xtype: 'container', name: 'NavQuickPayPatientEntry', layout: {type: 'vbox', pack: 'start'}, showBackButton: false, showMenuButton: false, scrollable: 'true', id: 'NavQuickPayPatientEntry', items: [ {xtype: 'container', docked: 'top', scrollable: null, id: 'NavQuickPayPatientEntry_container', items: [ {xtype: 'instamedNavigationBar', name: 'headerBar', layout: {type: 'hbox'}, hidden: false, cls: 'im-ignore-custom-colors im-ignore-background', scrollable: null, id: 'NavQuickPayPatientEntry_headerBar', items: [ {xtype: 'spacer', id: 'NavQuickPayPatientEntry_spacer', plugins: 'responsive', responsiveConfig: {'width > 1272':{flex : 1,},'width <= 1272':{flex :0,},} }, {xtype: 'titlebar', title: '<a href=\\"../../Form/PaymentPortal/Start\\"> <img src=\\"../../ContentHandler.aspx?URL=/Images/Database/cvscaremark@instamed.net/WolkenJ@cvscaremark/cvscaremark@instamed.net000013897108-001-002HeaderLogo/638482659224849466&id=SILVERSCRIPT\\" alt=\\"Company Logo\\" style=\\"height: 40px\\">', maxWidth: 1272, cls: 'largeTwelveColumn mediumTwelveColumn smallTwelveColumn xsmallTwelveColumn im-ignore-custom-colors im-ignore-background', scrollable: null, id: 'NavQuickPayPatientEntry_titlebar', plugins: 'responsive', responsiveConfig: {'width >= 1272':{title :'',},'width < 1272':{title : ' ',},}, items: [ {xtype: 'button', accessibleText: 'Back', iconCls: 'x-ma ma-arrow-back', align: 'left', name: 'TitleBarNavigationViewBack', margin: '', hidden: false, ariaRole: 'button', cls: 'x-button-icon-link-style white hiddenlg noprint', id: 'NavQuickPayPatientEntry_TitleBarNavigationViewBack', plugins: 'responsive', responsiveConfig: {'width > 1272':{iconCls :'',},'width <= 1272':{iconCls : 'x-ma ma-arrow-back',},}, listeners: {tap: function(){ headerPatientPortalBack(); }} }, {xtype: 'container', html: ' ', align: 'left', scrollable: null, id: 'NavQuickPayPatientEntry_container_1', plugins: 'responsive', responsiveConfig: {'width >= 1272':{hidden : false,},'width < 1272':{hidden :true,},} }, {xtype: 'button', name: 'HeaderTitlebarButton', ui: 'white', margin: '', hidden: true, ariaRole: 'button', cls: 'x-button-link-style im-center-header-button white noprint', id: 'NavQuickPayPatientEntry_HeaderTitlebarButton' }, {xtype: 'button', accessibleText: 'Log In or Sign Up', iconCls: 'x-ma ma-account-circle', align: 'right',menu:[{xtype: 'menuitem', text: 'Log In', handler: function() { PerformAction({}, PatientPortalLoginController.redirectToLogin,null); }, id: 'menuitem_LogIn_1'},{xtype: 'menuitem', text: 'Sign Up', handler: function() { PerformAction({}, SignUpController.redirectToSignUp,null); }, id: 'menuitem_SignUp_1'},], name: 'LoginOrSignUpProfileIcon', margin: '', ariaRole: 'button', cls: 'x-button-icon-link-style white noprint', id: 'NavQuickPayPatientEntry_button_LoginOrSignUpProfileIcon', plugins: 'responsive', responsiveConfig: {'!InstaMed.isLoggedIn & width > 960':{hidden: true,},'!InstaMed.isLoggedIn && width <= 960':{hidden: false,},}, listeners: {hiddenchange: function() { Ext.ComponentQuery.query('[name=LoginOrSignUpProfileIcon]')[0].getMenu().hide(); }} }, {xtype: 'button', text: '', align: 'right',menu:[{xtype: 'menuitem', text: 'Dashboard', handler: function(){ window.location.href='../../Form/PaymentPortal/Dashboard'; }, id: 'menuitem_Dashboard_2'},{xtype: 'menuitem', text: 'Help', handler: function() { window.open('https://help.instamed.com/patients/s/?dc_label=Patients')}, id: 'menuitem_Help_2'},{xtype: 'menuitem', text: 'Log Out', handler: function(){ window.location.href='../../Form/PaymentPortal/Logout?id=SILVERSCRIPT'; }, id: 'menuitem_LogOut_2'},], name: 'Profile', ui: 'white', margin: '', hidden: true, ariaRole: 'button', cls: 'x-button-link-style white noprint', id: 'NavQuickPayPatientEntry_button_Profile', plugins: 'responsive', responsiveConfig: {'InstaMed.isLoggedIn & width > 960':{hidden: false,},'InstaMed.isLoggedIn && width <= 960':{hidden: true,},}, listeners: {hiddenchange: function() { Ext.ComponentQuery.query('[name=Profile]')[0].getMenu().hide(); }} }, {xtype: 'container', align: 'right', name: 'LoginOrSignUpContainer', layout: {type: 'hbox'}, scrollable: null, id: 'NavQuickPayPatientEntry_LoginOrSignUpContainer', plugins: 'responsive', responsiveConfig: {'!InstaMed.isLoggedIn & width > 960':{hidden: false,},'!InstaMed.isLoggedIn && width <= 960':{hidden: true,},}, items: [ {xtype: 'button', text: 'Log In', align: 'right', name: 'LoginForDualLogin', ui: 'white', margin: '', hidden: false, ariaRole: 'button', cls: 'x-button-link-style hiddenxs hiddensm white noprint', id: 'NavQuickPayPatientEntry_button_LoginForDualLogin', listeners: {tap: function() { PerformAction({}, PatientPortalLoginController.redirectToLogin,null); }} }, {xtype: 'label', html: 'or', align: 'right', name: 'Or', ui: 'body1-white', cls: 'hiddenxs hiddensm body1-white', id: 'NavQuickPayPatientEntry_Or' }, {xtype: 'button', text: 'Sign Up', align: 'right', name: 'SignUpForDualLogin', ui: 'white', margin: '', ariaRole: 'button', cls: 'x-button-link-style hiddenxs hiddensm white noprint', id: 'NavQuickPayPatientEntry_button_SignUpForDualLogin', listeners: {tap: function() { PerformAction({}, SignUpController.redirectToSignUp,null); }} }] }, {xtype: 'button', accessibleText: 'Profile', iconCls: 'x-ma ma-account-circle', align: 'right',menu:[{xtype: 'menuitem', text: 'Dashboard', handler: function(){ window.location.href='../../Form/PaymentPortal/Dashboard'; }, id: 'menuitem_Dashboard_3'},{xtype: 'menuitem', text: 'Help', handler: function() { window.open('https://help.instamed.com/patients/s/?dc_label=Patients')}, id: 'menuitem_Help_3'},{xtype: 'menuitem', text: 'Log Out', handler: function(){ window.location.href='../../Form/PaymentPortal/Logout?id=SILVERSCRIPT'; }, id: 'menuitem_LogOut_3'},], name: 'ProfileIcon', margin: '', hidden: true, ariaRole: 'button', cls: 'x-button-icon-link-style white noprint', id: 'NavQuickPayPatientEntry_button_ProfileIcon', plugins: 'responsive', responsiveConfig: {'InstaMed.isLoggedIn & width > 960':{hidden: true,},'InstaMed.isLoggedIn && width <= 960':{hidden: false,},}, listeners: {hiddenchange: function() { Ext.ComponentQuery.query('[name=ProfileIcon]')[0].getMenu().hide(); }} }] }, {xtype: 'spacer', id: 'NavQuickPayPatientEntry_spacer_1', plugins: 'responsive', responsiveConfig: {'width > 1272':{flex : 1,},'width <= 1272':{flex :0,},} }] }] }, {xtype: 'container', layout: {type: 'hbox'}, cls: 'x-subheader-container', scrollable: null, id: 'NavQuickPayPatientEntry_container_2', items: [ {xtype: 'spacer', id: 'NavQuickPayPatientEntry_spacer_2', plugins: 'responsive', responsiveConfig: {'width > 1272':{flex : 1,},'width <= 1272':{flex :0,},} }, {xtype: 'container', maxWidth: 1272, layout: {type: 'hbox'}, cls: 'largeTwelveColumn mediumTwelveColumn smallTwelveColumn xsmallTwelveColumn x-subheader-panel ', scrollable: null, id: 'NavQuickPayPatientEntry_container_3', items: [ {xtype: 'image', src: '../../ContentHandler.aspx?URL=/Images/Database/1A6440F4-9734-4861-8F1B-82AEFA1C6DB1&id=SILVERSCRIPT&crop=true&maxWidth=150&maxHeight=64', hidden: true, cls: 'x-clickable x-button-provider-img', id: 'NavQuickPayPatientEntry_image', listeners: {painted: function() { var cmp = this; cmp.el.dom.setAttribute('aria-label', 'Aetna Medicare Prescription Drug Plan logo'); cmp.el.dom.setAttribute('role', 'img'); cmp.el.dom.setAttribute('title', ''); },tap: function(){ window.location.href='../../Form/PaymentPortal/Default?id=SILVERSCRIPT'; }} }, {xtype: 'container', layout: {type: 'vbox', pack: 'center', align: 'left'}, cls: 'im-provider-header-buttons', scrollable: null, id: 'NavQuickPayPatientEntry_container_4', items: [ {xtype: 'label', html: 'Aetna Medicare Prescription Drug Plan', name: 'SubheaderProviderName', ui: 'subheading-primary', cls: 'initial-caps font-400 im-bold-button subheading-primary', id: 'NavQuickPayPatientEntry_SubheaderProviderName' }, {xtype: 'container', layout: {type: 'hbox'}, scrollable: null, id: 'NavQuickPayPatientEntry_container_5', items: [ {xtype: 'container', html: '', hidden: true, cls: 'im-address-verification-icon', scrollable: null, id: 'NavQuickPayPatientEntry_container_6' }, {xtype: 'label', html: 'P.O. Box 504849, St Louis, MO 63150-4849', ui: 'body1-secondary', cls: 'line-height-20 body1-secondary', id: 'NavQuickPayPatientEntry_label' }] }, {xtype: 'container', layout: {type: 'hbox'}, hidden: false, scrollable: null, id: 'NavQuickPayPatientEntry_container_7', items: [ {xtype: 'label', html: '(855) 651-4856', ui: 'body1-primary', cls: 'body1-primary', id: 'NavQuickPayPatientEntry_label_1' }] }] }] }, {xtype: 'spacer', id: 'NavQuickPayPatientEntry_spacer_3', plugins: 'responsive', responsiveConfig: {'width > 1272':{flex : 1,},'width <= 1272':{flex :0,},} }] }, { xtype: 'panel', dock: 'top', frame: false, scrollable: 'true', id: 'panel_1', items: [ {xtype: 'container', maxWidth: 1272, layout: {type: 'hbox'}, cls: 'mainContent MainContentWithHeaerAndSubheader ', scrollable: null, id: 'container_4', items: [ {xtype: 'container', flex: 1, scrollable: null, id: 'container_5', items: [ { xtype: 'form', preventHeader: true, bodyCls: 'mypanel', api: { }, name: 'FormPatientPayment', itemId: 'FormPatientPayment', cls: 'col-large-offSet-3 col-medium-offSet-3 col-small-offSet-1 smallTenColumn xsmallTwelveColumn mediumSixColumn largeSixColumn ', scrollable: null, id: 'FormPatientPayment', items: [ {xtype: 'errorbox', name: 'ValidationSummary', ui: 'ErrorBox', hidden: true, cls: 'ErrorBox', id: 'ValidationSummary_1' }, {xtype: 'instamedHeading1', text: 'Member Information', id: 'FormPatientPayment_instamedHeading1' }, {xtype: 'dataviewlite', tpl: ['
', name: 'poweredbylogo', cls: 'hiddenxs hiddensm', scrollable: null, id: 'NavQuickPayPatientEntry_poweredbylogo' }, {xtype: 'container', cls: 'copyrightContainer hiddenxs hiddensm', scrollable: null, id: 'NavQuickPayPatientEntry_container_9', items: [ {xtype: 'spacer', cls: 'hiddenmd hiddenlg', id: 'NavQuickPayPatientEntry_spacer_4' }, {xtype: 'label', html: '© 2024 InstaMed. All Rights Reserved.', name: 'copyrightFooter', ui: 'body1-primary', cls: 'margin-bottom-10 body1-primary', id: 'NavQuickPayPatientEntry_copyrightFooter' }, {xtype: 'spacer', cls: 'hiddenmd hiddenlg', id: 'NavQuickPayPatientEntry_spacer_5' }] }, {xtype: 'spacer', cls: 'hiddenxs hiddensm', id: 'NavQuickPayPatientEntry_spacer_6' }, {xtype: 'container', cls: 'linkButtonContainer hiddenxs hiddensm', scrollable: null, id: 'NavQuickPayPatientEntry_container_10', items: [ {xtype: 'button', text: 'Security', iconCls: 'x-ma ma-lock-outline', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavQuickPayPatientEntry_button_Security', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/security/','open-window');}} }, {xtype: 'button', text: 'Privacy', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavQuickPayPatientEntry_button_Privacy', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/privacy-statement/','open-window');}} }, {xtype: 'button', text: 'Terms', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavQuickPayPatientEntry_button_Terms', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/terms-of-use/','open-window');}} }, {xtype: 'button', text: 'Help', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavQuickPayPatientEntry_button_Help', listeners: {tap: function() { InstaMed.popupNewWindow('../../Form/PaymentPortal/ContactUs?id=SILVERSCRIPT','open-window');}} }, {xtype: 'button', text: 'English', align: 'right',menu:[{xtype: 'menuitem', text: 'English', handler: function(cmp) { PerformAction({Language:'en'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'en', cls: 'hiddenxs hiddensm', id: 'menuitem_en_2'},{xtype: 'menuitem', text: 'Español', handler: function(cmp) { PerformAction({Language:'es'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'es', cls: 'hiddenxs hiddensm', id: 'menuitem_es_2'},{xtype: 'menuitem', text: 'Français', handler: function(cmp) { PerformAction({Language:'fr'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'fr', cls: 'hiddenxs hiddensm', id: 'menuitem_fr_2'},], name: 'ForeignLanguages', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavQuickPayPatientEntry_button_ForeignLanguages' }] }, {xtype: 'container', cls: 'hiddenmd hiddenlg', scrollable: null, id: 'NavQuickPayPatientEntry_container_11', items: [ {xtype: 'container', layout: {type: 'hbox', pack: 'center'}, cls: 'x-center-helper', scrollable: null, id: 'NavQuickPayPatientEntry_container_12', items: [ {xtype: 'spacer', id: 'NavQuickPayPatientEntry_spacer_7' }, {xtype: 'container', html: '
', name: 'poweredbylogo', scrollable: null, id: 'NavQuickPayPatientEntry_poweredbylogo_1' }, {xtype: 'spacer', id: 'NavQuickPayPatientEntry_spacer_8' }] }, {xtype: 'container', layout: {type: 'hbox', pack: 'center'}, cls: 'x-center-helper', scrollable: null, id: 'NavQuickPayPatientEntry_container_13', items: [ {xtype: 'spacer', id: 'NavQuickPayPatientEntry_spacer_9' }, {xtype: 'container', cls: 'copyrightContainer', scrollable: null, id: 'NavQuickPayPatientEntry_container_14', items: [ {xtype: 'spacer', cls: 'hiddenmd hiddenlg', id: 'NavQuickPayPatientEntry_spacer_10' }, {xtype: 'label', html: '© 2024 InstaMed. All Rights Reserved.', name: 'copyrightFooter', ui: 'body1-primary', cls: 'margin-bottom-10 body1-primary', id: 'NavQuickPayPatientEntry_copyrightFooter_1' }, {xtype: 'spacer', cls: 'hiddenmd hiddenlg', id: 'NavQuickPayPatientEntry_spacer_11' }] }, {xtype: 'spacer', id: 'NavQuickPayPatientEntry_spacer_12' }] }, {xtype: 'container', layout: {type: 'hbox', pack: 'center'}, cls: 'x-center-helper', scrollable: null, id: 'NavQuickPayPatientEntry_container_15', items: [ {xtype: 'spacer', id: 'NavQuickPayPatientEntry_spacer_13' }, {xtype: 'container', cls: 'linkButtonContainer ', scrollable: null, id: 'NavQuickPayPatientEntry_container_16', items: [ {xtype: 'button', text: 'Security', iconCls: 'x-ma ma-lock-outline', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavQuickPayPatientEntry_button_Security_1', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/security/','open-window');}} }, {xtype: 'button', text: 'Privacy', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavQuickPayPatientEntry_button_Privacy_1', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/privacy-statement/','open-window');}} }, {xtype: 'button', text: 'Terms', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavQuickPayPatientEntry_button_Terms_1', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/terms-of-use/','open-window');}} }, {xtype: 'button', text: 'Help', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavQuickPayPatientEntry_button_Help_1', listeners: {tap: function() { InstaMed.popupNewWindow('../../Form/PaymentPortal/ContactUs?id=SILVERSCRIPT','open-window');}} }] }, {xtype: 'spacer', id: 'NavQuickPayPatientEntry_spacer_14' }] }, {xtype: 'container', layout: {type: 'hbox', pack: 'center'}, cls: 'x-center-helper', scrollable: null, id: 'NavQuickPayPatientEntry_container_17', items: [ {xtype: 'spacer', id: 'NavQuickPayPatientEntry_spacer_15' }, {xtype: 'container', scrollable: null, id: 'NavQuickPayPatientEntry_container_18', items: [ {xtype: 'button', text: 'English', align: 'right',menu:[{xtype: 'menuitem', text: 'English', handler: function(cmp) { PerformAction({Language:'en'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'en', cls: 'hiddenmd hiddenlg', id: 'menuitem_en_3'},{xtype: 'menuitem', text: 'Español', handler: function(cmp) { PerformAction({Language:'es'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'es', cls: 'hiddenmd hiddenlg', id: 'menuitem_es_3'},{xtype: 'menuitem', text: 'Français', handler: function(cmp) { PerformAction({Language:'fr'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'fr', cls: 'hiddenmd hiddenlg', id: 'menuitem_fr_3'},], name: 'ForeignLanguages', ui: 'grey', margin: '', hidden: false, ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavQuickPayPatientEntry_button_ForeignLanguages_1' }] }, {xtype: 'spacer', id: 'NavQuickPayPatientEntry_spacer_16' }] }] }] }, {xtype: 'spacer', id: 'spacer_5' }] }] }, {xtype: 'container', name: 'NavQuickPayAccountSummary', layout: {type: 'vbox', pack: 'start'}, showBackButton: true, showMenuButton: false, scrollable: 'true', id: 'NavQuickPayAccountSummary', items: [ {xtype: 'container', docked: 'top', scrollable: null, id: 'NavQuickPayAccountSummary_container', items: [ {xtype: 'instamedNavigationBar', name: 'headerBar', layout: {type: 'hbox'}, hidden: false, cls: 'im-ignore-custom-colors im-ignore-background', scrollable: null, id: 'NavQuickPayAccountSummary_headerBar', items: [ {xtype: 'spacer', id: 'NavQuickPayAccountSummary_spacer', plugins: 'responsive', responsiveConfig: {'width > 1272':{flex : 1,},'width <= 1272':{flex :0,},} }, {xtype: 'titlebar', title: '<a href=\\"../../Form/PaymentPortal/Start\\"> <img src=\\"../../ContentHandler.aspx?URL=/Images/Database/cvscaremark@instamed.net/WolkenJ@cvscaremark/cvscaremark@instamed.net000013897108-001-002HeaderLogo/638482659224849466&id=SILVERSCRIPT\\" alt=\\"Company Logo\\" style=\\"height: 40px\\">', maxWidth: 1272, cls: 'largeTwelveColumn mediumTwelveColumn smallTwelveColumn xsmallTwelveColumn im-ignore-custom-colors im-ignore-background', scrollable: null, id: 'NavQuickPayAccountSummary_titlebar', plugins: 'responsive', responsiveConfig: {'width >= 1272':{title :'',},'width < 1272':{title : ' ',},}, items: [ {xtype: 'button', accessibleText: 'Back', iconCls: 'x-ma ma-arrow-back', align: 'left', name: 'TitleBarNavigationViewBack', margin: '', hidden: false, ariaRole: 'button', cls: 'x-button-icon-link-style white hiddenlg noprint', id: 'NavQuickPayAccountSummary_TitleBarNavigationViewBack', plugins: 'responsive', responsiveConfig: {'width > 1272':{iconCls :'',},'width <= 1272':{iconCls : 'x-ma ma-arrow-back',},}, listeners: {tap: function() { PerformAction({}, QuickPayPatientEntryController.navigateBack,null); }} }, {xtype: 'container', html: ' ', align: 'left', scrollable: null, id: 'NavQuickPayAccountSummary_container_1', plugins: 'responsive', responsiveConfig: {'width >= 1272':{hidden : false,},'width < 1272':{hidden :true,},} }, {xtype: 'button', name: 'HeaderTitlebarButton', ui: 'white', margin: '', hidden: true, ariaRole: 'button', cls: 'x-button-link-style im-center-header-button white noprint', id: 'NavQuickPayAccountSummary_HeaderTitlebarButton' }, {xtype: 'button', accessibleText: 'Log In or Sign Up', iconCls: 'x-ma ma-account-circle', align: 'right',menu:[{xtype: 'menuitem', text: 'Log In', handler: function() { PerformAction({}, PatientPortalLoginController.redirectToLogin,null); }, id: 'menuitem_LogIn_2'},{xtype: 'menuitem', text: 'Sign Up', handler: function() { PerformAction({}, SignUpController.redirectToSignUp,null); }, id: 'menuitem_SignUp_2'},], name: 'LoginOrSignUpProfileIcon', margin: '', ariaRole: 'button', cls: 'x-button-icon-link-style white noprint', id: 'NavQuickPayAccountSummary_button_LoginOrSignUpProfileIcon', plugins: 'responsive', responsiveConfig: {'!InstaMed.isLoggedIn & width > 960':{hidden: true,},'!InstaMed.isLoggedIn && width <= 960':{hidden: false,},}, listeners: {hiddenchange: function() { Ext.ComponentQuery.query('[name=LoginOrSignUpProfileIcon]')[0].getMenu().hide(); }} }, {xtype: 'button', text: '', align: 'right',menu:[{xtype: 'menuitem', text: 'Dashboard', handler: function(){ window.location.href='../../Form/PaymentPortal/Dashboard'; }, id: 'menuitem_Dashboard_4'},{xtype: 'menuitem', text: 'Help', handler: function() { window.open('https://help.instamed.com/patients/s/?dc_label=Patients')}, id: 'menuitem_Help_4'},{xtype: 'menuitem', text: 'Log Out', handler: function(){ window.location.href='../../Form/PaymentPortal/Logout?id=SILVERSCRIPT'; }, id: 'menuitem_LogOut_4'},], name: 'Profile', ui: 'white', margin: '', hidden: true, ariaRole: 'button', cls: 'x-button-link-style white noprint', id: 'NavQuickPayAccountSummary_button_Profile', plugins: 'responsive', responsiveConfig: {'InstaMed.isLoggedIn & width > 960':{hidden: false,},'InstaMed.isLoggedIn && width <= 960':{hidden: true,},}, listeners: {hiddenchange: function() { Ext.ComponentQuery.query('[name=Profile]')[0].getMenu().hide(); }} }, {xtype: 'container', align: 'right', name: 'LoginOrSignUpContainer', layout: {type: 'hbox'}, scrollable: null, id: 'NavQuickPayAccountSummary_LoginOrSignUpContainer', plugins: 'responsive', responsiveConfig: {'!InstaMed.isLoggedIn & width > 960':{hidden: false,},'!InstaMed.isLoggedIn && width <= 960':{hidden: true,},}, items: [ {xtype: 'button', text: 'Log In', align: 'right', name: 'LoginForDualLogin', ui: 'white', margin: '', hidden: false, ariaRole: 'button', cls: 'x-button-link-style hiddenxs hiddensm white noprint', id: 'NavQuickPayAccountSummary_button_LoginForDualLogin', listeners: {tap: function() { PerformAction({}, PatientPortalLoginController.redirectToLogin,null); }} }, {xtype: 'label', html: 'or', align: 'right', name: 'Or', ui: 'body1-white', cls: 'hiddenxs hiddensm body1-white', id: 'NavQuickPayAccountSummary_Or' }, {xtype: 'button', text: 'Sign Up', align: 'right', name: 'SignUpForDualLogin', ui: 'white', margin: '', ariaRole: 'button', cls: 'x-button-link-style hiddenxs hiddensm white noprint', id: 'NavQuickPayAccountSummary_button_SignUpForDualLogin', listeners: {tap: function() { PerformAction({}, SignUpController.redirectToSignUp,null); }} }] }, {xtype: 'button', accessibleText: 'Profile', iconCls: 'x-ma ma-account-circle', align: 'right',menu:[{xtype: 'menuitem', text: 'Dashboard', handler: function(){ window.location.href='../../Form/PaymentPortal/Dashboard'; }, id: 'menuitem_Dashboard_5'},{xtype: 'menuitem', text: 'Help', handler: function() { window.open('https://help.instamed.com/patients/s/?dc_label=Patients')}, id: 'menuitem_Help_5'},{xtype: 'menuitem', text: 'Log Out', handler: function(){ window.location.href='../../Form/PaymentPortal/Logout?id=SILVERSCRIPT'; }, id: 'menuitem_LogOut_5'},], name: 'ProfileIcon', margin: '', hidden: true, ariaRole: 'button', cls: 'x-button-icon-link-style white noprint', id: 'NavQuickPayAccountSummary_button_ProfileIcon', plugins: 'responsive', responsiveConfig: {'InstaMed.isLoggedIn & width > 960':{hidden: true,},'InstaMed.isLoggedIn && width <= 960':{hidden: false,},}, listeners: {hiddenchange: function() { Ext.ComponentQuery.query('[name=ProfileIcon]')[0].getMenu().hide(); }} }] }, {xtype: 'spacer', id: 'NavQuickPayAccountSummary_spacer_1', plugins: 'responsive', responsiveConfig: {'width > 1272':{flex : 1,},'width <= 1272':{flex :0,},} }] }] }, {xtype: 'container', layout: {type: 'hbox'}, cls: 'x-subheader-container', scrollable: null, id: 'NavQuickPayAccountSummary_container_2', items: [ {xtype: 'spacer', id: 'NavQuickPayAccountSummary_spacer_2', plugins: 'responsive', responsiveConfig: {'width > 1272':{flex : 1,},'width <= 1272':{flex :0,},} }, {xtype: 'container', maxWidth: 1272, layout: {type: 'hbox'}, cls: 'largeTwelveColumn mediumTwelveColumn smallTwelveColumn xsmallTwelveColumn x-subheader-panel ', scrollable: null, id: 'NavQuickPayAccountSummary_container_3', items: [ {xtype: 'image', src: '../../ContentHandler.aspx?URL=/Images/Database/1A6440F4-9734-4861-8F1B-82AEFA1C6DB1&id=SILVERSCRIPT&crop=true&maxWidth=150&maxHeight=64', hidden: true, cls: 'x-clickable x-button-provider-img', id: 'NavQuickPayAccountSummary_image', listeners: {painted: function() { var cmp = this; cmp.el.dom.setAttribute('aria-label', 'Aetna Medicare Prescription Drug Plan logo'); cmp.el.dom.setAttribute('role', 'img'); cmp.el.dom.setAttribute('title', ''); },tap: function(){ window.location.href='../../Form/PaymentPortal/Default?id=SILVERSCRIPT'; }} }, {xtype: 'container', layout: {type: 'vbox', pack: 'center', align: 'left'}, cls: 'im-provider-header-buttons', scrollable: null, id: 'NavQuickPayAccountSummary_container_4', items: [ {xtype: 'label', html: 'Aetna Medicare Prescription Drug Plan', name: 'SubheaderProviderName', ui: 'subheading-primary', cls: 'initial-caps font-400 im-bold-button subheading-primary', id: 'NavQuickPayAccountSummary_SubheaderProviderName' }, {xtype: 'container', layout: {type: 'hbox'}, scrollable: null, id: 'NavQuickPayAccountSummary_container_5', items: [ {xtype: 'container', html: '', hidden: true, cls: 'im-address-verification-icon', scrollable: null, id: 'NavQuickPayAccountSummary_container_6' }, {xtype: 'label', html: 'P.O. Box 504849, St Louis, MO 63150-4849', ui: 'body1-secondary', cls: 'line-height-20 body1-secondary', id: 'NavQuickPayAccountSummary_label' }] }, {xtype: 'container', layout: {type: 'hbox'}, hidden: false, scrollable: null, id: 'NavQuickPayAccountSummary_container_7', items: [ {xtype: 'label', html: '(855) 651-4856', ui: 'body1-primary', cls: 'body1-primary', id: 'NavQuickPayAccountSummary_label_1' }] }] }] }, {xtype: 'spacer', id: 'NavQuickPayAccountSummary_spacer_3', plugins: 'responsive', responsiveConfig: {'width > 1272':{flex : 1,},'width <= 1272':{flex :0,},} }] }, { xtype: 'panel', dock: 'top', frame: false, scrollable: 'true', id: 'panel_2', items: [ {xtype: 'container', maxWidth: 1272, layout: {type: 'hbox'}, cls: 'mainContent MainContentWithHeaerAndSubheader ', scrollable: null, id: 'container_7', items: [ {xtype: 'container', flex: 1, scrollable: null, id: 'container_8', items: [ { xtype: 'form', preventHeader: true, bodyCls: 'mypanel', api: { }, name: 'FormAccountSummary', itemId: 'FormAccountSummary', cls: 'col-large-offSet-3 col-medium-offSet-3 col-small-offSet-1 smallTenColumn xsmallTwelveColumn mediumSixColumn largeSixColumn ', scrollable: null, id: 'FormAccountSummary', items: [ {xtype: 'errorbox', name: 'ValidationSummary', ui: 'ErrorBox', hidden: true, cls: 'ErrorBox', id: 'ValidationSummary_2' }, {xtype: 'instamedHeading1', text: 'Account Summary', id: 'FormAccountSummary_instamedHeading1' }, {xtype: 'container', margin: '24 0 0 0', scrollable: null, id: 'FormAccountSummary_container', items: [ {xtype: 'container', layout: {type: 'hbox'}, cls: 'MultipleFieldsContainer im-account-summary-form-section-information', scrollable: null, id: 'FormAccountSummary_container_1', plugins: 'responsive', responsiveConfig: {'width > 600':{layout : { type : 'hbox'},},'width <= 600':{layout : { type : 'vbox'},},}, items: [ {xtype: 'container', flex: 1, scrollable: null, id: 'FormAccountSummary_container_2', items: [ {xtype: 'label', html: '', name: 'PatientInformation', ui: 'light-subheading-primary', cls: 'light-subheading-primary', id: 'FormAccountSummary_PatientInformation' }, {xtype: 'label', html: 'Aetna Medicare Prescription Drug Plan', name: 'ProviderName', ui: 'body1-secondary', cls: 'im-account-summary-form-patientname body1-secondary', id: 'FormAccountSummary_ProviderName' }] }, {xtype: 'container', width: 24, name: 'ViewStatementAsOfContainerSpacer', cls: 'x-spacer', id: 'FormAccountSummary_ViewStatementAsOfContainerSpacer' }, {xtype: 'container', align: 'right', name: 'ViewStatementAsOfContainer', flex: 1, hidden: true, cls: 'im-view-statement-asof-component', scrollable: null, id: 'FormAccountSummary_ViewStatementAsOfContainer', items: [ {xtype: 'container', html: '', name: 'ViewStatementLinkContainer', cls: 'im-view-statement-link im-view-statement-asof-component-link', scrollable: null, id: 'FormAccountSummary_ViewStatementLinkContainer' }, {xtype: 'label', html: '', name: 'AsOfDate', ui: 'body1-secondary', hidden: true, cls: 'im-view-statement-asof-component-asof body1-secondary', id: 'FormAccountSummary_AsOfDate' }] }] }] }, {xtype: 'container', margin: '24 0 0 0', cls: 'im-account-summary-form-section-graph', scrollable: null, id: 'FormAccountSummary_container_3', items: [ {xtype: 'container', layout: {type: 'hbox'}, scrollable: null, id: 'FormAccountSummary_container_4', plugins: 'responsive', responsiveConfig: {'width > 600':{layout : { type : 'hbox'},},'width <= 600':{layout : { type : 'vbox'},},}, items: [ {xtype: 'container', scrollable: null, id: 'FormAccountSummary_container_5', items: [ {xtype: 'container', width: 180, height: 180, cls: 'im-centered-content-donut-chart', scrollable: null, id: 'FormAccountSummary_container_6', items: [ {xtype: 'container', centered: true, cls: 'im-center-text-wrapper', scrollable: null, id: 'FormAccountSummary_container_7', items: [ {xtype: 'container', html: '
', name: 'poweredbylogo', cls: 'hiddenxs hiddensm', scrollable: null, id: 'NavQuickPayAccountSummary_poweredbylogo' }, {xtype: 'container', cls: 'copyrightContainer hiddenxs hiddensm', scrollable: null, id: 'NavQuickPayAccountSummary_container_9', items: [ {xtype: 'spacer', cls: 'hiddenmd hiddenlg', id: 'NavQuickPayAccountSummary_spacer_4' }, {xtype: 'label', html: '© 2024 InstaMed. All Rights Reserved.', name: 'copyrightFooter', ui: 'body1-primary', cls: 'margin-bottom-10 body1-primary', id: 'NavQuickPayAccountSummary_copyrightFooter' }, {xtype: 'spacer', cls: 'hiddenmd hiddenlg', id: 'NavQuickPayAccountSummary_spacer_5' }] }, {xtype: 'spacer', cls: 'hiddenxs hiddensm', id: 'NavQuickPayAccountSummary_spacer_6' }, {xtype: 'container', cls: 'linkButtonContainer hiddenxs hiddensm', scrollable: null, id: 'NavQuickPayAccountSummary_container_10', items: [ {xtype: 'button', text: 'Security', iconCls: 'x-ma ma-lock-outline', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavQuickPayAccountSummary_button_Security', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/security/','open-window');}} }, {xtype: 'button', text: 'Privacy', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavQuickPayAccountSummary_button_Privacy', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/privacy-statement/','open-window');}} }, {xtype: 'button', text: 'Terms', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavQuickPayAccountSummary_button_Terms', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/terms-of-use/','open-window');}} }, {xtype: 'button', text: 'Help', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavQuickPayAccountSummary_button_Help', listeners: {tap: function() { InstaMed.popupNewWindow('../../Form/PaymentPortal/ContactUs?id=SILVERSCRIPT','open-window');}} }, {xtype: 'button', text: 'English', align: 'right',menu:[{xtype: 'menuitem', text: 'English', handler: function(cmp) { PerformAction({Language:'en'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'en', cls: 'hiddenxs hiddensm', id: 'menuitem_en_4'},{xtype: 'menuitem', text: 'Español', handler: function(cmp) { PerformAction({Language:'es'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'es', cls: 'hiddenxs hiddensm', id: 'menuitem_es_4'},{xtype: 'menuitem', text: 'Français', handler: function(cmp) { PerformAction({Language:'fr'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'fr', cls: 'hiddenxs hiddensm', id: 'menuitem_fr_4'},], name: 'ForeignLanguages', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavQuickPayAccountSummary_button_ForeignLanguages' }] }, {xtype: 'container', cls: 'hiddenmd hiddenlg', scrollable: null, id: 'NavQuickPayAccountSummary_container_11', items: [ {xtype: 'container', layout: {type: 'hbox', pack: 'center'}, cls: 'x-center-helper', scrollable: null, id: 'NavQuickPayAccountSummary_container_12', items: [ {xtype: 'spacer', id: 'NavQuickPayAccountSummary_spacer_7' }, {xtype: 'container', html: '
', name: 'poweredbylogo', scrollable: null, id: 'NavQuickPayAccountSummary_poweredbylogo_1' }, {xtype: 'spacer', id: 'NavQuickPayAccountSummary_spacer_8' }] }, {xtype: 'container', layout: {type: 'hbox', pack: 'center'}, cls: 'x-center-helper', scrollable: null, id: 'NavQuickPayAccountSummary_container_13', items: [ {xtype: 'spacer', id: 'NavQuickPayAccountSummary_spacer_9' }, {xtype: 'container', cls: 'copyrightContainer', scrollable: null, id: 'NavQuickPayAccountSummary_container_14', items: [ {xtype: 'spacer', cls: 'hiddenmd hiddenlg', id: 'NavQuickPayAccountSummary_spacer_10' }, {xtype: 'label', html: '© 2024 InstaMed. All Rights Reserved.', name: 'copyrightFooter', ui: 'body1-primary', cls: 'margin-bottom-10 body1-primary', id: 'NavQuickPayAccountSummary_copyrightFooter_1' }, {xtype: 'spacer', cls: 'hiddenmd hiddenlg', id: 'NavQuickPayAccountSummary_spacer_11' }] }, {xtype: 'spacer', id: 'NavQuickPayAccountSummary_spacer_12' }] }, {xtype: 'container', layout: {type: 'hbox', pack: 'center'}, cls: 'x-center-helper', scrollable: null, id: 'NavQuickPayAccountSummary_container_15', items: [ {xtype: 'spacer', id: 'NavQuickPayAccountSummary_spacer_13' }, {xtype: 'container', cls: 'linkButtonContainer ', scrollable: null, id: 'NavQuickPayAccountSummary_container_16', items: [ {xtype: 'button', text: 'Security', iconCls: 'x-ma ma-lock-outline', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavQuickPayAccountSummary_button_Security_1', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/security/','open-window');}} }, {xtype: 'button', text: 'Privacy', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavQuickPayAccountSummary_button_Privacy_1', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/privacy-statement/','open-window');}} }, {xtype: 'button', text: 'Terms', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavQuickPayAccountSummary_button_Terms_1', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/terms-of-use/','open-window');}} }, {xtype: 'button', text: 'Help', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavQuickPayAccountSummary_button_Help_1', listeners: {tap: function() { InstaMed.popupNewWindow('../../Form/PaymentPortal/ContactUs?id=SILVERSCRIPT','open-window');}} }] }, {xtype: 'spacer', id: 'NavQuickPayAccountSummary_spacer_14' }] }, {xtype: 'container', layout: {type: 'hbox', pack: 'center'}, cls: 'x-center-helper', scrollable: null, id: 'NavQuickPayAccountSummary_container_17', items: [ {xtype: 'spacer', id: 'NavQuickPayAccountSummary_spacer_15' }, {xtype: 'container', scrollable: null, id: 'NavQuickPayAccountSummary_container_18', items: [ {xtype: 'button', text: 'English', align: 'right',menu:[{xtype: 'menuitem', text: 'English', handler: function(cmp) { PerformAction({Language:'en'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'en', cls: 'hiddenmd hiddenlg', id: 'menuitem_en_5'},{xtype: 'menuitem', text: 'Español', handler: function(cmp) { PerformAction({Language:'es'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'es', cls: 'hiddenmd hiddenlg', id: 'menuitem_es_5'},{xtype: 'menuitem', text: 'Français', handler: function(cmp) { PerformAction({Language:'fr'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'fr', cls: 'hiddenmd hiddenlg', id: 'menuitem_fr_5'},], name: 'ForeignLanguages', ui: 'grey', margin: '', hidden: false, ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavQuickPayAccountSummary_button_ForeignLanguages_1' }] }, {xtype: 'spacer', id: 'NavQuickPayAccountSummary_spacer_16' }] }] }] }, {xtype: 'spacer', id: 'spacer_8' }] }] }, {xtype: 'container', name: 'NavSelectProvider', layout: {type: 'vbox', pack: 'start'}, scrollable: 'true', id: 'NavSelectProvider', items: [ {xtype: 'container', docked: 'top', scrollable: null, id: 'NavSelectProvider_container', items: [ {xtype: 'instamedNavigationBar', name: 'headerBar', layout: {type: 'hbox'}, hidden: false, cls: 'im-ignore-custom-colors im-ignore-background', scrollable: null, id: 'NavSelectProvider_headerBar', items: [ {xtype: 'spacer', id: 'NavSelectProvider_spacer', plugins: 'responsive', responsiveConfig: {'width > 1272':{flex : 1,},'width <= 1272':{flex :0,},} }, {xtype: 'titlebar', title: '<a href=\\"../../Form/PaymentPortal/Start\\"> <img src=\\"../../ContentHandler.aspx?URL=/Images/Database/cvscaremark@instamed.net/WolkenJ@cvscaremark/cvscaremark@instamed.net000013897108-001-002HeaderLogo/638482659224849466&id=SILVERSCRIPT\\" alt=\\"Company Logo\\" style=\\"height: 40px\\">', maxWidth: 1272, cls: 'largeTwelveColumn mediumTwelveColumn smallTwelveColumn xsmallTwelveColumn im-ignore-custom-colors im-ignore-background', scrollable: null, id: 'NavSelectProvider_titlebar', plugins: 'responsive', responsiveConfig: {'width >= 1272':{title :'',},'width < 1272':{title : ' ',},}, items: [ {xtype: 'button', accessibleText: 'Back', iconCls: 'x-ma ma-arrow-back', align: 'left', name: 'TitleBarNavigationViewBack', margin: '', hidden: false, ariaRole: 'button', cls: 'x-button-icon-link-style white hiddenlg noprint', id: 'NavSelectProvider_TitleBarNavigationViewBack', plugins: 'responsive', responsiveConfig: {'width > 1272':{iconCls :'',},'width <= 1272':{iconCls : 'x-ma ma-arrow-back',},}, listeners: {tap: function() { PerformAction({}, QuickPayPatientEntryController.navigateBack,null); }} }, {xtype: 'container', html: ' ', align: 'left', scrollable: null, id: 'NavSelectProvider_container_1', plugins: 'responsive', responsiveConfig: {'width >= 1272':{hidden : false,},'width < 1272':{hidden :true,},} }, {xtype: 'button', name: 'HeaderTitlebarButton', ui: 'white', margin: '', hidden: true, ariaRole: 'button', cls: 'x-button-link-style im-center-header-button white noprint', id: 'NavSelectProvider_HeaderTitlebarButton' }, {xtype: 'button', accessibleText: 'Log In or Sign Up', iconCls: 'x-ma ma-account-circle', align: 'right',menu:[{xtype: 'menuitem', text: 'Log In', handler: function() { PerformAction({}, PatientPortalLoginController.redirectToLogin,null); }, id: 'menuitem_LogIn_3'},{xtype: 'menuitem', text: 'Sign Up', handler: function() { PerformAction({}, SignUpController.redirectToSignUp,null); }, id: 'menuitem_SignUp_3'},], name: 'LoginOrSignUpProfileIcon', margin: '', ariaRole: 'button', cls: 'x-button-icon-link-style white noprint', id: 'NavSelectProvider_button_LoginOrSignUpProfileIcon', plugins: 'responsive', responsiveConfig: {'!InstaMed.isLoggedIn & width > 960':{hidden: true,},'!InstaMed.isLoggedIn && width <= 960':{hidden: false,},}, listeners: {hiddenchange: function() { Ext.ComponentQuery.query('[name=LoginOrSignUpProfileIcon]')[0].getMenu().hide(); }} }, {xtype: 'button', text: '', align: 'right',menu:[{xtype: 'menuitem', text: 'Dashboard', handler: function(){ window.location.href='../../Form/PaymentPortal/Dashboard'; }, id: 'menuitem_Dashboard_6'},{xtype: 'menuitem', text: 'Help', handler: function() { window.open('https://help.instamed.com/patients/s/?dc_label=Patients')}, id: 'menuitem_Help_6'},{xtype: 'menuitem', text: 'Log Out', handler: function(){ window.location.href='../../Form/PaymentPortal/Logout?id=SILVERSCRIPT'; }, id: 'menuitem_LogOut_6'},], name: 'Profile', ui: 'white', margin: '', hidden: true, ariaRole: 'button', cls: 'x-button-link-style white noprint', id: 'NavSelectProvider_button_Profile', plugins: 'responsive', responsiveConfig: {'InstaMed.isLoggedIn & width > 960':{hidden: false,},'InstaMed.isLoggedIn && width <= 960':{hidden: true,},}, listeners: {hiddenchange: function() { Ext.ComponentQuery.query('[name=Profile]')[0].getMenu().hide(); }} }, {xtype: 'container', align: 'right', name: 'LoginOrSignUpContainer', layout: {type: 'hbox'}, scrollable: null, id: 'NavSelectProvider_LoginOrSignUpContainer', plugins: 'responsive', responsiveConfig: {'!InstaMed.isLoggedIn & width > 960':{hidden: false,},'!InstaMed.isLoggedIn && width <= 960':{hidden: true,},}, items: [ {xtype: 'button', text: 'Log In', align: 'right', name: 'LoginForDualLogin', ui: 'white', margin: '', hidden: false, ariaRole: 'button', cls: 'x-button-link-style hiddenxs hiddensm white noprint', id: 'NavSelectProvider_button_LoginForDualLogin', listeners: {tap: function() { PerformAction({}, PatientPortalLoginController.redirectToLogin,null); }} }, {xtype: 'label', html: 'or', align: 'right', name: 'Or', ui: 'body1-white', cls: 'hiddenxs hiddensm body1-white', id: 'NavSelectProvider_Or' }, {xtype: 'button', text: 'Sign Up', align: 'right', name: 'SignUpForDualLogin', ui: 'white', margin: '', ariaRole: 'button', cls: 'x-button-link-style hiddenxs hiddensm white noprint', id: 'NavSelectProvider_button_SignUpForDualLogin', listeners: {tap: function() { PerformAction({}, SignUpController.redirectToSignUp,null); }} }] }, {xtype: 'button', accessibleText: 'Profile', iconCls: 'x-ma ma-account-circle', align: 'right',menu:[{xtype: 'menuitem', text: 'Dashboard', handler: function(){ window.location.href='../../Form/PaymentPortal/Dashboard'; }, id: 'menuitem_Dashboard_7'},{xtype: 'menuitem', text: 'Help', handler: function() { window.open('https://help.instamed.com/patients/s/?dc_label=Patients')}, id: 'menuitem_Help_7'},{xtype: 'menuitem', text: 'Log Out', handler: function(){ window.location.href='../../Form/PaymentPortal/Logout?id=SILVERSCRIPT'; }, id: 'menuitem_LogOut_7'},], name: 'ProfileIcon', margin: '', hidden: true, ariaRole: 'button', cls: 'x-button-icon-link-style white noprint', id: 'NavSelectProvider_button_ProfileIcon', plugins: 'responsive', responsiveConfig: {'InstaMed.isLoggedIn & width > 960':{hidden: true,},'InstaMed.isLoggedIn && width <= 960':{hidden: false,},}, listeners: {hiddenchange: function() { Ext.ComponentQuery.query('[name=ProfileIcon]')[0].getMenu().hide(); }} }] }, {xtype: 'spacer', id: 'NavSelectProvider_spacer_1', plugins: 'responsive', responsiveConfig: {'width > 1272':{flex : 1,},'width <= 1272':{flex :0,},} }] }] }, {xtype: 'container', layout: {type: 'hbox'}, cls: 'x-subheader-container', scrollable: null, id: 'NavSelectProvider_container_2', items: [ {xtype: 'spacer', id: 'NavSelectProvider_spacer_2', plugins: 'responsive', responsiveConfig: {'width > 1272':{flex : 1,},'width <= 1272':{flex :0,},} }, {xtype: 'container', maxWidth: 1272, layout: {type: 'hbox'}, cls: 'largeTwelveColumn mediumTwelveColumn smallTwelveColumn xsmallTwelveColumn x-subheader-panel ', scrollable: null, id: 'NavSelectProvider_container_3', items: [ {xtype: 'image', src: '../../Forms/UtilForm/ContentHandler.aspx?URL=/Images/Database/D2D175C9-9D00-4559-A5AC-EB794B2023E3&id=SILVERSCRIPT&crop=true&maxWidth=150&maxHeight=64', hidden: true, cls: 'x-clickable x-button-provider-img', id: 'NavSelectProvider_image', listeners: {painted: function() { var cmp = this; cmp.el.dom.setAttribute('aria-label', 'Aetna Medicare Prescription Drug Plan logo'); cmp.el.dom.setAttribute('role', 'img'); cmp.el.dom.setAttribute('title', ''); },tap: function(){ window.location.href='../../Form/PaymentPortal/Default?id=SILVERSCRIPT'; }} }, {xtype: 'container', layout: {type: 'vbox', pack: 'center', align: 'left'}, cls: 'im-provider-header-buttons', scrollable: null, id: 'NavSelectProvider_container_4', items: [ {xtype: 'label', html: 'Aetna Medicare Prescription Drug Plan', name: 'SubheaderProviderName', ui: 'subheading-primary', cls: 'initial-caps font-400 im-bold-button subheading-primary', id: 'NavSelectProvider_SubheaderProviderName' }, {xtype: 'container', layout: {type: 'hbox'}, scrollable: null, id: 'NavSelectProvider_container_5', items: [ {xtype: 'container', html: '', hidden: true, cls: 'im-address-verification-icon', scrollable: null, id: 'NavSelectProvider_container_6' }, {xtype: 'label', html: 'P.O. Box 504849, St Louis, MO 63150-4849', ui: 'body1-secondary', cls: 'line-height-20 body1-secondary', id: 'NavSelectProvider_label' }] }, {xtype: 'container', layout: {type: 'hbox'}, hidden: false, scrollable: null, id: 'NavSelectProvider_container_7', items: [ {xtype: 'label', html: '(855) 651-4856', ui: 'body1-primary', cls: 'body1-primary', id: 'NavSelectProvider_label_1' }] }] }] }, {xtype: 'spacer', id: 'NavSelectProvider_spacer_3', plugins: 'responsive', responsiveConfig: {'width > 1272':{flex : 1,},'width <= 1272':{flex :0,},} }] }, { xtype: 'panel', dock: 'top', frame: false, scrollable: 'true', id: 'panel_3', items: [ {xtype: 'container', maxWidth: 1272, layout: {type: 'hbox'}, cls: 'mainContent MainContentWithHeaerAndSubheader ', scrollable: null, id: 'container_10', items: [ {xtype: 'container', flex: 1, scrollable: null, id: 'container_11', items: [ { xtype: 'form', preventHeader: true, bodyCls: 'mypanel', api: { }, name: 'MyFormPanel', itemId: 'MyFormPanel', cls: 'col-large-offSet-3 col-medium-offSet-3 col-small-offSet-1 smallTenColumn xsmallTwelveColumn mediumSixColumn largeSixColumn ', scrollable: null, id: 'MyFormPanel', items: [ {xtype: 'errorbox', name: 'ValidationSummary', ui: 'ErrorBox', hidden: true, cls: 'ErrorBox', id: 'ValidationSummary_3' }, {xtype: 'instamedHeading1', text: 'Select Healthcare Provider', id: 'MyFormPanel_instamedHeading1' }, {xtype: 'dataviewliteproviders', tpl: ['
', name: 'poweredbylogo', cls: 'hiddenxs hiddensm', scrollable: null, id: 'NavSelectProvider_poweredbylogo' }, {xtype: 'container', cls: 'copyrightContainer hiddenxs hiddensm', scrollable: null, id: 'NavSelectProvider_container_9', items: [ {xtype: 'spacer', cls: 'hiddenmd hiddenlg', id: 'NavSelectProvider_spacer_4' }, {xtype: 'label', html: '© 2024 InstaMed. All Rights Reserved.', name: 'copyrightFooter', ui: 'body1-primary', cls: 'margin-bottom-10 body1-primary', id: 'NavSelectProvider_copyrightFooter' }, {xtype: 'spacer', cls: 'hiddenmd hiddenlg', id: 'NavSelectProvider_spacer_5' }] }, {xtype: 'spacer', cls: 'hiddenxs hiddensm', id: 'NavSelectProvider_spacer_6' }, {xtype: 'container', cls: 'linkButtonContainer hiddenxs hiddensm', scrollable: null, id: 'NavSelectProvider_container_10', items: [ {xtype: 'button', text: 'Security', iconCls: 'x-ma ma-lock-outline', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavSelectProvider_button_Security', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/security/','open-window');}} }, {xtype: 'button', text: 'Privacy', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavSelectProvider_button_Privacy', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/privacy-statement/','open-window');}} }, {xtype: 'button', text: 'Terms', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavSelectProvider_button_Terms', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/terms-of-use/','open-window');}} }, {xtype: 'button', text: 'Help', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavSelectProvider_button_Help', listeners: {tap: function() { InstaMed.popupNewWindow('../../Form/PaymentPortal/ContactUs?id=SILVERSCRIPT','open-window');}} }, {xtype: 'button', text: 'English', align: 'right',menu:[{xtype: 'menuitem', text: 'English', handler: function(cmp) { PerformAction({Language:'en'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'en', cls: 'hiddenxs hiddensm', id: 'menuitem_en_6'},{xtype: 'menuitem', text: 'Español', handler: function(cmp) { PerformAction({Language:'es'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'es', cls: 'hiddenxs hiddensm', id: 'menuitem_es_6'},{xtype: 'menuitem', text: 'Français', handler: function(cmp) { PerformAction({Language:'fr'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'fr', cls: 'hiddenxs hiddensm', id: 'menuitem_fr_6'},], name: 'ForeignLanguages', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavSelectProvider_button_ForeignLanguages' }] }, {xtype: 'container', cls: 'hiddenmd hiddenlg', scrollable: null, id: 'NavSelectProvider_container_11', items: [ {xtype: 'container', layout: {type: 'hbox', pack: 'center'}, cls: 'x-center-helper', scrollable: null, id: 'NavSelectProvider_container_12', items: [ {xtype: 'spacer', id: 'NavSelectProvider_spacer_7' }, {xtype: 'container', html: '
', name: 'poweredbylogo', scrollable: null, id: 'NavSelectProvider_poweredbylogo_1' }, {xtype: 'spacer', id: 'NavSelectProvider_spacer_8' }] }, {xtype: 'container', layout: {type: 'hbox', pack: 'center'}, cls: 'x-center-helper', scrollable: null, id: 'NavSelectProvider_container_13', items: [ {xtype: 'spacer', id: 'NavSelectProvider_spacer_9' }, {xtype: 'container', cls: 'copyrightContainer', scrollable: null, id: 'NavSelectProvider_container_14', items: [ {xtype: 'spacer', cls: 'hiddenmd hiddenlg', id: 'NavSelectProvider_spacer_10' }, {xtype: 'label', html: '© 2024 InstaMed. All Rights Reserved.', name: 'copyrightFooter', ui: 'body1-primary', cls: 'margin-bottom-10 body1-primary', id: 'NavSelectProvider_copyrightFooter_1' }, {xtype: 'spacer', cls: 'hiddenmd hiddenlg', id: 'NavSelectProvider_spacer_11' }] }, {xtype: 'spacer', id: 'NavSelectProvider_spacer_12' }] }, {xtype: 'container', layout: {type: 'hbox', pack: 'center'}, cls: 'x-center-helper', scrollable: null, id: 'NavSelectProvider_container_15', items: [ {xtype: 'spacer', id: 'NavSelectProvider_spacer_13' }, {xtype: 'container', cls: 'linkButtonContainer ', scrollable: null, id: 'NavSelectProvider_container_16', items: [ {xtype: 'button', text: 'Security', iconCls: 'x-ma ma-lock-outline', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavSelectProvider_button_Security_1', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/security/','open-window');}} }, {xtype: 'button', text: 'Privacy', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavSelectProvider_button_Privacy_1', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/privacy-statement/','open-window');}} }, {xtype: 'button', text: 'Terms', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavSelectProvider_button_Terms_1', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/terms-of-use/','open-window');}} }, {xtype: 'button', text: 'Help', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavSelectProvider_button_Help_1', listeners: {tap: function() { InstaMed.popupNewWindow('../../Form/PaymentPortal/ContactUs?id=SILVERSCRIPT','open-window');}} }] }, {xtype: 'spacer', id: 'NavSelectProvider_spacer_14' }] }, {xtype: 'container', layout: {type: 'hbox', pack: 'center'}, cls: 'x-center-helper', scrollable: null, id: 'NavSelectProvider_container_17', items: [ {xtype: 'spacer', id: 'NavSelectProvider_spacer_15' }, {xtype: 'container', scrollable: null, id: 'NavSelectProvider_container_18', items: [ {xtype: 'button', text: 'English', align: 'right',menu:[{xtype: 'menuitem', text: 'English', handler: function(cmp) { PerformAction({Language:'en'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'en', cls: 'hiddenmd hiddenlg', id: 'menuitem_en_7'},{xtype: 'menuitem', text: 'Español', handler: function(cmp) { PerformAction({Language:'es'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'es', cls: 'hiddenmd hiddenlg', id: 'menuitem_es_7'},{xtype: 'menuitem', text: 'Français', handler: function(cmp) { PerformAction({Language:'fr'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'fr', cls: 'hiddenmd hiddenlg', id: 'menuitem_fr_7'},], name: 'ForeignLanguages', ui: 'grey', margin: '', hidden: false, ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavSelectProvider_button_ForeignLanguages_1' }] }, {xtype: 'spacer', id: 'NavSelectProvider_spacer_16' }] }] }] }, {xtype: 'spacer', id: 'spacer_11' }] }] }, {xtype: 'container', name: 'NavQuickPayGoGreen', layout: {type: 'vbox', pack: 'start'}, showBackButton: true, showMenuButton: false, scrollable: 'true', id: 'NavQuickPayGoGreen', items: [ {xtype: 'container', docked: 'top', scrollable: null, id: 'NavQuickPayGoGreen_container', items: [ {xtype: 'instamedNavigationBar', name: 'headerBar', layout: {type: 'hbox'}, hidden: false, cls: 'im-ignore-custom-colors im-ignore-background', scrollable: null, id: 'NavQuickPayGoGreen_headerBar', items: [ {xtype: 'spacer', id: 'NavQuickPayGoGreen_spacer', plugins: 'responsive', responsiveConfig: {'width > 1272':{flex : 1,},'width <= 1272':{flex :0,},} }, {xtype: 'titlebar', title: '<a href=\\"../../Form/PaymentPortal/Start\\"> <img src=\\"../../ContentHandler.aspx?URL=/Images/Database/cvscaremark@instamed.net/WolkenJ@cvscaremark/cvscaremark@instamed.net000013897108-001-002HeaderLogo/638482659224849466&id=SILVERSCRIPT\\" alt=\\"Company Logo\\" style=\\"height: 40px\\">', maxWidth: 1272, cls: 'largeTwelveColumn mediumTwelveColumn smallTwelveColumn xsmallTwelveColumn im-ignore-custom-colors im-ignore-background', scrollable: null, id: 'NavQuickPayGoGreen_titlebar', plugins: 'responsive', responsiveConfig: {'width >= 1272':{title :'',},'width < 1272':{title : ' ',},}, items: [ {xtype: 'button', accessibleText: 'Back', iconCls: 'x-ma ma-arrow-back', align: 'left', name: 'TitleBarNavigationViewBack', margin: '', hidden: false, ariaRole: 'button', cls: 'x-button-icon-link-style white hiddenlg noprint', id: 'NavQuickPayGoGreen_TitleBarNavigationViewBack', plugins: 'responsive', responsiveConfig: {'width > 1272':{iconCls :'',},'width <= 1272':{iconCls : 'x-ma ma-arrow-back',},}, listeners: {tap: function(){ headerPatientPortalBack(); }} }, {xtype: 'container', html: ' ', align: 'left', scrollable: null, id: 'NavQuickPayGoGreen_container_1', plugins: 'responsive', responsiveConfig: {'width >= 1272':{hidden : false,},'width < 1272':{hidden :true,},} }, {xtype: 'button', name: 'HeaderTitlebarButton', ui: 'white', margin: '', hidden: true, ariaRole: 'button', cls: 'x-button-link-style im-center-header-button white noprint', id: 'NavQuickPayGoGreen_HeaderTitlebarButton' }, {xtype: 'button', accessibleText: 'Log In or Sign Up', iconCls: 'x-ma ma-account-circle', align: 'right',menu:[{xtype: 'menuitem', text: 'Log In', handler: function() { PerformAction({}, PatientPortalLoginController.redirectToLogin,null); }, id: 'menuitem_LogIn_8'},{xtype: 'menuitem', text: 'Sign Up', handler: function() { PerformAction({}, SignUpController.redirectToSignUp,null); }, id: 'menuitem_SignUp_8'},], name: 'LoginOrSignUpProfileIcon', margin: '', ariaRole: 'button', cls: 'x-button-icon-link-style white noprint', id: 'NavQuickPayGoGreen_button_LoginOrSignUpProfileIcon', plugins: 'responsive', responsiveConfig: {'!InstaMed.isLoggedIn & width > 960':{hidden: true,},'!InstaMed.isLoggedIn && width <= 960':{hidden: false,},}, listeners: {hiddenchange: function() { Ext.ComponentQuery.query('[name=LoginOrSignUpProfileIcon]')[0].getMenu().hide(); }} }, {xtype: 'button', text: '', align: 'right',menu:[{xtype: 'menuitem', text: 'Dashboard', handler: function(){ window.location.href='../../Form/PaymentPortal/Dashboard'; }, id: 'menuitem_Dashboard_16'},{xtype: 'menuitem', text: 'Help', handler: function() { window.open('https://help.instamed.com/patients/s/?dc_label=Patients')}, id: 'menuitem_Help_16'},{xtype: 'menuitem', text: 'Log Out', handler: function(){ window.location.href='../../Form/PaymentPortal/Logout?id=SILVERSCRIPT'; }, id: 'menuitem_LogOut_16'},], name: 'Profile', ui: 'white', margin: '', hidden: true, ariaRole: 'button', cls: 'x-button-link-style white noprint', id: 'NavQuickPayGoGreen_button_Profile', plugins: 'responsive', responsiveConfig: {'InstaMed.isLoggedIn & width > 960':{hidden: false,},'InstaMed.isLoggedIn && width <= 960':{hidden: true,},}, listeners: {hiddenchange: function() { Ext.ComponentQuery.query('[name=Profile]')[0].getMenu().hide(); }} }, {xtype: 'container', align: 'right', name: 'LoginOrSignUpContainer', layout: {type: 'hbox'}, scrollable: null, id: 'NavQuickPayGoGreen_LoginOrSignUpContainer', plugins: 'responsive', responsiveConfig: {'!InstaMed.isLoggedIn & width > 960':{hidden: false,},'!InstaMed.isLoggedIn && width <= 960':{hidden: true,},}, items: [ {xtype: 'button', text: 'Log In', align: 'right', name: 'LoginForDualLogin', ui: 'white', margin: '', hidden: false, ariaRole: 'button', cls: 'x-button-link-style hiddenxs hiddensm white noprint', id: 'NavQuickPayGoGreen_button_LoginForDualLogin', listeners: {tap: function() { PerformAction({}, PatientPortalLoginController.redirectToLogin,null); }} }, {xtype: 'label', html: 'or', align: 'right', name: 'Or', ui: 'body1-white', cls: 'hiddenxs hiddensm body1-white', id: 'NavQuickPayGoGreen_Or' }, {xtype: 'button', text: 'Sign Up', align: 'right', name: 'SignUpForDualLogin', ui: 'white', margin: '', ariaRole: 'button', cls: 'x-button-link-style hiddenxs hiddensm white noprint', id: 'NavQuickPayGoGreen_button_SignUpForDualLogin', listeners: {tap: function() { PerformAction({}, SignUpController.redirectToSignUp,null); }} }] }, {xtype: 'button', accessibleText: 'Profile', iconCls: 'x-ma ma-account-circle', align: 'right',menu:[{xtype: 'menuitem', text: 'Dashboard', handler: function(){ window.location.href='../../Form/PaymentPortal/Dashboard'; }, id: 'menuitem_Dashboard_17'},{xtype: 'menuitem', text: 'Help', handler: function() { window.open('https://help.instamed.com/patients/s/?dc_label=Patients')}, id: 'menuitem_Help_17'},{xtype: 'menuitem', text: 'Log Out', handler: function(){ window.location.href='../../Form/PaymentPortal/Logout?id=SILVERSCRIPT'; }, id: 'menuitem_LogOut_17'},], name: 'ProfileIcon', margin: '', hidden: true, ariaRole: 'button', cls: 'x-button-icon-link-style white noprint', id: 'NavQuickPayGoGreen_button_ProfileIcon', plugins: 'responsive', responsiveConfig: {'InstaMed.isLoggedIn & width > 960':{hidden: true,},'InstaMed.isLoggedIn && width <= 960':{hidden: false,},}, listeners: {hiddenchange: function() { Ext.ComponentQuery.query('[name=ProfileIcon]')[0].getMenu().hide(); }} }] }, {xtype: 'spacer', id: 'NavQuickPayGoGreen_spacer_1', plugins: 'responsive', responsiveConfig: {'width > 1272':{flex : 1,},'width <= 1272':{flex :0,},} }] }] }, {xtype: 'container', layout: {type: 'hbox'}, cls: 'x-subheader-container', scrollable: null, id: 'NavQuickPayGoGreen_container_2', items: [ {xtype: 'spacer', id: 'NavQuickPayGoGreen_spacer_2', plugins: 'responsive', responsiveConfig: {'width > 1272':{flex : 1,},'width <= 1272':{flex :0,},} }, {xtype: 'container', maxWidth: 1272, layout: {type: 'hbox'}, cls: 'largeTwelveColumn mediumTwelveColumn smallTwelveColumn xsmallTwelveColumn x-subheader-panel ', scrollable: null, id: 'NavQuickPayGoGreen_container_3', items: [ {xtype: 'image', src: '../../ContentHandler.aspx?URL=/Images/Database/1A6440F4-9734-4861-8F1B-82AEFA1C6DB1&id=SILVERSCRIPT&crop=true&maxWidth=150&maxHeight=64', hidden: true, cls: 'x-clickable x-button-provider-img', id: 'NavQuickPayGoGreen_image', listeners: {painted: function() { var cmp = this; cmp.el.dom.setAttribute('aria-label', 'Aetna Medicare Prescription Drug Plan logo'); cmp.el.dom.setAttribute('role', 'img'); cmp.el.dom.setAttribute('title', ''); },tap: function(){ window.location.href='../../Form/PaymentPortal/Default?id=SILVERSCRIPT'; }} }, {xtype: 'container', layout: {type: 'vbox', pack: 'center', align: 'left'}, cls: 'im-provider-header-buttons', scrollable: null, id: 'NavQuickPayGoGreen_container_4', items: [ {xtype: 'label', html: 'Aetna Medicare Prescription Drug Plan', name: 'SubheaderProviderName', ui: 'subheading-primary', cls: 'initial-caps font-400 im-bold-button subheading-primary', id: 'NavQuickPayGoGreen_SubheaderProviderName' }, {xtype: 'container', layout: {type: 'hbox'}, scrollable: null, id: 'NavQuickPayGoGreen_container_5', items: [ {xtype: 'container', html: '', hidden: true, cls: 'im-address-verification-icon', scrollable: null, id: 'NavQuickPayGoGreen_container_6' }, {xtype: 'label', html: 'P.O. Box 504849, St Louis, MO 63150-4849', ui: 'body1-secondary', cls: 'line-height-20 body1-secondary', id: 'NavQuickPayGoGreen_label' }] }, {xtype: 'container', layout: {type: 'hbox'}, hidden: false, scrollable: null, id: 'NavQuickPayGoGreen_container_7', items: [ {xtype: 'label', html: '(855) 651-4856', ui: 'body1-primary', cls: 'body1-primary', id: 'NavQuickPayGoGreen_label_1' }] }] }] }, {xtype: 'spacer', id: 'NavQuickPayGoGreen_spacer_3', plugins: 'responsive', responsiveConfig: {'width > 1272':{flex : 1,},'width <= 1272':{flex :0,},} }] }, { xtype: 'panel', dock: 'top', frame: false, scrollable: 'true', id: 'panel_8', items: [ {xtype: 'container', maxWidth: 1272, layout: {type: 'hbox'}, cls: 'mainContent MainContentWithHeaerAndSubheader ', scrollable: null, id: 'container_28', items: [ {xtype: 'container', flex: 1, scrollable: null, id: 'container_29', items: [ { xtype: 'form', preventHeader: true, bodyCls: 'mypanel', api: { }, name: 'FormQuickPayGoGreen', itemId: 'FormQuickPayGoGreen', cls: 'col-large-offSet-3 col-medium-offSet-3 col-small-offSet-1 smallTenColumn xsmallTwelveColumn mediumSixColumn largeSixColumn ', scrollable: null, id: 'FormQuickPayGoGreen', items: [ {xtype: 'errorbox', name: 'ValidationSummary', ui: 'ErrorBox', hidden: true, cls: 'ErrorBox', id: 'ValidationSummary_8' }, {xtype: 'instamedHeading1', text: 'Paperless Statements', id: 'FormQuickPayGoGreen_instamedHeading1' }, {xtype: 'label', html: 'Enroll today and start receiving your statements online.', name: 'ReceiveEmailStatements', ui: 'body1-primary', hidden: false, cls: 'im-top-label im-bottom-label body1-primary', id: 'FormQuickPayGoGreen_ReceiveEmailStatements' }, {xtype: 'container', name: 'EStatementEnrollmentContainer', hidden: false, cls: 'im-estatement-enrollment-container', scrollable: null, id: 'FormQuickPayGoGreen_EStatementEnrollmentContainer', items: [ {xtype: 'container', layout: {type: 'hbox'}, scrollable: null, id: 'FormQuickPayGoGreen_container', items: [ {xtype: 'checkboxfield', value: 'true', uncheckedValue: 'false', checked: false, labelFieldComponentName: 'CheckboxScreenReadableLabel', fieldLabel: '', label: '', labelSeparator: ' ', required: false, labelWrap: true, labelAlign: 'right', errorTarget: 'under', clearable: false, requiredMessage: ' is required', autoComplete: 'on', name: 'EnrollInEstatement', ui: 'subheading-primary', hideLabel: true, margin: '', cls: 'im-estatement-enrollment-checkbox x-circle-checkboxfield subheading-primary', id: 'FormQuickPayGoGreen_EnrollInEstatement', listeners: {blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'container', html: '
Learn More', name: 'poweredbylogo', cls: 'hiddenxs hiddensm', scrollable: null, id: 'NavQuickPayGoGreen_poweredbylogo' }, {xtype: 'container', cls: 'copyrightContainer hiddenxs hiddensm', scrollable: null, id: 'NavQuickPayGoGreen_container_9', items: [ {xtype: 'spacer', cls: 'hiddenmd hiddenlg', id: 'NavQuickPayGoGreen_spacer_4' }, {xtype: 'label', html: '© 2024 InstaMed. All Rights Reserved.', name: 'copyrightFooter', ui: 'body1-primary', cls: 'margin-bottom-10 body1-primary', id: 'NavQuickPayGoGreen_copyrightFooter' }, {xtype: 'spacer', cls: 'hiddenmd hiddenlg', id: 'NavQuickPayGoGreen_spacer_5' }] }, {xtype: 'spacer', cls: 'hiddenxs hiddensm', id: 'NavQuickPayGoGreen_spacer_6' }, {xtype: 'container', cls: 'linkButtonContainer hiddenxs hiddensm', scrollable: null, id: 'NavQuickPayGoGreen_container_10', items: [ {xtype: 'button', text: 'Security', iconCls: 'x-ma ma-lock-outline', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavQuickPayGoGreen_button_Security', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/security/','open-window');}} }, {xtype: 'button', text: 'Privacy', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavQuickPayGoGreen_button_Privacy', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/privacy-statement/','open-window');}} }, {xtype: 'button', text: 'Terms', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavQuickPayGoGreen_button_Terms', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/terms-of-use/','open-window');}} }, {xtype: 'button', text: 'Help', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavQuickPayGoGreen_button_Help', listeners: {tap: function() { InstaMed.popupNewWindow('../../Form/PaymentPortal/ContactUs?id=SILVERSCRIPT','open-window');}} }, {xtype: 'button', text: 'English', align: 'right',menu:[{xtype: 'menuitem', text: 'English', handler: function(cmp) { PerformAction({Language:'en'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'en', cls: 'hiddenxs hiddensm', id: 'menuitem_en_16'},{xtype: 'menuitem', text: 'Español', handler: function(cmp) { PerformAction({Language:'es'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'es', cls: 'hiddenxs hiddensm', id: 'menuitem_es_16'},{xtype: 'menuitem', text: 'Français', handler: function(cmp) { PerformAction({Language:'fr'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'fr', cls: 'hiddenxs hiddensm', id: 'menuitem_fr_16'},], name: 'ForeignLanguages', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavQuickPayGoGreen_button_ForeignLanguages' }] }, {xtype: 'container', cls: 'hiddenmd hiddenlg', scrollable: null, id: 'NavQuickPayGoGreen_container_11', items: [ {xtype: 'container', layout: {type: 'hbox', pack: 'center'}, cls: 'x-center-helper', scrollable: null, id: 'NavQuickPayGoGreen_container_12', items: [ {xtype: 'spacer', id: 'NavQuickPayGoGreen_spacer_7' }, {xtype: 'container', html: '
', name: 'poweredbylogo', scrollable: null, id: 'NavQuickPayGoGreen_poweredbylogo_1' }, {xtype: 'spacer', id: 'NavQuickPayGoGreen_spacer_8' }] }, {xtype: 'container', layout: {type: 'hbox', pack: 'center'}, cls: 'x-center-helper', scrollable: null, id: 'NavQuickPayGoGreen_container_13', items: [ {xtype: 'spacer', id: 'NavQuickPayGoGreen_spacer_9' }, {xtype: 'container', cls: 'copyrightContainer', scrollable: null, id: 'NavQuickPayGoGreen_container_14', items: [ {xtype: 'spacer', cls: 'hiddenmd hiddenlg', id: 'NavQuickPayGoGreen_spacer_10' }, {xtype: 'label', html: '© 2024 InstaMed. All Rights Reserved.', name: 'copyrightFooter', ui: 'body1-primary', cls: 'margin-bottom-10 body1-primary', id: 'NavQuickPayGoGreen_copyrightFooter_1' }, {xtype: 'spacer', cls: 'hiddenmd hiddenlg', id: 'NavQuickPayGoGreen_spacer_11' }] }, {xtype: 'spacer', id: 'NavQuickPayGoGreen_spacer_12' }] }, {xtype: 'container', layout: {type: 'hbox', pack: 'center'}, cls: 'x-center-helper', scrollable: null, id: 'NavQuickPayGoGreen_container_15', items: [ {xtype: 'spacer', id: 'NavQuickPayGoGreen_spacer_13' }, {xtype: 'container', cls: 'linkButtonContainer ', scrollable: null, id: 'NavQuickPayGoGreen_container_16', items: [ {xtype: 'button', text: 'Security', iconCls: 'x-ma ma-lock-outline', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavQuickPayGoGreen_button_Security_1', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/security/','open-window');}} }, {xtype: 'button', text: 'Privacy', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavQuickPayGoGreen_button_Privacy_1', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/privacy-statement/','open-window');}} }, {xtype: 'button', text: 'Terms', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavQuickPayGoGreen_button_Terms_1', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/terms-of-use/','open-window');}} }, {xtype: 'button', text: 'Help', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavQuickPayGoGreen_button_Help_1', listeners: {tap: function() { InstaMed.popupNewWindow('../../Form/PaymentPortal/ContactUs?id=SILVERSCRIPT','open-window');}} }] }, {xtype: 'spacer', id: 'NavQuickPayGoGreen_spacer_14' }] }, {xtype: 'container', layout: {type: 'hbox', pack: 'center'}, cls: 'x-center-helper', scrollable: null, id: 'NavQuickPayGoGreen_container_17', items: [ {xtype: 'spacer', id: 'NavQuickPayGoGreen_spacer_15' }, {xtype: 'container', scrollable: null, id: 'NavQuickPayGoGreen_container_18', items: [ {xtype: 'button', text: 'English', align: 'right',menu:[{xtype: 'menuitem', text: 'English', handler: function(cmp) { PerformAction({Language:'en'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'en', cls: 'hiddenmd hiddenlg', id: 'menuitem_en_17'},{xtype: 'menuitem', text: 'Español', handler: function(cmp) { PerformAction({Language:'es'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'es', cls: 'hiddenmd hiddenlg', id: 'menuitem_es_17'},{xtype: 'menuitem', text: 'Français', handler: function(cmp) { PerformAction({Language:'fr'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'fr', cls: 'hiddenmd hiddenlg', id: 'menuitem_fr_17'},], name: 'ForeignLanguages', ui: 'grey', margin: '', hidden: false, ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavQuickPayGoGreen_button_ForeignLanguages_1' }] }, {xtype: 'spacer', id: 'NavQuickPayGoGreen_spacer_16' }] }] }] }, {xtype: 'spacer', id: 'spacer_26' }] }] }, { xtype: 'window', title: '
What is Automatic Payment?
', titleAlign: 'center', itemId: 'APCAboutWindow', flex: 1, defaultFocus: 'tool', closable: true, modal: true, draggable: false, constrainHeader: true, constrainTo: 'mainBorderPanel', closeAction: 'hide', name: 'APCAboutWindow', ui: 'large', maxWidth: 600, flex: 1, cls: 'large', id: 'APCAboutWindow', listeners: {show: function() { var listenerArgs = arguments; Ext.Array.each([function(cmp) { if (cmp._closable) { cmp.el.dom.querySelector('.x-tool').setAttribute('aria-label', 'Close'); } },function(cmp) { Ext.each(Ext.DomQuery.select('.x-panel-body', Ext.DomQuery.selectNode('.x-window[id=APCAboutWindow]')), function(p) { Ext.get(p.id).scrollTo('top', 0); }); }], function(func) { func.apply(this, listenerArgs); }); }}, items: [ {xtype: 'label', html: '
\r\n\r\n
\r\n A: The automatically scheduled payment will be charged to the payment method you have on file.
\r\n
\r\n A: Yes, you can edit the maximum payment amount, payment method, or cancel your enrollment from this portal.
\r\n
\r\n A: A notification will be sent with your balance, the scheduled payment amount, and the date the payment is scheduled for.
', flex: 1, id: 'label' }] }, {xtype: 'container', name: 'NavReceiptPreview', layout: {type: 'vbox', pack: 'start'}, showBackButton: false, showMenuButton: false, scrollable: 'true', id: 'NavReceiptPreview', items: [ {xtype: 'container', docked: 'top', scrollable: null, id: 'NavReceiptPreview_container', items: [ {xtype: 'instamedNavigationBar', name: 'headerBar', layout: {type: 'hbox'}, hidden: false, cls: 'im-ignore-custom-colors im-ignore-background', scrollable: null, id: 'NavReceiptPreview_headerBar', items: [ {xtype: 'spacer', id: 'NavReceiptPreview_spacer', plugins: 'responsive', responsiveConfig: {'width > 1272':{flex : 1,},'width <= 1272':{flex :0,},} }, {xtype: 'titlebar', title: '<a href=\\"../../Form/PaymentPortal/Start\\"> <img src=\\"../../ContentHandler.aspx?URL=/Images/Database/cvscaremark@instamed.net/WolkenJ@cvscaremark/cvscaremark@instamed.net000013897108-001-002HeaderLogo/638482659224849466&id=SILVERSCRIPT\\" alt=\\"Company Logo\\" style=\\"height: 40px\\">', maxWidth: 1272, cls: 'largeTwelveColumn mediumTwelveColumn smallTwelveColumn xsmallTwelveColumn im-ignore-custom-colors im-ignore-background', scrollable: null, id: 'NavReceiptPreview_titlebar', plugins: 'responsive', responsiveConfig: {'width >= 1272':{title :'',},'width < 1272':{title : ' ',},}, items: [ {xtype: 'button', accessibleText: 'Back', iconCls: 'x-ma ma-arrow-back', align: 'left', name: 'TitleBarNavigationViewBack', margin: '', hidden: false, ariaRole: 'button', cls: 'x-button-icon-link-style white hiddenlg noprint', id: 'NavReceiptPreview_TitleBarNavigationViewBack', plugins: 'responsive', responsiveConfig: {'width > 1272':{iconCls :'',},'width <= 1272':{iconCls : 'x-ma ma-arrow-back',},}, listeners: {tap: function(){ headerPatientPortalBack(); }} }, {xtype: 'container', html: ' ', align: 'left', scrollable: null, id: 'NavReceiptPreview_container_1', plugins: 'responsive', responsiveConfig: {'width >= 1272':{hidden : false,},'width < 1272':{hidden :true,},} }, {xtype: 'button', name: 'HeaderTitlebarButton', ui: 'white', margin: '', hidden: true, ariaRole: 'button', cls: 'x-button-link-style im-center-header-button white noprint', id: 'NavReceiptPreview_HeaderTitlebarButton' }, {xtype: 'button', accessibleText: 'Log In or Sign Up', iconCls: 'x-ma ma-account-circle', align: 'right',menu:[{xtype: 'menuitem', text: 'Log In', handler: function() { PerformAction({}, PatientPortalLoginController.redirectToLogin,null); }, id: 'menuitem_LogIn_10'},{xtype: 'menuitem', text: 'Sign Up', handler: function() { PerformAction({}, SignUpController.redirectToSignUp,null); }, id: 'menuitem_SignUp_10'},], name: 'LoginOrSignUpProfileIcon', margin: '', ariaRole: 'button', cls: 'x-button-icon-link-style white noprint', id: 'NavReceiptPreview_button_LoginOrSignUpProfileIcon', plugins: 'responsive', responsiveConfig: {'!InstaMed.isLoggedIn & width > 960':{hidden: true,},'!InstaMed.isLoggedIn && width <= 960':{hidden: false,},}, listeners: {hiddenchange: function() { Ext.ComponentQuery.query('[name=LoginOrSignUpProfileIcon]')[0].getMenu().hide(); }} }, {xtype: 'button', text: '', align: 'right',menu:[{xtype: 'menuitem', text: 'Dashboard', handler: function(){ window.location.href='../../Form/PaymentPortal/Dashboard'; }, id: 'menuitem_Dashboard_20'},{xtype: 'menuitem', text: 'Help', handler: function() { window.open('https://help.instamed.com/patients/s/?dc_label=Patients')}, id: 'menuitem_Help_20'},{xtype: 'menuitem', text: 'Log Out', handler: function(){ window.location.href='../../Form/PaymentPortal/Logout?id=SILVERSCRIPT'; }, id: 'menuitem_LogOut_20'},], name: 'Profile', ui: 'white', margin: '', hidden: true, ariaRole: 'button', cls: 'x-button-link-style white noprint', id: 'NavReceiptPreview_button_Profile', plugins: 'responsive', responsiveConfig: {'InstaMed.isLoggedIn & width > 960':{hidden: false,},'InstaMed.isLoggedIn && width <= 960':{hidden: true,},}, listeners: {hiddenchange: function() { Ext.ComponentQuery.query('[name=Profile]')[0].getMenu().hide(); }} }, {xtype: 'container', align: 'right', name: 'LoginOrSignUpContainer', layout: {type: 'hbox'}, scrollable: null, id: 'NavReceiptPreview_LoginOrSignUpContainer', plugins: 'responsive', responsiveConfig: {'!InstaMed.isLoggedIn & width > 960':{hidden: false,},'!InstaMed.isLoggedIn && width <= 960':{hidden: true,},}, items: [ {xtype: 'button', text: 'Log In', align: 'right', name: 'LoginForDualLogin', ui: 'white', margin: '', hidden: false, ariaRole: 'button', cls: 'x-button-link-style hiddenxs hiddensm white noprint', id: 'NavReceiptPreview_button_LoginForDualLogin', listeners: {tap: function() { PerformAction({}, PatientPortalLoginController.redirectToLogin,null); }} }, {xtype: 'label', html: 'or', align: 'right', name: 'Or', ui: 'body1-white', cls: 'hiddenxs hiddensm body1-white', id: 'NavReceiptPreview_Or' }, {xtype: 'button', text: 'Sign Up', align: 'right', name: 'SignUpForDualLogin', ui: 'white', margin: '', ariaRole: 'button', cls: 'x-button-link-style hiddenxs hiddensm white noprint', id: 'NavReceiptPreview_button_SignUpForDualLogin', listeners: {tap: function() { PerformAction({}, SignUpController.redirectToSignUp,null); }} }] }, {xtype: 'button', accessibleText: 'Profile', iconCls: 'x-ma ma-account-circle', align: 'right',menu:[{xtype: 'menuitem', text: 'Dashboard', handler: function(){ window.location.href='../../Form/PaymentPortal/Dashboard'; }, id: 'menuitem_Dashboard_21'},{xtype: 'menuitem', text: 'Help', handler: function() { window.open('https://help.instamed.com/patients/s/?dc_label=Patients')}, id: 'menuitem_Help_21'},{xtype: 'menuitem', text: 'Log Out', handler: function(){ window.location.href='../../Form/PaymentPortal/Logout?id=SILVERSCRIPT'; }, id: 'menuitem_LogOut_21'},], name: 'ProfileIcon', margin: '', hidden: true, ariaRole: 'button', cls: 'x-button-icon-link-style white noprint', id: 'NavReceiptPreview_button_ProfileIcon', plugins: 'responsive', responsiveConfig: {'InstaMed.isLoggedIn & width > 960':{hidden: true,},'InstaMed.isLoggedIn && width <= 960':{hidden: false,},}, listeners: {hiddenchange: function() { Ext.ComponentQuery.query('[name=ProfileIcon]')[0].getMenu().hide(); }} }] }, {xtype: 'spacer', id: 'NavReceiptPreview_spacer_1', plugins: 'responsive', responsiveConfig: {'width > 1272':{flex : 1,},'width <= 1272':{flex :0,},} }] }] }, {xtype: 'container', layout: {type: 'hbox'}, cls: 'x-subheader-container', scrollable: null, id: 'NavReceiptPreview_container_2', items: [ {xtype: 'spacer', id: 'NavReceiptPreview_spacer_2', plugins: 'responsive', responsiveConfig: {'width > 1272':{flex : 1,},'width <= 1272':{flex :0,},} }, {xtype: 'container', maxWidth: 1272, layout: {type: 'hbox'}, cls: 'largeTwelveColumn mediumTwelveColumn smallTwelveColumn xsmallTwelveColumn x-subheader-panel ', scrollable: null, id: 'NavReceiptPreview_container_3', items: [ {xtype: 'image', src: '../../ContentHandler.aspx?URL=/Images/Database/1A6440F4-9734-4861-8F1B-82AEFA1C6DB1&id=SILVERSCRIPT&crop=true&maxWidth=150&maxHeight=64', hidden: true, cls: 'x-clickable x-button-provider-img', id: 'NavReceiptPreview_image', listeners: {painted: function() { var cmp = this; cmp.el.dom.setAttribute('aria-label', 'Aetna Medicare Prescription Drug Plan logo'); cmp.el.dom.setAttribute('role', 'img'); cmp.el.dom.setAttribute('title', ''); },tap: function(){ window.location.href='../../Form/PaymentPortal/Default?id=SILVERSCRIPT'; }} }, {xtype: 'container', layout: {type: 'vbox', pack: 'center', align: 'left'}, cls: 'im-provider-header-buttons', scrollable: null, id: 'NavReceiptPreview_container_4', items: [ {xtype: 'label', html: 'Aetna Medicare Prescription Drug Plan', name: 'SubheaderProviderName', ui: 'subheading-primary', cls: 'initial-caps font-400 im-bold-button subheading-primary', id: 'NavReceiptPreview_SubheaderProviderName' }, {xtype: 'container', layout: {type: 'hbox'}, scrollable: null, id: 'NavReceiptPreview_container_5', items: [ {xtype: 'container', html: '', hidden: true, cls: 'im-address-verification-icon', scrollable: null, id: 'NavReceiptPreview_container_6' }, {xtype: 'label', html: 'P.O. Box 504849, St Louis, MO 63150-4849', ui: 'body1-secondary', cls: 'line-height-20 body1-secondary', id: 'NavReceiptPreview_label' }] }, {xtype: 'container', layout: {type: 'hbox'}, hidden: false, scrollable: null, id: 'NavReceiptPreview_container_7', items: [ {xtype: 'label', html: '(855) 651-4856', ui: 'body1-primary', cls: 'body1-primary', id: 'NavReceiptPreview_label_1' }] }] }] }, {xtype: 'spacer', id: 'NavReceiptPreview_spacer_3', plugins: 'responsive', responsiveConfig: {'width > 1272':{flex : 1,},'width <= 1272':{flex :0,},} }] }, { xtype: 'panel', dock: 'top', frame: false, scrollable: 'true', id: 'panel_10', items: [ {xtype: 'container', maxWidth: 1272, layout: {type: 'hbox'}, cls: 'mainContent MainContentWithHeaerAndSubheader ', scrollable: null, id: 'container_34', items: [ {xtype: 'container', flex: 1, scrollable: null, id: 'container_35', items: [ {xtype: 'container', cls: 'col-large-offSet-3 col-medium-offSet-3 col-small-offSet-1 smallTenColumn xsmallTwelveColumn mediumSixColumn largeSixColumn reverse im-form-wrapper', scrollable: null, id: 'container_36', items: [ { xtype: 'form', preventHeader: true, bodyCls: 'mypanel', api: { }, defaultSubmitButton: 'Verify', name: 'TextMsgEnrollTile', itemId: 'TextMsgEnrollTile', cls: 'bottom-pad-20', scrollable: null, id: 'TextMsgEnrollTile', items: [ {xtype: 'errorbox', name: 'ValidationSummary', ui: 'ErrorBox', hidden: true, cls: 'ErrorBox', id: 'ValidationSummary_11' }, {xtype: 'button', iconCls: 'md-icon-close', name: 'HideContainerX', ui: 'grey', margin: '', ariaRole: 'button', cls: 'container-x-closebutton grey noprint', id: 'TextMsgEnrollTile_HideContainerX', listeners: {tap: function(cmp) { var cmpForm = InstaMed.findParentForm(cmp); var containerToHide = Ext.getCmp('TextMsgEnrollTile'); if(containerToHide, cmpForm) { containerToHide.setVisible(false); }}} }, {xtype: 'container', name: 'TextMsgEnroll', flex: 2, scrollable: null, id: 'TextMsgEnrollTile_TextMsgEnroll', items: [ {xtype: 'instamedHeading1', text: 'Keep Your Account Safe and Updated', name: 'TextMessageEnrollTileTitle', id: 'TextMsgEnrollTile_TextMessageEnrollTileTitle' }, {xtype: 'container', html: 'To increase your security, please verify your mobile phone number. Add Number\r\n You can use this to reset passwords, enable two-step verification and \r\n enroll in payment alerts via text message.', name: 'TextMsgTwoStepFactorAndText', hidden: true, cls: 'im-form-bodytext', scrollable: null, id: 'TextMsgEnrollTile_TextMsgTwoStepFactorAndText' }, {xtype: 'container', html: 'To increase your security, please add and verify your mobile phone number. Add Number \r\n You can use this to reset passwords and enable two-step verification.', name: 'TextMsgTwoStepFactorOnly', hidden: false, cls: 'im-form-bodytext', scrollable: null, id: 'TextMsgEnrollTile_TextMsgTwoStepFactorOnly' }, {xtype: 'textfield', selectOnFocus: true, autoCorrect: false, fieldLabel: 'Mobile Phone Number', label: 'Mobile Phone Number', component: {"type":"tel","pattern":null}, inputType: 'tel', hidden: true, labelSeparator: ' ', required: false, labelWrap: true, labelAlign: 'placeholder', errorTarget: 'under', clearable: false, requiredMessage: 'Mobile Phone Number is required', autoComplete: 'on', name: 'MobilePhoneNumber2', margin: '', id: 'TextMsgEnrollTile_MobilePhoneNumber2', listeners: {action: submitOnEnter,blur: function(cmp){if(cmp.validate){cmp.validate();}},change: function(field, event, opts ){ var s = new String(field.getValue()); if(s != null && s != '') { s = s.replace(/[-,()\s]/g,'');var newValue='(';newValue+=s.substring(0,3);if(s.length>3){newValue+=') ';}newValue+=s.substring(3,6);if(s.length>6){newValue+='-';}newValue+=s.substring(6,10); if(isNaN(parseInt(newValue.substring(1,3)))){ newValue = ''; } field.setValue(newValue); if(InstaMed.isResponsive){ field.setInputValue(newValue); } } }} }, {xtype: 'container', layout: {type: 'hbox', pack: 'start', align: 'bottom'}, cls: 'ppp-button-group', scrollable: null, id: 'TextMsgEnrollTile_container', items: [ {xtype: 'button', text: 'Verify', name: 'Verify', ui: 'action', margin: '', ariaRole: 'button', cls: 'action noprint', id: 'TextMsgEnrollTile_button_Verify', listeners: {tap: function(cmp, newValue, oldValue, eOpts) { myForm = InstaMed.findParentForm(cmp); PerformAction(myForm.getValues(),TextMessageEnrollmentController.sendEnrollmentText,cmp,undefined,undefined,undefined,undefined,undefined); }} }, {xtype: 'button', text: 'Enroll', name: 'Enroll', ui: 'action', margin: '', hidden: true, ariaRole: 'button', cls: 'action noprint', id: 'TextMsgEnrollTile_button_Enroll', listeners: {tap: function(cmp, newValue, oldValue, eOpts) { myForm = InstaMed.findParentForm(cmp); PerformAction(myForm.getValues(),TextMessageEnrollmentController.enableTwoStepVerification,cmp,undefined,undefined,undefined,undefined,undefined); }} }, {xtype: 'button', text: 'No, Thanks', name: 'NoThanks', ui: 'secondary', margin: '', ariaRole: 'button', cls: 'secondary noprint', id: 'TextMsgEnrollTile_button_NoThanks', listeners: {tap: function(cmp) { if (cmp) { var containerToHide = Ext.getCmp('TextMsgEnrollTile'); containerToHide.setVisible(false); }}} }] }, {xtype: 'container', name: 'EnableTwoStepCheckbox', layout: {type: 'hbox'}, scrollable: null, id: 'TextMsgEnrollTile_EnableTwoStepCheckbox', items: [ {xtype: 'checkboxfield', value: 'true', uncheckedValue: 'false', checked: true, labelFieldComponentName: 'LabelEnableTwoStepVerification', fieldLabel: '', label: '', labelSeparator: ' ', required: false, labelWrap: true, labelAlign: 'right', errorTarget: 'under', clearable: false, requiredMessage: ' is required', autoComplete: 'on', name: 'EnableTwoStepVerification', hideLabel: true, margin: '', id: 'TextMsgEnrollTile_EnableTwoStepVerification', listeners: {render: function(cmp){ cmp.setChecked(true); cmp.setValue(true); },change: function(cmp){ if(InstaMed.isTrue(cmp.getChecked())){ cmp.setValue(true); }else{ cmp.setValue(false); } },blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'container', html: 'Enable Two-Step Verification', name: 'LabelEnableTwoStepVerification', cls: 'im-checkbox-label im-checkbox-label-single-field-form ', scrollable: null, id: 'TextMsgEnrollTile_LabelEnableTwoStepVerification' }] }, {xtype: 'container', html: 'By enrolling in two-step verification and/or text alerts, you agree to all InstaMed Communications\r\n Terms and Conditions. InstaMed will only use this number for account security and payment alerts. Message and data rates may apply.', name: 'TextMsgTwoStepTermsClause', cls: 'im-form-bodytext', scrollable: null, id: 'TextMsgEnrollTile_TextMsgTwoStepTermsClause' }] }, {xtype: 'container', name: 'TextMsgConfirmation', flex: 2, hidden: true, scrollable: null, id: 'TextMsgEnrollTile_TextMsgConfirmation', items: [ {xtype: 'instamedHeading1', text: 'Please Complete Verification', id: 'TextMsgEnrollTile_instamedHeading1' }, {xtype: 'container', html: 'Use the link in the text we just sent to complete verification. Once verified, you can go to preferences to manage your security and text message settings.', name: 'TextMsgEnrollVerifyDescription', cls: 'im-form-bodytext', scrollable: null, id: 'TextMsgEnrollTile_TextMsgEnrollVerifyDescription' }] }] }, { xtype: 'form', preventHeader: true, bodyCls: 'mypanel', api: { }, name: 'FormPaymentReceipt', itemId: 'FormPaymentReceipt', showBackButton: false, scrollable: null, id: 'FormPaymentReceipt', items: [ {xtype: 'errorbox', name: 'ValidationSummary', ui: 'ErrorBox', hidden: true, cls: 'ErrorBox', id: 'ValidationSummary_12' }, {xtype: 'instamedHeading1', text: 'Payment Summary', id: 'FormPaymentReceipt_instamedHeading1' }, {xtype: 'container', name: 'PaymentPlanContainer', hidden: true, cls: 'im-dataview-tile im-dataview-tile-relative im-dataview-tile-payment-plan mod-is-selectable mod-is-not-selectable', scrollable: null, id: 'FormPaymentReceipt_PaymentPlanContainer', items: [ {xtype: 'container', layout: {type: 'hbox'}, cls: 'im-dataview-tile-container', scrollable: null, id: 'FormPaymentReceipt_container', items: [ {xtype: 'container', name: 'PaymentPlanStatus', cls: 'im-dataview-tile-select-item', scrollable: null, id: 'FormPaymentReceipt_PaymentPlanStatus' }, {xtype: 'container', cls: 'im-dataview-tile-content', scrollable: null, id: 'FormPaymentReceipt_container_1', items: [ {xtype: 'label', name: 'PaymentPlanInstallment', cls: 'im-dataview-text-label', id: 'FormPaymentReceipt_PaymentPlanInstallment' }, {xtype: 'label', name: 'PaymentPlanDuration', ui: 'body1-secondary', cls: 'im-dataview-text-value x-show-block body1-secondary', id: 'FormPaymentReceipt_PaymentPlanDuration' }, {xtype: 'label', name: 'PaymentPlanStartDate', ui: 'body1-secondary', cls: 'im-dataview-text-value x-show-block body1-secondary', id: 'FormPaymentReceipt_PaymentPlanStartDate' }, {xtype: 'label', name: 'PaymentPlanInitialPaymentStatus', ui: 'body1-secondary', cls: 'im-dataview-text-value x-show-block body1-secondary', id: 'FormPaymentReceipt_PaymentPlanInitialPaymentStatus' }] }] }] }, {xtype: 'container', cls: 'im-transaction-status-wrapper', scrollable: null, id: 'FormPaymentReceipt_container_2', items: [ {xtype: 'container', name: 'TransactionStatusResponseMessage', layout: {type: 'hbox'}, hidden: false, cls: 'im-transaction-status-container', scrollable: null, id: 'FormPaymentReceipt_TransactionStatusResponseMessage', items: [ {xtype: 'container', name: 'htmlTransactionStatusResponseMessage', scrollable: null, id: 'FormPaymentReceipt_htmlTransactionStatusResponseMessage' }, {xtype: 'label', name: 'labelTransactionStatusResponseMessage', ui: 'light-subheading-primary', cls: 'light-subheading-primary', id: 'FormPaymentReceipt_labelTransactionStatusResponseMessage' }] }, {xtype: 'container', name: 'TransactionStatusAPC', layout: {type: 'hbox'}, hidden: true, cls: 'im-transaction-status-container', scrollable: null, id: 'FormPaymentReceipt_TransactionStatusAPC', items: [ {xtype: 'container', name: 'htmlTransactionStatusAPC', scrollable: null, id: 'FormPaymentReceipt_htmlTransactionStatusAPC' }, {xtype: 'label', name: 'labelTransactionStatusAPC', ui: 'light-subheading-primary', cls: 'light-subheading-primary', id: 'FormPaymentReceipt_labelTransactionStatusAPC' }] }, {xtype: 'container', name: 'TransactionEStatement', layout: {type: 'hbox'}, hidden: true, cls: 'im-transaction-status-container', scrollable: null, id: 'FormPaymentReceipt_TransactionEStatement', items: [ {xtype: 'container', name: 'htmlTransactionEStatement', scrollable: null, id: 'FormPaymentReceipt_htmlTransactionEStatement' }, {xtype: 'label', name: 'labelTransactionEStatement', ui: 'light-subheading-primary', cls: 'light-subheading-primary', id: 'FormPaymentReceipt_labelTransactionEStatement' }] }, {xtype: 'container', name: 'InitialPayment', layout: {type: 'hbox'}, hidden: true, cls: 'im-transaction-status-container', scrollable: null, id: 'FormPaymentReceipt_InitialPayment', items: [ {xtype: 'container', name: 'htmlInitialPayment', scrollable: null, id: 'FormPaymentReceipt_htmlInitialPayment' }, {xtype: 'label', name: 'labelInitialPayment', ui: 'light-subheading-primary', cls: 'light-subheading-primary', id: 'FormPaymentReceipt_labelInitialPayment' }] }, {xtype: 'container', name: 'PaymentPlanPrint', layout: {type: 'hbox'}, hidden: true, cls: 'im-transaction-status-container', scrollable: null, id: 'FormPaymentReceipt_PaymentPlanPrint', items: [ {xtype: 'container', name: 'htmlPaymentPlanPrint', scrollable: null, id: 'FormPaymentReceipt_htmlPaymentPlanPrint' }, {xtype: 'label', name: 'labelPaymentPlanPrint', ui: 'light-subheading-primary', cls: 'light-subheading-primary', id: 'FormPaymentReceipt_labelPaymentPlanPrint' }] }] }, {xtype: 'container', name: 'PatientPaymentConfirmHeaderContainer', cls: 'x-payment-header-container', scrollable: null, id: 'FormPaymentReceipt_PatientPaymentConfirmHeaderContainer', items: [ {xtype: 'instamedHeading1', name: '', hidden: true, id: 'FormPaymentReceipt_instamedHeading1_1' }, {xtype: 'container', layout: {type: 'hbox'}, scrollable: null, id: 'FormPaymentReceipt_container_3', items: [ {xtype: 'label', align: 'left', name: 'PatientPaymentConfirmHeaderMessage', ui: 'body1-primary', cls: 'body1-primary', id: 'FormPaymentReceipt_PatientPaymentConfirmHeaderMessage' }] }, {xtype: 'label', align: 'left', name: 'TransactionMessage', ui: 'body2-secondary', hidden: true, cls: 'x-label-payment-header body2-secondary', id: 'FormPaymentReceipt_TransactionMessage' }] }, {xtype: 'label', html: 'Your request for eStatement Enrollment has been sent. If you prefer to receive statements by mail, you can update your Statement Delivery Settings.', name: 'eStatementDelivery', ui: 'body1-primary', hidden: true, cls: 'im-bottom-label body1-primary', id: 'FormPaymentReceipt_eStatementDelivery' }, {xtype: 'container', hidden: true, cls: 'im-subtitle-container', scrollable: null, id: 'FormPaymentReceipt_container_4', items: [ {xtype: 'instamedLabelHeading2', html: 'Provider Information', ui: 'body2-secondary', cls: 'im-subtitle-header body2-secondary', id: 'FormPaymentReceipt_instamedLabelHeading2' }, {xtype: 'container', layout: {type: 'hbox'}, cls: 'im-editable-provider-info', scrollable: null, id: 'FormPaymentReceipt_container_5', items: [ {xtype: 'container', scrollable: null, id: 'FormPaymentReceipt_container_6', items: [ {xtype: 'label', name: 'ProviderName', ui: 'light-subheading-primary', cls: 'light-subheading-primary', id: 'FormPaymentReceipt_ProviderName' }, {xtype: 'label', name: 'ProviderAddress', ui: 'body1-secondary', cls: 'body1-secondary', id: 'FormPaymentReceipt_ProviderAddress' }, {xtype: 'label', name: 'PayeePhoneNumber', ui: 'body1-secondary', cls: 'body1-secondary', id: 'FormPaymentReceipt_PayeePhoneNumber' }] }] }] }, {xtype: 'container', name: 'PatientInformationContainer', cls: 'im-subtitle-container', scrollable: null, id: 'FormPaymentReceipt_PatientInformationContainer', items: [ {xtype: 'instamedLabelHeading2', html: 'Member Information', ui: 'body2-secondary', cls: 'im-subtitle-header body2-secondary', id: 'FormPaymentReceipt_instamedLabelHeading2_1' }, {xtype: 'dataviewlite', tpl: ['', name: 'poweredbylogo', cls: 'hiddenxs hiddensm', scrollable: null, id: 'NavReceiptPreview_poweredbylogo' }, {xtype: 'container', cls: 'copyrightContainer hiddenxs hiddensm', scrollable: null, id: 'NavReceiptPreview_container_9', items: [ {xtype: 'spacer', cls: 'hiddenmd hiddenlg', id: 'NavReceiptPreview_spacer_4' }, {xtype: 'label', html: '© 2024 InstaMed. All Rights Reserved.', name: 'copyrightFooter', ui: 'body1-primary', cls: 'margin-bottom-10 body1-primary', id: 'NavReceiptPreview_copyrightFooter' }, {xtype: 'spacer', cls: 'hiddenmd hiddenlg', id: 'NavReceiptPreview_spacer_5' }] }, {xtype: 'spacer', cls: 'hiddenxs hiddensm', id: 'NavReceiptPreview_spacer_6' }, {xtype: 'container', cls: 'linkButtonContainer hiddenxs hiddensm', scrollable: null, id: 'NavReceiptPreview_container_10', items: [ {xtype: 'button', text: 'Security', iconCls: 'x-ma ma-lock-outline', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavReceiptPreview_button_Security', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/security/','open-window');}} }, {xtype: 'button', text: 'Privacy', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavReceiptPreview_button_Privacy', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/privacy-statement/','open-window');}} }, {xtype: 'button', text: 'Terms', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavReceiptPreview_button_Terms', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/terms-of-use/','open-window');}} }, {xtype: 'button', text: 'Help', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavReceiptPreview_button_Help', listeners: {tap: function() { InstaMed.popupNewWindow('../../Form/PaymentPortal/ContactUs?id=SILVERSCRIPT','open-window');}} }, {xtype: 'button', text: 'English', align: 'right',menu:[{xtype: 'menuitem', text: 'English', handler: function(cmp) { PerformAction({Language:'en'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'en', cls: 'hiddenxs hiddensm', id: 'menuitem_en_20'},{xtype: 'menuitem', text: 'Español', handler: function(cmp) { PerformAction({Language:'es'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'es', cls: 'hiddenxs hiddensm', id: 'menuitem_es_20'},{xtype: 'menuitem', text: 'Français', handler: function(cmp) { PerformAction({Language:'fr'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'fr', cls: 'hiddenxs hiddensm', id: 'menuitem_fr_20'},], name: 'ForeignLanguages', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavReceiptPreview_button_ForeignLanguages' }] }, {xtype: 'container', cls: 'hiddenmd hiddenlg', scrollable: null, id: 'NavReceiptPreview_container_11', items: [ {xtype: 'container', layout: {type: 'hbox', pack: 'center'}, cls: 'x-center-helper', scrollable: null, id: 'NavReceiptPreview_container_12', items: [ {xtype: 'spacer', id: 'NavReceiptPreview_spacer_7' }, {xtype: 'container', html: '
', name: 'poweredbylogo', scrollable: null, id: 'NavReceiptPreview_poweredbylogo_1' }, {xtype: 'spacer', id: 'NavReceiptPreview_spacer_8' }] }, {xtype: 'container', layout: {type: 'hbox', pack: 'center'}, cls: 'x-center-helper', scrollable: null, id: 'NavReceiptPreview_container_13', items: [ {xtype: 'spacer', id: 'NavReceiptPreview_spacer_9' }, {xtype: 'container', cls: 'copyrightContainer', scrollable: null, id: 'NavReceiptPreview_container_14', items: [ {xtype: 'spacer', cls: 'hiddenmd hiddenlg', id: 'NavReceiptPreview_spacer_10' }, {xtype: 'label', html: '© 2024 InstaMed. All Rights Reserved.', name: 'copyrightFooter', ui: 'body1-primary', cls: 'margin-bottom-10 body1-primary', id: 'NavReceiptPreview_copyrightFooter_1' }, {xtype: 'spacer', cls: 'hiddenmd hiddenlg', id: 'NavReceiptPreview_spacer_11' }] }, {xtype: 'spacer', id: 'NavReceiptPreview_spacer_12' }] }, {xtype: 'container', layout: {type: 'hbox', pack: 'center'}, cls: 'x-center-helper', scrollable: null, id: 'NavReceiptPreview_container_15', items: [ {xtype: 'spacer', id: 'NavReceiptPreview_spacer_13' }, {xtype: 'container', cls: 'linkButtonContainer ', scrollable: null, id: 'NavReceiptPreview_container_16', items: [ {xtype: 'button', text: 'Security', iconCls: 'x-ma ma-lock-outline', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavReceiptPreview_button_Security_1', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/security/','open-window');}} }, {xtype: 'button', text: 'Privacy', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavReceiptPreview_button_Privacy_1', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/privacy-statement/','open-window');}} }, {xtype: 'button', text: 'Terms', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavReceiptPreview_button_Terms_1', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/terms-of-use/','open-window');}} }, {xtype: 'button', text: 'Help', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavReceiptPreview_button_Help_1', listeners: {tap: function() { InstaMed.popupNewWindow('../../Form/PaymentPortal/ContactUs?id=SILVERSCRIPT','open-window');}} }] }, {xtype: 'spacer', id: 'NavReceiptPreview_spacer_14' }] }, {xtype: 'container', layout: {type: 'hbox', pack: 'center'}, cls: 'x-center-helper', scrollable: null, id: 'NavReceiptPreview_container_17', items: [ {xtype: 'spacer', id: 'NavReceiptPreview_spacer_15' }, {xtype: 'container', scrollable: null, id: 'NavReceiptPreview_container_18', items: [ {xtype: 'button', text: 'English', align: 'right',menu:[{xtype: 'menuitem', text: 'English', handler: function(cmp) { PerformAction({Language:'en'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'en', cls: 'hiddenmd hiddenlg', id: 'menuitem_en_21'},{xtype: 'menuitem', text: 'Español', handler: function(cmp) { PerformAction({Language:'es'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'es', cls: 'hiddenmd hiddenlg', id: 'menuitem_es_21'},{xtype: 'menuitem', text: 'Français', handler: function(cmp) { PerformAction({Language:'fr'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'fr', cls: 'hiddenmd hiddenlg', id: 'menuitem_fr_21'},], name: 'ForeignLanguages', ui: 'grey', margin: '', hidden: false, ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavReceiptPreview_button_ForeignLanguages_1' }] }, {xtype: 'spacer', id: 'NavReceiptPreview_spacer_16' }] }] }] }, {xtype: 'spacer', id: 'spacer_32' }] }] }, { xtype: 'window', title: '
Share Receipt
', titleAlign: 'center', itemId: 'ShareReceiptWindow', flex: 1, defaultFocus: 'textfield', closable: true, modal: true, draggable: false, constrainHeader: true, constrainTo: 'mainBorderPanel', closeAction: 'hide', name: 'ShareReceiptWindow', ui: 'medium', flex: 1, cls: 'medium', id: 'ShareReceiptWindow', listeners: {show: function() { var listenerArgs = arguments; Ext.Array.each([function(cmp) { if (cmp._closable) { cmp.el.dom.querySelector('.x-tool').setAttribute('aria-label', 'Close'); } },function(cmp) { Ext.each(Ext.DomQuery.select('.x-panel-body', Ext.DomQuery.selectNode('.x-window[id=ShareReceiptWindow]')), function(p) { Ext.get(p.id).scrollTo('top', 0); }); }], function(func) { func.apply(this, listenerArgs); }); }}, items: [ { xtype: 'form', preventHeader: true, bodyCls: 'mypanel', api: { submit: QuickPayReviewAndConfirmController.emailReceipt }, defaultSubmitButton: 'Submit', allowReset: false, name: 'MyFormPanel', ui: 'flat', itemId: 'MyFormPanel', flex: 1, cls: 'flat', scrollable: null, id: 'MyFormPanel_2', items: [ {xtype: 'errorbox', name: 'ValidationSummary', ui: 'ErrorBox', flex: 1, hidden: true, cls: 'ErrorBox', id: 'ValidationSummary_15' }, {xtype: 'container', flex: 1, scrollable: null, id: 'MyFormPanel_container_3', items: [ {xtype: 'textfield', allowBlank: false, allowOnlyWhitespace: false, maxLength: 200, maxLength: 200, enforceMaxLength: true, minLength: 0, selectOnFocus: true, autoCorrect: false, fieldLabel: 'Email Receipt To:', label: 'Email Receipt To:', component: {"type":"email","pattern":null}, inputType: 'email', labelSeparator: ' ', required: true, labelWrap: true, labelAlign: 'placeholder', errorTarget: 'under', clearable: false, requiredMessage: 'Email Receipt To: is required', autoComplete: 'on', name: 'Email', flex: 5, margin: '', id: 'MyFormPanel_Email', listeners: {action: submitOnEnter,blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'hiddenfield', fieldLabel: 'TransactionAccountID', label: 'TransactionAccountID', labelSeparator: ' ', required: false, labelWrap: true, errorTarget: 'under', clearable: false, requiredMessage: 'TransactionAccountID is required', autoComplete: 'on', name: 'TransactionAccountID', flex: 1, margin: '', id: 'MyFormPanel_TransactionAccountID', listeners: {blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'hiddenfield', fieldLabel: 'TransactionGroupID', label: 'TransactionGroupID', labelSeparator: ' ', required: false, labelWrap: true, errorTarget: 'under', clearable: false, requiredMessage: 'TransactionGroupID is required', autoComplete: 'on', name: 'TransactionGroupID', flex: 1, margin: '', id: 'MyFormPanel_TransactionGroupID', listeners: {blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'hiddenfield', fieldLabel: 'PkTransaction', label: 'PkTransaction', labelSeparator: ' ', required: false, labelWrap: true, errorTarget: 'under', clearable: false, requiredMessage: 'PkTransaction is required', autoComplete: 'on', name: 'PkTransaction', flex: 1, margin: '', id: 'MyFormPanel_PkTransaction', listeners: {blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'hiddenfield', fieldLabel: 'Transaction Type', label: 'Transaction Type', labelSeparator: ' ', required: false, labelWrap: true, errorTarget: 'under', clearable: false, requiredMessage: 'Transaction Type is required', autoComplete: 'on', name: 'TransactionType', flex: 1, margin: '', id: 'MyFormPanel_TransactionType', listeners: {blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'hiddenfield', fieldLabel: 'TransactionAction', label: 'TransactionAction', labelSeparator: ' ', required: false, labelWrap: true, errorTarget: 'under', clearable: false, requiredMessage: 'TransactionAction is required', autoComplete: 'on', name: 'TransactionAction', flex: 1, margin: '', id: 'MyFormPanel_TransactionAction', listeners: {blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'hiddenfield', fieldLabel: 'IsPaymentPlanFlow', label: 'IsPaymentPlanFlow', labelSeparator: ' ', required: false, labelWrap: true, errorTarget: 'under', clearable: false, requiredMessage: 'IsPaymentPlanFlow is required', autoComplete: 'on', name: 'IsPaymentPlanFlow', flex: 1, margin: '', id: 'MyFormPanel_IsPaymentPlanFlow', listeners: {blur: function(cmp){if(cmp.validate){cmp.validate();}}} }] }, {xtype: 'container', flex: 1, scrollable: null, id: 'MyFormPanel_container_4', items: [ {xtype: 'container', layout: {type: 'hbox', pack: 'start', align: 'bottom'}, flex: 1, cls: 'buttonContainer', scrollable: null, id: 'MyFormPanel_container_5', items: [ {xtype: 'button', text: 'Cancel', flex: 1, margin: '', ariaRole: 'button', cls: 'noprint', id: 'MyFormPanel_button_Cancel', listeners: {tap: function(cmp, e, options) { InstaMed.getNavigationView().back(); }} }, {xtype: 'spacer', flex: 1, id: 'MyFormPanel_spacer_2' }, {xtype: 'button', text: 'Send', name: 'Submit', ui: 'action', flex: 1, margin: '', ariaRole: 'button', cls: 'action noprint', id: 'MyFormPanel_button_Send', listeners: {tap: function(cmp, e, options) { var cmpForm = InstaMed.findParentForm(cmp); InstaMed.submitForm(cmpForm,function(cmp, e, options) { InstaMed.getNavigationView().back(); }); }} }] }] }] }] }, {xtype: 'container', name: 'NavAPCTerms', layout: {type: 'vbox', pack: 'start'}, scrollable: 'true', id: 'NavAPCTerms', items: [ {xtype: 'container', docked: 'top', scrollable: null, id: 'NavAPCTerms_container', items: [ {xtype: 'instamedNavigationBar', name: 'headerBar', layout: {type: 'hbox'}, hidden: false, cls: 'im-ignore-custom-colors im-ignore-background', scrollable: null, id: 'NavAPCTerms_headerBar', items: [ {xtype: 'spacer', id: 'NavAPCTerms_spacer', plugins: 'responsive', responsiveConfig: {'width > 1272':{flex : 1,},'width <= 1272':{flex :0,},} }, {xtype: 'titlebar', title: '<a href=\\"../../Form/PaymentPortal/Start\\"> <img src=\\"../../ContentHandler.aspx?URL=/Images/Database/cvscaremark@instamed.net/WolkenJ@cvscaremark/cvscaremark@instamed.net000013897108-001-002HeaderLogo/638482659224849466&id=SILVERSCRIPT\\" alt=\\"Company Logo\\" style=\\"height: 40px\\">', maxWidth: 1272, cls: 'largeTwelveColumn mediumTwelveColumn smallTwelveColumn xsmallTwelveColumn im-ignore-custom-colors im-ignore-background', scrollable: null, id: 'NavAPCTerms_titlebar', plugins: 'responsive', responsiveConfig: {'width >= 1272':{title :'',},'width < 1272':{title : ' ',},}, items: [ {xtype: 'button', accessibleText: 'Back', iconCls: 'x-ma ma-arrow-back', align: 'left', name: 'TitleBarNavigationViewBack', margin: '', hidden: false, ariaRole: 'button', cls: 'x-button-icon-link-style white hiddenlg noprint', id: 'NavAPCTerms_TitleBarNavigationViewBack', plugins: 'responsive', responsiveConfig: {'width > 1272':{iconCls :'',},'width <= 1272':{iconCls : 'x-ma ma-arrow-back',},}, listeners: {tap: function(cmp, e, options) { InstaMed.getNavigationView().back(); }} }, {xtype: 'container', html: ' ', align: 'left', scrollable: null, id: 'NavAPCTerms_container_1', plugins: 'responsive', responsiveConfig: {'width >= 1272':{hidden : false,},'width < 1272':{hidden :true,},} }, {xtype: 'button', name: 'HeaderTitlebarButton', ui: 'white', margin: '', hidden: true, ariaRole: 'button', cls: 'x-button-link-style im-center-header-button white noprint', id: 'NavAPCTerms_HeaderTitlebarButton' }, {xtype: 'button', accessibleText: 'Log In or Sign Up', iconCls: 'x-ma ma-account-circle', align: 'right',menu:[{xtype: 'menuitem', text: 'Log In', handler: function() { PerformAction({}, PatientPortalLoginController.redirectToLogin,null); }, id: 'menuitem_LogIn_14'},{xtype: 'menuitem', text: 'Sign Up', handler: function() { PerformAction({}, SignUpController.redirectToSignUp,null); }, id: 'menuitem_SignUp_14'},], name: 'LoginOrSignUpProfileIcon', margin: '', ariaRole: 'button', cls: 'x-button-icon-link-style white noprint', id: 'NavAPCTerms_button_LoginOrSignUpProfileIcon', plugins: 'responsive', responsiveConfig: {'!InstaMed.isLoggedIn & width > 960':{hidden: true,},'!InstaMed.isLoggedIn && width <= 960':{hidden: false,},}, listeners: {hiddenchange: function() { Ext.ComponentQuery.query('[name=LoginOrSignUpProfileIcon]')[0].getMenu().hide(); }} }, {xtype: 'button', text: '', align: 'right',menu:[{xtype: 'menuitem', text: 'Dashboard', handler: function(){ window.location.href='../../Form/PaymentPortal/Dashboard'; }, id: 'menuitem_Dashboard_28'},{xtype: 'menuitem', text: 'Help', handler: function() { window.open('https://help.instamed.com/patients/s/?dc_label=Patients')}, id: 'menuitem_Help_28'},{xtype: 'menuitem', text: 'Log Out', handler: function(){ window.location.href='../../Form/PaymentPortal/Logout?id=SILVERSCRIPT'; }, id: 'menuitem_LogOut_28'},], name: 'Profile', ui: 'white', margin: '', hidden: true, ariaRole: 'button', cls: 'x-button-link-style white noprint', id: 'NavAPCTerms_button_Profile', plugins: 'responsive', responsiveConfig: {'InstaMed.isLoggedIn & width > 960':{hidden: false,},'InstaMed.isLoggedIn && width <= 960':{hidden: true,},}, listeners: {hiddenchange: function() { Ext.ComponentQuery.query('[name=Profile]')[0].getMenu().hide(); }} }, {xtype: 'container', align: 'right', name: 'LoginOrSignUpContainer', layout: {type: 'hbox'}, scrollable: null, id: 'NavAPCTerms_LoginOrSignUpContainer', plugins: 'responsive', responsiveConfig: {'!InstaMed.isLoggedIn & width > 960':{hidden: false,},'!InstaMed.isLoggedIn && width <= 960':{hidden: true,},}, items: [ {xtype: 'button', text: 'Log In', align: 'right', name: 'LoginForDualLogin', ui: 'white', margin: '', hidden: false, ariaRole: 'button', cls: 'x-button-link-style hiddenxs hiddensm white noprint', id: 'NavAPCTerms_button_LoginForDualLogin', listeners: {tap: function() { PerformAction({}, PatientPortalLoginController.redirectToLogin,null); }} }, {xtype: 'label', html: 'or', align: 'right', name: 'Or', ui: 'body1-white', cls: 'hiddenxs hiddensm body1-white', id: 'NavAPCTerms_Or' }, {xtype: 'button', text: 'Sign Up', align: 'right', name: 'SignUpForDualLogin', ui: 'white', margin: '', ariaRole: 'button', cls: 'x-button-link-style hiddenxs hiddensm white noprint', id: 'NavAPCTerms_button_SignUpForDualLogin', listeners: {tap: function() { PerformAction({}, SignUpController.redirectToSignUp,null); }} }] }, {xtype: 'button', accessibleText: 'Profile', iconCls: 'x-ma ma-account-circle', align: 'right',menu:[{xtype: 'menuitem', text: 'Dashboard', handler: function(){ window.location.href='../../Form/PaymentPortal/Dashboard'; }, id: 'menuitem_Dashboard_29'},{xtype: 'menuitem', text: 'Help', handler: function() { window.open('https://help.instamed.com/patients/s/?dc_label=Patients')}, id: 'menuitem_Help_29'},{xtype: 'menuitem', text: 'Log Out', handler: function(){ window.location.href='../../Form/PaymentPortal/Logout?id=SILVERSCRIPT'; }, id: 'menuitem_LogOut_29'},], name: 'ProfileIcon', margin: '', hidden: true, ariaRole: 'button', cls: 'x-button-icon-link-style white noprint', id: 'NavAPCTerms_button_ProfileIcon', plugins: 'responsive', responsiveConfig: {'InstaMed.isLoggedIn & width > 960':{hidden: true,},'InstaMed.isLoggedIn && width <= 960':{hidden: false,},}, listeners: {hiddenchange: function() { Ext.ComponentQuery.query('[name=ProfileIcon]')[0].getMenu().hide(); }} }] }, {xtype: 'spacer', id: 'NavAPCTerms_spacer_1', plugins: 'responsive', responsiveConfig: {'width > 1272':{flex : 1,},'width <= 1272':{flex :0,},} }] }] }, {xtype: 'container', layout: {type: 'hbox'}, cls: 'x-subheader-container', scrollable: null, id: 'NavAPCTerms_container_2', items: [ {xtype: 'spacer', id: 'NavAPCTerms_spacer_2', plugins: 'responsive', responsiveConfig: {'width > 1272':{flex : 1,},'width <= 1272':{flex :0,},} }, {xtype: 'container', maxWidth: 1272, layout: {type: 'hbox'}, cls: 'largeTwelveColumn mediumTwelveColumn smallTwelveColumn xsmallTwelveColumn x-subheader-panel ', scrollable: null, id: 'NavAPCTerms_container_3', items: [ {xtype: 'image', src: '../../ContentHandler.aspx?URL=/Images/Database/1A6440F4-9734-4861-8F1B-82AEFA1C6DB1&id=SILVERSCRIPT&crop=true&maxWidth=150&maxHeight=64', hidden: true, cls: 'x-clickable x-button-provider-img', id: 'NavAPCTerms_image', listeners: {painted: function() { var cmp = this; cmp.el.dom.setAttribute('aria-label', 'Aetna Medicare Prescription Drug Plan logo'); cmp.el.dom.setAttribute('role', 'img'); cmp.el.dom.setAttribute('title', ''); },tap: function(){ window.location.href='../../Form/PaymentPortal/Default?id=SILVERSCRIPT'; }} }, {xtype: 'container', layout: {type: 'vbox', pack: 'center', align: 'left'}, cls: 'im-provider-header-buttons', scrollable: null, id: 'NavAPCTerms_container_4', items: [ {xtype: 'label', html: 'Aetna Medicare Prescription Drug Plan', name: 'SubheaderProviderName', ui: 'subheading-primary', cls: 'initial-caps font-400 im-bold-button subheading-primary', id: 'NavAPCTerms_SubheaderProviderName' }, {xtype: 'container', layout: {type: 'hbox'}, scrollable: null, id: 'NavAPCTerms_container_5', items: [ {xtype: 'container', html: '', hidden: true, cls: 'im-address-verification-icon', scrollable: null, id: 'NavAPCTerms_container_6' }, {xtype: 'label', html: 'P.O. Box 504849, St Louis, MO 63150-4849', ui: 'body1-secondary', cls: 'line-height-20 body1-secondary', id: 'NavAPCTerms_label' }] }, {xtype: 'container', layout: {type: 'hbox'}, hidden: false, scrollable: null, id: 'NavAPCTerms_container_7', items: [ {xtype: 'label', html: '(855) 651-4856', ui: 'body1-primary', cls: 'body1-primary', id: 'NavAPCTerms_label_1' }] }] }] }, {xtype: 'spacer', id: 'NavAPCTerms_spacer_3', plugins: 'responsive', responsiveConfig: {'width > 1272':{flex : 1,},'width <= 1272':{flex :0,},} }] }, { xtype: 'panel', dock: 'top', frame: false, scrollable: 'true', id: 'panel_14', items: [ {xtype: 'container', maxWidth: 1272, layout: {type: 'hbox'}, cls: 'mainContent MainContentWithHeaerAndSubheader ', scrollable: null, id: 'container_47', items: [ {xtype: 'container', flex: 1, scrollable: null, id: 'container_48', items: [ { xtype: 'form', preventHeader: true, bodyCls: 'mypanel', api: { }, name: 'MyFormPanel', itemId: 'MyFormPanel', cls: 'col-large-offSet-3 col-medium-offSet-3 col-small-offSet-1 smallTenColumn xsmallTwelveColumn mediumSixColumn largeSixColumn ', scrollable: null, id: 'MyFormPanel_3', items: [ {xtype: 'errorbox', name: 'ValidationSummary', ui: 'ErrorBox', hidden: true, cls: 'ErrorBox', id: 'ValidationSummary_17' }, {xtype: 'instamedHeading1', text: 'Payment Plan Authorization', id: 'MyFormPanel_instamedHeading1_1' }, {xtype: 'container', html: '
\t\t\t
\t \t\t\t
', name: 'poweredbylogo', cls: 'hiddenxs hiddensm', scrollable: null, id: 'NavAPCTerms_poweredbylogo' }, {xtype: 'container', cls: 'copyrightContainer hiddenxs hiddensm', scrollable: null, id: 'NavAPCTerms_container_9', items: [ {xtype: 'spacer', cls: 'hiddenmd hiddenlg', id: 'NavAPCTerms_spacer_4' }, {xtype: 'label', html: '© 2024 InstaMed. All Rights Reserved.', name: 'copyrightFooter', ui: 'body1-primary', cls: 'margin-bottom-10 body1-primary', id: 'NavAPCTerms_copyrightFooter' }, {xtype: 'spacer', cls: 'hiddenmd hiddenlg', id: 'NavAPCTerms_spacer_5' }] }, {xtype: 'spacer', cls: 'hiddenxs hiddensm', id: 'NavAPCTerms_spacer_6' }, {xtype: 'container', cls: 'linkButtonContainer hiddenxs hiddensm', scrollable: null, id: 'NavAPCTerms_container_10', items: [ {xtype: 'button', text: 'Security', iconCls: 'x-ma ma-lock-outline', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavAPCTerms_button_Security', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/security/','open-window');}} }, {xtype: 'button', text: 'Privacy', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavAPCTerms_button_Privacy', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/privacy-statement/','open-window');}} }, {xtype: 'button', text: 'Terms', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavAPCTerms_button_Terms', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/terms-of-use/','open-window');}} }, {xtype: 'button', text: 'Help', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavAPCTerms_button_Help', listeners: {tap: function() { InstaMed.popupNewWindow('../../Form/PaymentPortal/ContactUs?id=SILVERSCRIPT','open-window');}} }, {xtype: 'button', text: 'English', align: 'right',menu:[{xtype: 'menuitem', text: 'English', handler: function(cmp) { PerformAction({Language:'en'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'en', cls: 'hiddenxs hiddensm', id: 'menuitem_en_28'},{xtype: 'menuitem', text: 'Español', handler: function(cmp) { PerformAction({Language:'es'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'es', cls: 'hiddenxs hiddensm', id: 'menuitem_es_28'},{xtype: 'menuitem', text: 'Français', handler: function(cmp) { PerformAction({Language:'fr'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'fr', cls: 'hiddenxs hiddensm', id: 'menuitem_fr_28'},], name: 'ForeignLanguages', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavAPCTerms_button_ForeignLanguages' }] }, {xtype: 'container', cls: 'hiddenmd hiddenlg', scrollable: null, id: 'NavAPCTerms_container_11', items: [ {xtype: 'container', layout: {type: 'hbox', pack: 'center'}, cls: 'x-center-helper', scrollable: null, id: 'NavAPCTerms_container_12', items: [ {xtype: 'spacer', id: 'NavAPCTerms_spacer_7' }, {xtype: 'container', html: '
', name: 'poweredbylogo', scrollable: null, id: 'NavAPCTerms_poweredbylogo_1' }, {xtype: 'spacer', id: 'NavAPCTerms_spacer_8' }] }, {xtype: 'container', layout: {type: 'hbox', pack: 'center'}, cls: 'x-center-helper', scrollable: null, id: 'NavAPCTerms_container_13', items: [ {xtype: 'spacer', id: 'NavAPCTerms_spacer_9' }, {xtype: 'container', cls: 'copyrightContainer', scrollable: null, id: 'NavAPCTerms_container_14', items: [ {xtype: 'spacer', cls: 'hiddenmd hiddenlg', id: 'NavAPCTerms_spacer_10' }, {xtype: 'label', html: '© 2024 InstaMed. All Rights Reserved.', name: 'copyrightFooter', ui: 'body1-primary', cls: 'margin-bottom-10 body1-primary', id: 'NavAPCTerms_copyrightFooter_1' }, {xtype: 'spacer', cls: 'hiddenmd hiddenlg', id: 'NavAPCTerms_spacer_11' }] }, {xtype: 'spacer', id: 'NavAPCTerms_spacer_12' }] }, {xtype: 'container', layout: {type: 'hbox', pack: 'center'}, cls: 'x-center-helper', scrollable: null, id: 'NavAPCTerms_container_15', items: [ {xtype: 'spacer', id: 'NavAPCTerms_spacer_13' }, {xtype: 'container', cls: 'linkButtonContainer ', scrollable: null, id: 'NavAPCTerms_container_16', items: [ {xtype: 'button', text: 'Security', iconCls: 'x-ma ma-lock-outline', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavAPCTerms_button_Security_1', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/security/','open-window');}} }, {xtype: 'button', text: 'Privacy', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavAPCTerms_button_Privacy_1', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/privacy-statement/','open-window');}} }, {xtype: 'button', text: 'Terms', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavAPCTerms_button_Terms_1', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/terms-of-use/','open-window');}} }, {xtype: 'button', text: 'Help', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavAPCTerms_button_Help_1', listeners: {tap: function() { InstaMed.popupNewWindow('../../Form/PaymentPortal/ContactUs?id=SILVERSCRIPT','open-window');}} }] }, {xtype: 'spacer', id: 'NavAPCTerms_spacer_14' }] }, {xtype: 'container', layout: {type: 'hbox', pack: 'center'}, cls: 'x-center-helper', scrollable: null, id: 'NavAPCTerms_container_17', items: [ {xtype: 'spacer', id: 'NavAPCTerms_spacer_15' }, {xtype: 'container', scrollable: null, id: 'NavAPCTerms_container_18', items: [ {xtype: 'button', text: 'English', align: 'right',menu:[{xtype: 'menuitem', text: 'English', handler: function(cmp) { PerformAction({Language:'en'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'en', cls: 'hiddenmd hiddenlg', id: 'menuitem_en_29'},{xtype: 'menuitem', text: 'Español', handler: function(cmp) { PerformAction({Language:'es'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'es', cls: 'hiddenmd hiddenlg', id: 'menuitem_es_29'},{xtype: 'menuitem', text: 'Français', handler: function(cmp) { PerformAction({Language:'fr'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'fr', cls: 'hiddenmd hiddenlg', id: 'menuitem_fr_29'},], name: 'ForeignLanguages', ui: 'grey', margin: '', hidden: false, ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavAPCTerms_button_ForeignLanguages_1' }] }, {xtype: 'spacer', id: 'NavAPCTerms_spacer_16' }] }] }] }, {xtype: 'spacer', id: 'spacer_44' }] }] }, { xtype: 'window', title: '
Payment Plan Details
', titleAlign: 'center', itemId: 'PaymentPlanPaymentsBreakdownWindow', flex: 1, defaultFocus: 'button', closable: true, modal: true, draggable: false, constrainHeader: true, constrainTo: 'mainBorderPanel', closeAction: 'hide', width: 700, name: 'PaymentPlanPaymentsBreakdownWindow', ui: 'medium', flex: 1, cls: 'medium', id: 'PaymentPlanPaymentsBreakdownWindow', listeners: {show: function() { var listenerArgs = arguments; Ext.Array.each([function(cmp) { if (cmp._closable) { cmp.el.dom.querySelector('.x-tool').setAttribute('aria-label', 'Close'); } },function(cmp) { Ext.each(Ext.DomQuery.select('.x-panel-body', Ext.DomQuery.selectNode('.x-window[id=PaymentPlanPaymentsBreakdownWindow]')), function(p) { Ext.get(p.id).scrollTo('top', 0); }); }], function(func) { func.apply(this, listenerArgs); }); }}, items: [ { xtype: 'form', preventHeader: true, bodyCls: 'mypanel', api: { }, name: 'MyFormPanel', ui: 'flat', itemId: 'MyFormPanel', flex: 1, cls: 'flat', scrollable: null, id: 'MyFormPanel_4', items: [ {xtype: 'errorbox', name: 'ValidationSummary', ui: 'ErrorBox', flex: 1, hidden: true, cls: 'ErrorBox', id: 'ValidationSummary_18' }, {xtype: 'container', flex: 1, scrollable: null, id: 'MyFormPanel_container_7', items: [ {xtype: 'dataviewlite', tpl: '\r\n Paperless Statements
', titleAlign: 'center', itemId: 'EStatementEnrollmentInfo', flex: 1, defaultFocus: 'button', closable: true, modal: true, draggable: false, constrainHeader: true, constrainTo: 'mainBorderPanel', closeAction: 'hide', name: 'EStatementEnrollmentInfo', ui: 'medium', flex: 1, cls: 'medium', id: 'EStatementEnrollmentInfo', listeners: {painted: function(cmp, eOpts){ var myHeight = cmp.getSize().height; var windowHeight = Ext.getBody().getViewSize().height; var yPos = Math.max((windowHeight-myHeight)/2, 0); cmp.setY(yPos); },show: function() { var listenerArgs = arguments; Ext.Array.each([function(cmp) { if (cmp._closable) { cmp.el.dom.querySelector('.x-tool').setAttribute('aria-label', 'Close'); } },function(cmp) { Ext.each(Ext.DomQuery.select('.x-panel-body', Ext.DomQuery.selectNode('.x-window[id=EStatementEnrollmentInfo]')), function(p) { Ext.get(p.id).scrollTo('top', 0); }); }], function(func) { func.apply(this, listenerArgs); }); }}, items: [ {xtype: 'label', html: 'View current and past statements from your phone, tablet, or computer anytime and save paper too. You can choose to receive paper statements again after enrolling in paperless statements by visiting your preferences.', ui: 'body1-secondary', flex: 1, cls: 'body1-secondary', id: 'label_1' }, {xtype: 'container', layout: {type: 'hbox', pack: 'start', align: 'bottom'}, flex: 1, cls: 'buttonContainer im-bottom-label', scrollable: null, id: 'container_50', items: [ {xtype: 'spacer', flex: 1, id: 'spacer_45' }, {xtype: 'button', text: 'Close', name: 'btnClose', ui: 'action', flex: 1, margin: '', ariaRole: 'button', cls: 'action noprint', id: 'button_Close', listeners: {tap: function(cmp, e, options) { InstaMed.getNavigationView().back(); }} }] }] }, { xtype: 'window', title: 'Paperless Statements
', titleAlign: 'center', itemId: 'EStatementEnrollmentInfo', flex: 1, defaultFocus: 'button', closable: true, modal: true, draggable: false, constrainHeader: true, constrainTo: 'mainBorderPanel', closeAction: 'hide', name: 'EStatementEnrollmentInfo', ui: 'medium', flex: 1, cls: 'medium', id: 'EStatementEnrollmentInfo_1', listeners: {painted: function(cmp, eOpts){ var myHeight = cmp.getSize().height; var windowHeight = Ext.getBody().getViewSize().height; var yPos = Math.max((windowHeight-myHeight)/2, 0); cmp.setY(yPos); },show: function() { var listenerArgs = arguments; Ext.Array.each([function(cmp) { if (cmp._closable) { cmp.el.dom.querySelector('.x-tool').setAttribute('aria-label', 'Close'); } },function(cmp) { Ext.each(Ext.DomQuery.select('.x-panel-body', Ext.DomQuery.selectNode('.x-window[id=EStatementEnrollmentInfo]')), function(p) { Ext.get(p.id).scrollTo('top', 0); }); }], function(func) { func.apply(this, listenerArgs); }); }}, items: [ {xtype: 'label', html: 'View current and past statements from your phone, tablet, or computer anytime and save paper too. You can choose to receive paper statements again after enrolling in paperless statements by visiting your preferences.', ui: 'body1-secondary', flex: 1, cls: 'body1-secondary', id: 'label_2' }, {xtype: 'container', layout: {type: 'hbox', pack: 'start', align: 'bottom'}, flex: 1, cls: 'buttonContainer im-bottom-label', scrollable: null, id: 'container_51', items: [ {xtype: 'spacer', flex: 1, id: 'spacer_46' }, {xtype: 'button', text: 'Close', name: 'btnClose', ui: 'action', flex: 1, margin: '', ariaRole: 'button', cls: 'action noprint', id: 'button_Close_1', listeners: {tap: function(cmp, e, options) { InstaMed.getNavigationView().back(); }} }] }] }, {xtype: 'container', name: 'APCTermsWindow', scrollable: 'true', id: 'APCTermsWindow_1', items: [ {xtype: 'container', html: '
\t\t\t
\t \t\t\t
Mobile Phone Number
', titleAlign: 'center', itemId: 'EditMobilePhoneWindow', flex: 1, defaultFocus: 'textfield', closable: true, modal: true, draggable: false, constrainHeader: true, constrainTo: 'mainBorderPanel', closeAction: 'hide', name: 'EditMobilePhoneWindow', ui: 'medium', flex: 1, cls: 'medium', id: 'EditMobilePhoneWindow', listeners: {painted: function(cmp, eOpts){ var myHeight = cmp.getSize().height; var windowHeight = Ext.getBody().getViewSize().height; var yPos = Math.max((windowHeight-myHeight)/2, 0); cmp.setY(yPos); },show: function() { var listenerArgs = arguments; Ext.Array.each([function(cmp) { if (cmp._closable) { cmp.el.dom.querySelector('.x-tool').setAttribute('aria-label', 'Close'); } },function(cmp) { Ext.each(Ext.DomQuery.select('.x-panel-body', Ext.DomQuery.selectNode('.x-window[id=EditMobilePhoneWindow]')), function(p) { Ext.get(p.id).scrollTo('top', 0); }); }], function(func) { func.apply(this, listenerArgs); }); }}, items: [ { xtype: 'form', preventHeader: true, bodyCls: 'mypanel', api: { }, name: 'EditMobilePhoneNumber', ui: 'flat', itemId: 'EditMobilePhoneNumber', flex: 1, cls: 'flat', scrollable: null, id: 'EditMobilePhoneNumber', items: [ {xtype: 'errorbox', name: 'ValidationSummary', ui: 'ErrorBox', flex: 1, hidden: true, cls: 'ErrorBox', id: 'ValidationSummary_20' }, {xtype: 'textfield', allowBlank: false, allowOnlyWhitespace: false, maxLength: 14, maxLength: 14, enforceMaxLength: true, minLength: 10, selectOnFocus: true, autoCorrect: false, fieldLabel: 'Mobile Phone Number', label: 'Mobile Phone Number', component: {"type":"tel","pattern":null}, inputType: 'tel', labelSeparator: ' ', required: true, labelWrap: true, labelAlign: 'placeholder', errorTarget: 'under', clearable: false, requiredMessage: 'Mobile Phone Number is required', autoComplete: 'on', name: 'MobilePhoneNumber2', flex: 1, margin: '', id: 'EditMobilePhoneNumber_MobilePhoneNumber2', listeners: {action: submitOnEnter,blur: function(cmp){if(cmp.validate){cmp.validate();}},change: function(field, event, opts ){ var s = new String(field.getValue()); if(s != null && s != '') { s = s.replace(/[-,()\s]/g,'');var newValue='(';newValue+=s.substring(0,3);if(s.length>3){newValue+=') ';}newValue+=s.substring(3,6);if(s.length>6){newValue+='-';}newValue+=s.substring(6,10); if(isNaN(parseInt(newValue.substring(1,3)))){ newValue = ''; } field.setValue(newValue); if(InstaMed.isResponsive){ field.setInputValue(newValue); } } }} }, {xtype: 'container', layout: {type: 'hbox', pack: 'start', align: 'bottom'}, flex: 1, cls: 'buttonContainer', scrollable: null, id: 'EditMobilePhoneNumber_container', items: [ {xtype: 'spacer', flex: 1, id: 'EditMobilePhoneNumber_spacer' }, {xtype: 'button', text: 'Cancel', ui: 'secondary', flex: 1, margin: '', ariaRole: 'button', cls: 'secondary noprint', id: 'EditMobilePhoneNumber_button_Cancel', listeners: {tap: function(){ windowCmp = Ext.ComponentQuery.query('[name=EditMobilePhoneWindow]')[0].hide() }} }, {xtype: 'button', text: 'Verify', name: 'Submit', ui: 'secondary', flex: 1, margin: '', ariaRole: 'button', cls: 'secondary noprint', id: 'EditMobilePhoneNumber_button_Verify', listeners: {tap: function() { PerformAction({MobilePhoneNumber2:InstaMed.getValue('MobilePhoneNumber2'),EnableTwoStepVerification:Ext.ComponentQuery.query("[name='EnableTwoStepVerification']")[0].isChecked()}, TextMessageEnrollmentController.updateMobilePhoneNumberFromPopUp,null); }} }] }] }] }, { xtype: 'window', title: 'Inactivity Alert
', titleAlign: 'center', itemId: 'NavPageIdleTimeoutForm', flex: 1, defaultFocus: 'button', closable: true, modal: true, draggable: false, constrainHeader: true, constrainTo: 'mainBorderPanel', closeAction: 'hide', name: 'NavPageIdleTimeoutForm', maxWidth: 400, flex: 1, id: 'NavPageIdleTimeoutForm', listeners: {beforeshow: function(){ InstaMed.query("Logout") && InstaMed.query("Logout").setVisible(InstaMed.isLoggedIn); if(!InstaMed.isSSO){ InstaMed.query("IdleTimerNotification") && InstaMed.query("IdleTimerNotification").setHtml && InstaMed.query("IdleTimerNotification").setHtml(InstaMed.isLoggedIn ? "You have been idle for 12 minutes. If you do not select Continue or you make no selection in 3 minutes and 0 seconds, you will be automatically logged out.":"You have been idle for 12 minutes. If you do not select Continue or you make no selection in 3 minutes and 0 seconds, your session will be refreshed and you may lose any unprocessed information."); InstaMed.query("IdleTimerNotification") && InstaMed.query("IdleTimerNotification").setTitle && InstaMed.query("IdleTimerNotification").setTitle(InstaMed.isLoggedIn ? "Automatic Logout":"Inactivity Alert"); } },show: function() { var listenerArgs = arguments; Ext.Array.each([function(cmp) { if (cmp._closable) { cmp.el.dom.querySelector('.x-tool').setAttribute('aria-label', 'Close'); } },function(cmp) { Ext.each(Ext.DomQuery.select('.x-panel-body', Ext.DomQuery.selectNode('.x-window[id=NavPageIdleTimeoutForm]')), function(p) { Ext.get(p.id).scrollTo('top', 0); }); }], function(func) { func.apply(this, listenerArgs); }); }}, items: [ { xtype: 'form', preventHeader: true, bodyCls: 'mypanel', api: { submit: IdleTimerController.submit }, defaultSubmitButton: 'btnContinue', name: 'MyFormPanel', ui: 'flat', itemId: 'MyFormPanel', flex: 1, cls: 'flat', scrollable: null, id: 'MyFormPanel_6', items: [ {xtype: 'errorbox', name: 'ValidationSummary', ui: 'ErrorBox', flex: 1, hidden: true, cls: 'ErrorBox', id: 'ValidationSummary_21' }, {xtype: 'label', html: 'You have been idle for 12 minutes. If you do not select Continue or you make no selection in 3 minutes and 0 seconds, your session will be refreshed and you may lose any unprocessed information.', name: 'IdleTimerNotification', flex: 1, id: 'MyFormPanel_IdleTimerNotification' }, {xtype: 'container', flex: 1, scrollable: null, id: 'MyFormPanel_container_11', items: [ {xtype: 'container', layout: {type: 'hbox', pack: 'start', align: 'bottom'}, flex: 1, cls: 'buttonContainer', scrollable: null, id: 'MyFormPanel_container_12', items: [ {xtype: 'spacer', flex: 1, id: 'MyFormPanel_spacer_6' }, {xtype: 'button', text: 'Logout', name: 'Logout', ui: 'secondary', flex: 1, margin: '', hidden: true, ariaRole: 'button', cls: 'secondary noprint', id: 'MyFormPanel_button_Logout', listeners: {painted: function(cmp) {cmp.el.dom.setAttribute('aria-label', 'Logout');},tap: function() { LogoutTimer.logOut(); }} }, {xtype: 'button', text: 'Continue', name: 'btnContinue', ui: 'secondary', flex: 1, margin: '', ariaRole: 'button', cls: 'secondary noprint', id: 'MyFormPanel_button_Continue', listeners: {painted: function(cmp) {cmp.el.dom.setAttribute('aria-label', 'Continue');},tap: function(cmp, newValue, oldValue, eOpts) {LogoutTimer.resetMainTimer(); myForm = InstaMed.findParentForm(cmp);PerformAction(myForm.getValues(),IdleTimerController.submit,cmp);}} }] }] }] }] }] }});Ext.Loader.setConfig({ enabled: false});Ext.application({ name: 'MyApp', launch: function() { Ext.create('MyApp.view.NavigationView', {fullscreen: true}); }});LogoutTimer && setTimeout(LogoutTimer.reinitiateMainTimer,5000);}