{"id":4411,"date":"2024-03-14T08:47:50","date_gmt":"2024-03-14T13:47:50","guid":{"rendered":"https:\/\/cgm.tailfish1.com\/?page_id=4411"},"modified":"2024-04-09T10:57:59","modified_gmt":"2024-04-09T15:57:59","slug":"inscribirse","status":"publish","type":"page","link":"https:\/\/commongoodmedical.org\/es\/enroll\/","title":{"rendered":"Inscribirse"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"4411\" class=\"elementor elementor-4411\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-f7ee220 e-flex e-con-boxed e-con e-parent\" data-id=\"f7ee220\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-0454f7a elementor-widget elementor-widget-heading\" data-id=\"0454f7a\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h1 class=\"elementor-heading-title elementor-size-default\">Determine Eligibility for Services<\/h1>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-615d8d2 e-flex e-con-boxed e-con e-parent\" data-id=\"615d8d2\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-6c80a3f elementor-widget elementor-widget-pp-advanced-tabs\" data-id=\"6c80a3f\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"pp-advanced-tabs.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"pp-advanced-tabs pp-style-6 pp-tabs-responsive-tablet pp-advabced-tabs-responsive\" data-scroll-top=\"yes\">\n\t\t\t<div class=\"pp-advanced-tabs-wrapper pp-tabs-labels at-horizontal  at-no-hover\" role=\"tablist\">\n\t\t\t\t\t\t\t\t\t\t\t<div id=\"pp-advanced-tabs-title-1131\" class=\"pp-advanced-tabs-title pp-tabs-label pp-advanced-tabs-desktop-title pp-tab-active\" data-tab=\"1\" data-index=\"1131\" tabindex=\"0\" role=\"tab\" aria-controls=\"pp-advanced-tabs-content-1131\">\n\n\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t<span class=\"pp-advanced-tabs-title-text\">English<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<div id=\"pp-advanced-tabs-title-1132\" class=\"pp-advanced-tabs-title pp-tabs-label pp-advanced-tabs-desktop-title \" data-tab=\"2\" data-index=\"1132\" tabindex=\"0\" role=\"tab\" aria-controls=\"pp-advanced-tabs-content-1132\">\n\n\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t<span class=\"pp-advanced-tabs-title-text\">Espa\u00f1ol<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<div class=\"pp-advanced-tabs-content-wrapper pp-tabs-panels at-horizontal-content\">\n\t\t\t\t\t\t\t\t\t<div class=\"pp-tabs-panel\">\n\t\t\t\t\t\t<div class=\"pp-advanced-tabs-title pp-tabs-label pp-tab-responsive pp-tab-active  at-no-hover\" data-index=\"1131\">\n\t\t\t\t\t\t\t<div class=\"pp-advanced-tabs-title-inner\">\n\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t<span class=\"pp-advanced-tabs-title-text\">English<\/span>\n\t\t\t\t\t\t\t\t<i class=\"pp-toggle-icon pp-tab-open fa\"><\/i>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div id=\"pp-advanced-tabs-content-1131\" class=\"pp-advanced-tabs-content elementor-clearfix pp-advanced-tabs-tab_content pp-tab-active\" data-tab=\"1\" data-index=\"1131\" role=\"tabpanel\" aria-labelledby=\"pp-advanced-tabs-title-1131\">\n\t\t\t\t\t\t\t<div style=\"text-align:left;background:white;padding:24px;border:1px solid #ccc;\"><script>\n\/\/----------------------------------------------------------\n\/\/------ JAVASCRIPT HOOK FUNCTIONS FOR GRAVITY FORMS -------\n\/\/----------------------------------------------------------\n\nif ( ! gform ) {\n\tdocument.addEventListener( 'gform_main_scripts_loaded', function() { gform.scriptsLoaded = true; } );\n\tdocument.addEventListener( 'gform\/theme\/scripts_loaded', function() { gform.themeScriptsLoaded = true; } );\n\twindow.addEventListener( 'DOMContentLoaded', function() { gform.domLoaded = true; } );\n\n\tvar gform = {\n\t\tdomLoaded: false,\n\t\tscriptsLoaded: false,\n\t\tthemeScriptsLoaded: false,\n\t\tisFormEditor: () => typeof InitializeEditor === 'function',\n\n\t\t\/**\n\t\t * @deprecated 2.9 the use of initializeOnLoaded in the form editor context is deprecated.\n\t\t * @remove-in 4.0 this function will not check for gform.isFormEditor().\n\t\t *\/\n\t\tcallIfLoaded: function ( fn ) {\n\t\t\tif ( gform.domLoaded && gform.scriptsLoaded && ( gform.themeScriptsLoaded || gform.isFormEditor() ) ) {\n\t\t\t\tif ( gform.isFormEditor() ) {\n\t\t\t\t\tconsole.warn( 'The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.' );\n\t\t\t\t}\n\t\t\t\tfn();\n\t\t\t\treturn true;\n\t\t\t}\n\t\t\treturn false;\n\t\t},\n\n\t\t\/**\n\t\t * Call a function when all scripts are loaded\n\t\t *\n\t\t * @param function fn the callback function to call when all scripts are loaded\n\t\t *\n\t\t * @returns void\n\t\t *\/\n\t\tinitializeOnLoaded: function( fn ) {\n\t\t\tif ( ! gform.callIfLoaded( fn ) ) {\n\t\t\t\tdocument.addEventListener( 'gform_main_scripts_loaded', () => { gform.scriptsLoaded = true; gform.callIfLoaded( fn ); } );\n\t\t\t\tdocument.addEventListener( 'gform\/theme\/scripts_loaded', () => { gform.themeScriptsLoaded = true; gform.callIfLoaded( fn ); } );\n\t\t\t\twindow.addEventListener( 'DOMContentLoaded', () => { gform.domLoaded = true; gform.callIfLoaded( fn ); } );\n\t\t\t}\n\t\t},\n\n\t\thooks: { action: {}, filter: {} },\n\t\taddAction: function( action, callable, priority, tag ) {\n\t\t\tgform.addHook( 'action', action, callable, priority, tag );\n\t\t},\n\t\taddFilter: function( action, callable, priority, tag ) {\n\t\t\tgform.addHook( 'filter', action, callable, priority, tag );\n\t\t},\n\t\tdoAction: function( action ) {\n\t\t\tgform.doHook( 'action', action, arguments );\n\t\t},\n\t\tapplyFilters: function( action ) {\n\t\t\treturn gform.doHook( 'filter', action, arguments );\n\t\t},\n\t\tremoveAction: function( action, tag ) {\n\t\t\tgform.removeHook( 'action', action, tag );\n\t\t},\n\t\tremoveFilter: function( action, priority, tag ) {\n\t\t\tgform.removeHook( 'filter', action, priority, tag );\n\t\t},\n\t\taddHook: function( hookType, action, callable, priority, tag ) {\n\t\t\tif ( undefined == gform.hooks[hookType][action] ) {\n\t\t\t\tgform.hooks[hookType][action] = [];\n\t\t\t}\n\t\t\tvar hooks = gform.hooks[hookType][action];\n\t\t\tif ( undefined == tag ) {\n\t\t\t\ttag = action + '_' + hooks.length;\n\t\t\t}\n\t\t\tif( priority == undefined ){\n\t\t\t\tpriority = 10;\n\t\t\t}\n\n\t\t\tgform.hooks[hookType][action].push( { tag:tag, callable:callable, priority:priority } );\n\t\t},\n\t\tdoHook: function( hookType, action, args ) {\n\n\t\t\t\/\/ splice args from object into array and remove first index which is the hook name\n\t\t\targs = Array.prototype.slice.call(args, 1);\n\n\t\t\tif ( undefined != gform.hooks[hookType][action] ) {\n\t\t\t\tvar hooks = gform.hooks[hookType][action], hook;\n\t\t\t\t\/\/sort by priority\n\t\t\t\thooks.sort(function(a,b){return a[\"priority\"]-b[\"priority\"]});\n\n\t\t\t\thooks.forEach( function( hookItem ) {\n\t\t\t\t\thook = hookItem.callable;\n\n\t\t\t\t\tif(typeof hook != 'function')\n\t\t\t\t\t\thook = window[hook];\n\t\t\t\t\tif ( 'action' == hookType ) {\n\t\t\t\t\t\thook.apply(null, args);\n\t\t\t\t\t} else {\n\t\t\t\t\t\targs[0] = hook.apply(null, args);\n\t\t\t\t\t}\n\t\t\t\t} );\n\t\t\t}\n\t\t\tif ( 'filter'==hookType ) {\n\t\t\t\treturn args[0];\n\t\t\t}\n\t\t},\n\t\tremoveHook: function( hookType, action, priority, tag ) {\n\t\t\tif ( undefined != gform.hooks[hookType][action] ) {\n\t\t\t\tvar hooks = gform.hooks[hookType][action];\n\t\t\t\thooks = hooks.filter( function(hook, index, arr) {\n\t\t\t\t\tvar removeHook = (undefined==tag||tag==hook.tag) && (undefined==priority||priority==hook.priority);\n\t\t\t\t\treturn !removeHook;\n\t\t\t\t} );\n\t\t\t\tgform.hooks[hookType][action] = hooks;\n\t\t\t}\n\t\t}\n\t};\n}\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform-theme gform-theme--foundation gform-theme--framework gform-theme--orbital' data-form-theme='orbital' data-form-index='0' id='gform_wrapper_1' style='display:none'><style>#gform_wrapper_1[data-form-index=\"0\"].gform-theme,[data-parent-form=\"1_0\"]{--gf-color-primary: #204ce5;--gf-color-primary-rgb: 32, 76, 229;--gf-color-primary-contrast: #fff;--gf-color-primary-contrast-rgb: 255, 255, 255;--gf-color-primary-darker: #001AB3;--gf-color-primary-lighter: #527EFF;--gf-color-secondary: #fff;--gf-color-secondary-rgb: 255, 255, 255;--gf-color-secondary-contrast: #112337;--gf-color-secondary-contrast-rgb: 17, 35, 55;--gf-color-secondary-darker: #F5F5F5;--gf-color-secondary-lighter: #FFFFFF;--gf-color-out-ctrl-light: rgba(17, 35, 55, 0.1);--gf-color-out-ctrl-light-rgb: 17, 35, 55;--gf-color-out-ctrl-light-darker: rgba(104, 110, 119, 0.35);--gf-color-out-ctrl-light-lighter: #F5F5F5;--gf-color-out-ctrl-dark: #585e6a;--gf-color-out-ctrl-dark-rgb: 88, 94, 106;--gf-color-out-ctrl-dark-darker: #112337;--gf-color-out-ctrl-dark-lighter: rgba(17, 35, 55, 0.65);--gf-color-in-ctrl: #fff;--gf-color-in-ctrl-rgb: 255, 255, 255;--gf-color-in-ctrl-contrast: #112337;--gf-color-in-ctrl-contrast-rgb: 17, 35, 55;--gf-color-in-ctrl-darker: #F5F5F5;--gf-color-in-ctrl-lighter: #FFFFFF;--gf-color-in-ctrl-primary: #204ce5;--gf-color-in-ctrl-primary-rgb: 32, 76, 229;--gf-color-in-ctrl-primary-contrast: #fff;--gf-color-in-ctrl-primary-contrast-rgb: 255, 255, 255;--gf-color-in-ctrl-primary-darker: #001AB3;--gf-color-in-ctrl-primary-lighter: #527EFF;--gf-color-in-ctrl-light: rgba(17, 35, 55, 0.1);--gf-color-in-ctrl-light-rgb: 17, 35, 55;--gf-color-in-ctrl-light-darker: rgba(104, 110, 119, 0.35);--gf-color-in-ctrl-light-lighter: #F5F5F5;--gf-color-in-ctrl-dark: #585e6a;--gf-color-in-ctrl-dark-rgb: 88, 94, 106;--gf-color-in-ctrl-dark-darker: #112337;--gf-color-in-ctrl-dark-lighter: rgba(17, 35, 55, 0.65);--gf-radius: 3px;--gf-font-size-secondary: 14px;--gf-font-size-tertiary: 13px;--gf-icon-ctrl-number: url(\"data:image\/svg+xml,%3Csvg width='8' height='14' viewBox='0 0 8 14' fill='none' xmlns='http:\/\/www.w3.org\/2000\/svg'%3E%3Cpath fill-rule='evenodd' clip-rule='evenodd' d='M4 0C4.26522 5.96046e-08 4.51957 0.105357 4.70711 0.292893L7.70711 3.29289C8.09763 3.68342 8.09763 4.31658 7.70711 4.70711C7.31658 5.09763 6.68342 5.09763 6.29289 4.70711L4 2.41421L1.70711 4.70711C1.31658 5.09763 0.683417 5.09763 0.292893 4.70711C-0.0976311 4.31658 -0.097631 3.68342 0.292893 3.29289L3.29289 0.292893C3.48043 0.105357 3.73478 0 4 0ZM0.292893 9.29289C0.683417 8.90237 1.31658 8.90237 1.70711 9.29289L4 11.5858L6.29289 9.29289C6.68342 8.90237 7.31658 8.90237 7.70711 9.29289C8.09763 9.68342 8.09763 10.3166 7.70711 10.7071L4.70711 13.7071C4.31658 14.0976 3.68342 14.0976 3.29289 13.7071L0.292893 10.7071C-0.0976311 10.3166 -0.0976311 9.68342 0.292893 9.29289Z' fill='rgba(17, 35, 55, 0.65)'\/%3E%3C\/svg%3E\");--gf-icon-ctrl-select: url(\"data:image\/svg+xml,%3Csvg width='10' height='6' viewBox='0 0 10 6' fill='none' xmlns='http:\/\/www.w3.org\/2000\/svg'%3E%3Cpath fill-rule='evenodd' clip-rule='evenodd' d='M0.292893 0.292893C0.683417 -0.097631 1.31658 -0.097631 1.70711 0.292893L5 3.58579L8.29289 0.292893C8.68342 -0.0976311 9.31658 -0.0976311 9.70711 0.292893C10.0976 0.683417 10.0976 1.31658 9.70711 1.70711L5.70711 5.70711C5.31658 6.09763 4.68342 6.09763 4.29289 5.70711L0.292893 1.70711C-0.0976311 1.31658 -0.0976311 0.683418 0.292893 0.292893Z' fill='rgba(17, 35, 55, 0.65)'\/%3E%3C\/svg%3E\");--gf-icon-ctrl-search: url(\"data:image\/svg+xml,%3Csvg width='640' height='640' xmlns='http:\/\/www.w3.org\/2000\/svg'%3E%3Cpath d='M256 128c-70.692 0-128 57.308-128 128 0 70.691 57.308 128 128 128 70.691 0 128-57.309 128-128 0-70.692-57.309-128-128-128zM64 256c0-106.039 85.961-192 192-192s192 85.961 192 192c0 41.466-13.146 79.863-35.498 111.248l154.125 154.125c12.496 12.496 12.496 32.758 0 45.254s-32.758 12.496-45.254 0L367.248 412.502C335.862 434.854 297.467 448 256 448c-106.039 0-192-85.962-192-192z' fill='rgba(17, 35, 55, 0.65)'\/%3E%3C\/svg%3E\");--gf-label-space-y-secondary: var(--gf-label-space-y-md-secondary);--gf-ctrl-border-color: #686e77;--gf-ctrl-size: var(--gf-ctrl-size-md);--gf-ctrl-label-color-primary: #112337;--gf-ctrl-label-color-secondary: #112337;--gf-ctrl-choice-size: var(--gf-ctrl-choice-size-md);--gf-ctrl-checkbox-check-size: var(--gf-ctrl-checkbox-check-size-md);--gf-ctrl-radio-check-size: var(--gf-ctrl-radio-check-size-md);--gf-ctrl-btn-font-size: var(--gf-ctrl-btn-font-size-md);--gf-ctrl-btn-padding-x: var(--gf-ctrl-btn-padding-x-md);--gf-ctrl-btn-size: var(--gf-ctrl-btn-size-md);--gf-ctrl-btn-border-color-secondary: #686e77;--gf-ctrl-file-btn-bg-color-hover: #EBEBEB;--gf-field-img-choice-size: var(--gf-field-img-choice-size-md);--gf-field-img-choice-card-space: var(--gf-field-img-choice-card-space-md);--gf-field-img-choice-check-ind-size: var(--gf-field-img-choice-check-ind-size-md);--gf-field-img-choice-check-ind-icon-size: var(--gf-field-img-choice-check-ind-icon-size-md);--gf-field-pg-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style><div id='gf_1' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_1' id='gform_1'  action='\/es\/wp-json\/wp\/v2\/pages\/4411#gf_1' data-formid='1' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_1_14\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Determine Eligibility<\/h3><\/div><fieldset id=\"field_1_20\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_1_20'>\n                            \n                            <span id='input_1_20_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_20.3' id='input_1_20_3' value='' tabindex='50'  aria-required='true'     \/>\n                                                    <label for='input_1_20_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_1_20_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_20.6' id='input_1_20_6' value='' tabindex='52'  aria-required='true'     \/>\n                                                    <label for='input_1_20_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_1_21\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_21'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_21' id='input_1_21' type='email' value='' class='large' tabindex='54'   aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_1_1\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gf_list_inline field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you live in Collin County?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_1'>\n\t\t\t<div class='gchoice gchoice_1_1_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_1' type='radio' value='Yes'  id='choice_1_1_0' onchange='gformToggleRadioOther( this )'  tabindex='55'  \/>\n\t\t\t\t\t<label for='choice_1_1_0' id='label_1_1_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_1_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_1' type='radio' value='No'  id='choice_1_1_1' onchange='gformToggleRadioOther( this )'  tabindex='56'  \/>\n\t\t\t\t\t<label for='choice_1_1_1' id='label_1_1_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_23\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you prefer to communicate in:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_23'>\n\t\t\t<div class='gchoice gchoice_1_23_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='English'  id='choice_1_23_0' onchange='gformToggleRadioOther( this )'  tabindex='57'  \/>\n\t\t\t\t\t<label for='choice_1_23_0' id='label_1_23_0' class='gform-field-label gform-field-label--type-inline'>English<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_23_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='Spanish'  id='choice_1_23_1' onchange='gformToggleRadioOther( this )'  tabindex='58'  \/>\n\t\t\t\t\t<label for='choice_1_23_1' id='label_1_23_1' class='gform-field-label gform-field-label--type-inline'>Spanish<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_2\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><div style=\"color:#111111;border:2px solid #8f0d0b;background:#eeeeee;padding:12px;\">\nWe are sorry.  We only see residents of Collin County.  Please visit <a target=\"_blank\" href=\"https:\/\/texasacc.org\/\">TXACC<\/a> to explore other options.<\/div><\/div><fieldset id=\"field_1_3\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you have health insurance?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_3'>\n\t\t\t<div class='gchoice gchoice_1_3_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_3' type='radio' value='Yes'  id='choice_1_3_0' onchange='gformToggleRadioOther( this )'  tabindex='59'  \/>\n\t\t\t\t\t<label for='choice_1_3_0' id='label_1_3_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_3_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_3' type='radio' value='No'  id='choice_1_3_1' onchange='gformToggleRadioOther( this )'  tabindex='60'  \/>\n\t\t\t\t\t<label for='choice_1_3_1' id='label_1_3_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_4\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><div style=\"color:#111111;border:2px solid #8f0d0b;background:#eeeeee;padding:12px;\">\nWe are sorry.  We are a charitable clinic. We do not take patients with health insurance.<\/div><\/div><div id=\"field_1_7\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_7'>How much total ANNUAL income does your household earn?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_7' id='input_1_7' type='text' step='any'   value='' class='small' tabindex='61'    aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><fieldset id=\"field_1_24\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Have you considered ALL sources of income such as SNAP, welfare, disability, child support, and unemployment benefits?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_24'><div class='gchoice gchoice_1_24_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.1' type='checkbox'  value='Yes'  id='choice_1_24_1' tabindex='62'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_24_1' id='label_1_24_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_24_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.2' type='checkbox'  value='No'  id='choice_1_24_2' tabindex='63'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_24_2' id='label_1_24_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_27\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><div style=\"color:#111111;border:2px solid #8f0d0b;background:#eeeeee;padding:12px;\">Please re-answer this question after considering all sources of income. A complete list can be found <a href=\"https:\/\/commongoodmedical.org\/wp-content\/uploads\/Income-Sources-on-CGM-Template.eng_.span_.pdf\">here.<\/a> <\/div><\/div><div id=\"field_1_6\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_6'>How many members are in your household?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_6' id='input_1_6' type='number' step='any'   value='' class='small' tabindex='64'    aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_1_10\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full gfield_calculation field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_10'>Calculated Income Threshold<\/label><div class='ginput_container ginput_container_number'><input name='input_10' id='input_1_10' type='text' step='any'   value='' class='large gform-text-input-reset' tabindex='65' readonly=\"readonly\"    aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_1_11\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full gfield_calculation field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_11'>Relative to Threshold<\/label><div class='ginput_container ginput_container_number'><input name='input_11' id='input_1_11' type='text' step='any'   value='' class='large gform-text-input-reset' tabindex='66' readonly=\"readonly\"    aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_1_8\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><div style=\"color:#111111;border:2px solid #8f0d0b;background:#eeeeee;padding:12px;\">We&#8217;re sorry.  You do not qualify to be seen in our clinic. \n Consider visiting <a href=\"https:\/\/healthcare.gov\" target=\"_blank\">HealthCare.gov<\/a> to explore insurance options.<\/div><\/div><div id=\"field_1_19\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><div style=\"font-size:22px;font-weight:bold;color:#111111;border:2px solid #6d9064;background:#eeeeee;padding:12px;\">Congratulations! 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id=\"pp-advanced-tabs-content-1132\" class=\"pp-advanced-tabs-content elementor-clearfix pp-advanced-tabs-tab_content \" data-tab=\"2\" data-index=\"1132\" role=\"tabpanel\" aria-labelledby=\"pp-advanced-tabs-title-1132\">\n\t\t\t\t\t\t\t<p>(spanish version of enrollment smartform)<\/p>\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Determine Eligibility for Services English Espa\u00f1ol English Determine Eligibility Name(Required) First Last Email(Required) Do you live in Collin County? Yes No We are sorry. We only see residents of Collin County. Please visit FreeClinics.com to explore other options. Do you have health insurance? Yes No We are sorry. We are a charitable clinic. 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