{"id":5379,"date":"2024-03-28T15:20:28","date_gmt":"2024-03-28T20:20:28","guid":{"rendered":"https:\/\/cgm.tailfish1.com\/?page_id=5379"},"modified":"2024-04-09T10:37:49","modified_gmt":"2024-04-09T15:37:49","slug":"divulgacion-de-registros-medicos","status":"publish","type":"page","link":"https:\/\/commongoodmedical.org\/es\/medical-records-release\/","title":{"rendered":"Divulgaci\u00f3n de registros m\u00e9dicos"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"5379\" class=\"elementor elementor-5379\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-5a76b45 e-flex e-con-boxed e-con e-parent\" data-id=\"5a76b45\" 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-890a9e5 elementor-widget elementor-widget-heading\" data-id=\"890a9e5\" 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\">Medical Records Release<\/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-e7382b8 e-flex e-con-boxed e-con e-parent\" data-id=\"e7382b8\" 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-e4af565 elementor-widget elementor-widget-pp-advanced-tabs\" data-id=\"e4af565\" 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-2391\" class=\"pp-advanced-tabs-title pp-tabs-label pp-advanced-tabs-desktop-title pp-tab-active\" data-tab=\"1\" data-index=\"2391\" tabindex=\"0\" role=\"tab\" aria-controls=\"pp-advanced-tabs-content-2391\">\n\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"pp-icon pp-advanced-tabs-icon-top\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-fas-check\" viewBox=\"0 0 512 512\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M173.898 439.404l-166.4-166.4c-9.997-9.997-9.997-26.206 0-36.204l36.203-36.204c9.997-9.998 26.207-9.998 36.204 0L192 312.69 432.095 72.596c9.997-9.997 26.207-9.997 36.204 0l36.203 36.204c9.997 9.997 9.997 26.206 0 36.204l-294.4 294.401c-9.998 9.997-26.207 9.997-36.204-.001z\"><\/path><\/svg>\t\t\t<\/span>\n\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-2392\" class=\"pp-advanced-tabs-title pp-tabs-label pp-advanced-tabs-desktop-title \" data-tab=\"2\" data-index=\"2392\" tabindex=\"0\" role=\"tab\" aria-controls=\"pp-advanced-tabs-content-2392\">\n\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"pp-icon pp-advanced-tabs-icon-top\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-fas-check\" viewBox=\"0 0 512 512\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M173.898 439.404l-166.4-166.4c-9.997-9.997-9.997-26.206 0-36.204l36.203-36.204c9.997-9.998 26.207-9.998 36.204 0L192 312.69 432.095 72.596c9.997-9.997 26.207-9.997 36.204 0l36.203 36.204c9.997 9.997 9.997 26.206 0 36.204l-294.4 294.401c-9.998 9.997-26.207 9.997-36.204-.001z\"><\/path><\/svg>\t\t\t<\/span>\n\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=\"2391\">\n\t\t\t\t\t\t\t<div class=\"pp-advanced-tabs-title-inner\">\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"pp-icon pp-advanced-tabs-icon-top\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-fas-check\" viewBox=\"0 0 512 512\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M173.898 439.404l-166.4-166.4c-9.997-9.997-9.997-26.206 0-36.204l36.203-36.204c9.997-9.998 26.207-9.998 36.204 0L192 312.69 432.095 72.596c9.997-9.997 26.207-9.997 36.204 0l36.203 36.204c9.997 9.997 9.997 26.206 0 36.204l-294.4 294.401c-9.998 9.997-26.207 9.997-36.204-.001z\"><\/path><\/svg>\t\t\t<\/span>\n\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-2391\" class=\"pp-advanced-tabs-content elementor-clearfix pp-advanced-tabs-tab_content pp-tab-active\" data-tab=\"1\" data-index=\"2391\" role=\"tabpanel\" aria-labelledby=\"pp-advanced-tabs-title-2391\">\n\t\t\t\t\t\t\t<p><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_6' style='display:none'><style>#gform_wrapper_6[data-form-index=\"0\"].gform-theme,[data-parent-form=\"6_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: 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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_6' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Medical Records Release<\/h2>\n                            <p class='gform_description'><\/p>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_6'  action='\/es\/wp-json\/wp\/v2\/pages\/5379#gf_6' data-formid='6' novalidate>\n        <div id='gf_progressbar_wrapper_6' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<p class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>3<\/span><span class='gf_step_page_name'><\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_33' style='width:33%;'><span>33%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_6_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><div id='gform_fields_6' class='gform_fields top_label form_sublabel_below description_above validation_below'><fieldset id=\"field_6_1\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-third 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' >Patient Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/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_6_1'>\n                            \n                            <span id='input_6_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_6_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_6_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_6_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_6_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_6_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_6_23\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-third 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_6_23'>Email Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_23' id='input_6_23' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_6_3\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-third 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_6_3'>Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_3' id='input_6_3' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_6_3_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_6_3_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_3' class='gform_hidden' value='https:\/\/commongoodmedical.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_6_4\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third 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_6_4'>Release Patient&#039;s Medical Records to:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_6_4' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_6\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-third 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_6_6'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_6' id='input_6_6' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_28\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-third 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_6_28'>Fax Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_28' id='input_6_28' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_7\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_7'>Release Patient&#039;s Medical Records from:<\/label><div class='ginput_container ginput_container_text'><input readonly='readonly' name='input_7' id='input_6_7' type='text' value='CommonGood Medical, 103 E Lamar St, McKinney, 75069' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_8\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_8'>Phone<\/label><div class='ginput_container ginput_container_phone'><input readonly='readonly' name='input_8' id='input_6_8' type='tel' value='(469) 712-4246' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_10\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_4col 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' >Information to be released<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_6_10'><div class='gchoice gchoice_6_10_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.1' type='checkbox'  value='All Information'  id='choice_6_10_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_10_1' id='label_6_10_1' class='gform-field-label gform-field-label--type-inline'>All Information<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_10_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.2' type='checkbox'  value='All Progress Notes'  id='choice_6_10_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_10_2' id='label_6_10_2' class='gform-field-label gform-field-label--type-inline'>All Progress Notes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_10_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.3' type='checkbox'  value='Lab Reports'  id='choice_6_10_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_10_3' id='label_6_10_3' class='gform-field-label gform-field-label--type-inline'>Lab Reports<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_10_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.4' type='checkbox'  value='X-Ray Reports'  id='choice_6_10_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_10_4' id='label_6_10_4' class='gform-field-label gform-field-label--type-inline'>X-Ray Reports<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_10_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.5' type='checkbox'  value='Electrocardiogram (ECG)'  id='choice_6_10_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_10_5' id='label_6_10_5' class='gform-field-label gform-field-label--type-inline'>Electrocardiogram (ECG)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_10_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.6' type='checkbox'  value='Allergy Records'  id='choice_6_10_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_10_6' id='label_6_10_6' class='gform-field-label gform-field-label--type-inline'>Allergy Records<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_10_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.7' type='checkbox'  value='Immunization Records'  id='choice_6_10_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_10_7' id='label_6_10_7' class='gform-field-label gform-field-label--type-inline'>Immunization Records<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_10_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.8' type='checkbox'  value='Discharge Summary'  id='choice_6_10_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_10_8' id='label_6_10_8' class='gform-field-label gform-field-label--type-inline'>Discharge Summary<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_10_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.9' type='checkbox'  value='Latest Labs'  id='choice_6_10_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_10_9' id='label_6_10_9' class='gform-field-label gform-field-label--type-inline'>Latest Labs<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_10_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.11' type='checkbox'  value='Surgical Reports'  id='choice_6_10_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_10_11' id='label_6_10_11' class='gform-field-label gform-field-label--type-inline'>Surgical Reports<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_10_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.12' type='checkbox'  value='Imaging (past two years)'  id='choice_6_10_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_10_12' id='label_6_10_12' class='gform-field-label gform-field-label--type-inline'>Imaging (past two years)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_10_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.13' type='checkbox'  value='Last Office Visit Progress Notes'  id='choice_6_10_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_10_13' id='label_6_10_13' class='gform-field-label gform-field-label--type-inline'>Last Office Visit Progress Notes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_10_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.14' type='checkbox'  value='Other'  id='choice_6_10_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_10_14' id='label_6_10_14' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_11\" class=\"gfield gfield--type-text gfield--input-type-text 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_6_11'>Other. Please specify.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_6_11' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_6_13' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> <button type='button'  id='gform_save_6_2_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save &#038; Continue<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_6_2' class='gform_page' data-js='page-field-id-13' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_6_2' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_6_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\">Special Authorization<\/h3><\/div><fieldset id=\"field_6_15\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gf_list_3col gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >By signing below, I am authorizing the office to release any and all information regarding:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_6_15'>Check all that apply.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_6_15'><div class='gchoice gchoice_6_15_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.1' type='checkbox'  value='Alcohol'  id='choice_6_15_1'   aria-describedby=\"gfield_description_6_15\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_6_15_1' id='label_6_15_1' class='gform-field-label gform-field-label--type-inline'>Alcohol<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_15_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.2' type='checkbox'  value='Drugs'  id='choice_6_15_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_15_2' id='label_6_15_2' class='gform-field-label gform-field-label--type-inline'>Drugs<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_15_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.3' type='checkbox'  value='Mental Health'  id='choice_6_15_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_15_3' id='label_6_15_3' class='gform-field-label gform-field-label--type-inline'>Mental Health<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_15_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.4' type='checkbox'  value='Sexually Transmitted Diseases'  id='choice_6_15_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_15_4' id='label_6_15_4' class='gform-field-label gform-field-label--type-inline'>Sexually Transmitted Diseases<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_15_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.5' type='checkbox'  value='HIV'  id='choice_6_15_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_15_5' id='label_6_15_5' class='gform-field-label gform-field-label--type-inline'>HIV<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_15_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.6' type='checkbox'  value='AIDS'  id='choice_6_15_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_15_6' id='label_6_15_6' class='gform-field-label gform-field-label--type-inline'>AIDS<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_15_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.7' type='checkbox'  value='None of the Above'  id='choice_6_15_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_15_7' id='label_6_15_7' class='gform-field-label gform-field-label--type-inline'>None of the Above<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_16\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent 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' >Note: If this release pertains to alcohol, drug, or mental health information, please note that this information has been disclosed to you from records protected by federal confidentiality rules (42 CFR part 2). The federal rules prohibit you from making any further disclosure of this information unless additional further disclosure is expressly permitted by written consent of the person to whom it pertains or as otherwise permitted by 42 CFR part 2. A general authorization for the release of medical or other information is not sufficient for this purpose. The federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_16.1' id='input_6_16_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_6_16_1' >I have read and understand this statement.<\/label><input type='hidden' name='input_16.2' value='I have read and understand this statement.' class='gform_hidden' \/><input type='hidden' name='input_16.3' value='2' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_6_17\" class=\"gfield gfield--type-signature gfield--input-type-signature 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_6_17'>Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><input type='hidden' value='' name='input_17' id='input_6_17_signature_filename'\/><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_6_17_Container' class='gfield_signature_container ginput_container' style='height:180px; width:500px; ' ><canvas id='input_6_17' width='500' height='180' style='border-style: solid; border-width: 1px; border-color: #DDDDDD; background-color:#FFFFFF; cursor: url(https:\/\/commongoodmedical.org\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;'><\/canvas><\/div><div id='input_6_17_toolbar' style='margin:5px 0;position:relative;height:20px;width:500px;max-width:100%;'><img id = 'input_6_17_resetbutton' src='data:image\/png;base64,iVBORw0KGgoAAAANSUhEUgAAABgAAAAYCAYAAADgdz34AAAAGXRFWHRTb2Z0d2FyZQBBZG9iZSBJbWFnZVJlYWR5ccllPAAAAtRJREFUeNrsld9rklEYx32nc7i2GulGtZg6XJbJyBeJzbGZJJVuAyFD7D8QumiG7nLXQuw6dtHN7oYwFtIgDG+2CGQtGf1grBpWIkPHaDpJZvZ95F2cqfPHRTfRgY\/H85znfb7nPc85z8sVi0XR32zcf4GmBTiOk8GWY8YSdEpwHpwG7eAA\/ABJsA3\/w5MEJOUGi8VyCUFFeCiGvlcsFvOFQqGtzK1d4Bzmr8DvDfy\/NyTgcDj6I5GIGA91YdiN4CW7RqNp83g8fZ2dna17e3v5ubm5r1tbWz8F8WH4v4PIh7oCTOumH4VCIQkGg6axsTElgkRhyoJTXq\/33srKStzpdL5KpVK0RVcxvw+Rb40KlNr09LTSbDZH8HcJ\/DqyY2sksE9Go1GHVqsN5fP5Yk9Pz3WIJNmctNQT8Pl8n\/DQZza40CjIokqlerywsMCTYWdnpwVjTb0kF1dXVy2sLR6Pn4HIJnu6mLZht9s3KUeUE7VarYPt459ZOqZlKMFEFRRVfI+QzMzMeBHOOTAw4GbnKt4AK6Vte0\/nHA6pBu\/T4ejoqAgnS4dTlT82U74aJOourYTn+ds1VlyNm+AReMjaK5LsdrvpxoqSyWSX8DbVSwDHtYJ+hi9gETxl\/SoCWK1WGfWJRKLQ0dGhO0kAq5MGAoFB\/OVZXC6XtqYAzvamwWCgMiDK5XKXsSL5CRpZv98vnp+fH2SNJpPpYk0BlIIXSJaB\/lOZkEqlNyCi4ahAHd8iajGUj41a2a+2xzmj0fgsFAoN0QA3lAJfAxMISDeVpx7jSbJnMplSOZ6amuptVIBaZHx8\/G0sFruj1+tlgo2KWh\/oF3opGWl+bW3t1uzsrHJ5eXm42Q+OGW\/wADc7gYe3w+Fwen19\/YByhMMgt9lsqpGRkQvYxifwfQnup9PprFwuX2rmi0ZvYAdDwurPgl1A9ek1eE7byqYR7P873+TfAgwATQiKdubVli0AAAAASUVORK5CYII=' style='cursor:pointer;float:right;height:24px;width:24px;border:0px solid transparent' alt='Clear Signature' \/ ><\/div><input type='hidden' id='input_6_17_data' name='input_6_17_data' value=''><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_6_18' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_6_18' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> <button type='button'  id='gform_save_6_3_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save &#038; Continue<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_6_3' class='gform_page' data-js='page-field-id-18' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_6_3' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_6_19\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_19'>Release Records from Start Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_19' id='input_6_19' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_6_19_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_6_19_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_19' class='gform_hidden' value='https:\/\/commongoodmedical.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_6_20\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_20'>To End Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_20' id='input_6_20' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_6_20_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_6_20_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_20' class='gform_hidden' value='https:\/\/commongoodmedical.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_6_21\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gf_list_3col 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' >Purpose of Disclosure<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_6_21'><div class='gchoice gchoice_6_21_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.1' type='checkbox'  value='Continued Medical Care'  id='choice_6_21_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_21_1' id='label_6_21_1' class='gform-field-label gform-field-label--type-inline'>Continued Medical Care<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_21_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.2' type='checkbox'  value='Payment of Insurance Claim'  id='choice_6_21_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_21_2' id='label_6_21_2' class='gform-field-label gform-field-label--type-inline'>Payment of Insurance Claim<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_21_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.3' type='checkbox'  value='Legal'  id='choice_6_21_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_21_3' id='label_6_21_3' class='gform-field-label gform-field-label--type-inline'>Legal<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_21_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.4' type='checkbox'  value='Personal'  id='choice_6_21_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_21_4' id='label_6_21_4' class='gform-field-label gform-field-label--type-inline'>Personal<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_21_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.5' type='checkbox'  value='Worker&#039;s Compensation Claim'  id='choice_6_21_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_21_5' id='label_6_21_5' class='gform-field-label gform-field-label--type-inline'>Worker&#8217;s Compensation Claim<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_21_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.6' type='checkbox'  value='Other'  id='choice_6_21_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_21_6' id='label_6_21_6' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_22\" class=\"gfield gfield--type-text gfield--input-type-text 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_6_22'>Other. Please Explain.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_6_22' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_24\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent 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' >I understand that this authorization shall be valid for five years. I understand that I may revoke this consent at any time except to the extent that action has already been taken.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_24.1' id='input_6_24_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_6_24_1' >I agree<\/label><input type='hidden' name='input_24.2' value='I agree' class='gform_hidden' \/><input type='hidden' name='input_24.3' value='2' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_6_25\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent 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' >I understand that a copy of this request will be emailed to me.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_25.1' id='input_6_25_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_6_25_1' >Send a copy to the email address provided above.<\/label><input type='hidden' name='input_25.2' value='Send a copy to the email address provided above.' class='gform_hidden' \/><input type='hidden' name='input_25.3' value='2' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_6_27\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_27'>Submit Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input readonly='readonly' name='input_27' id='input_6_27' type='text' value='' class='gpro-disabled-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='abril 28, 2026' aria-describedby=\"input_6_27_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_6_27_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <input type=\"hidden\" id=\"gwro_hidden_capture_6_27\" name=\"gwro_hidden_capture_6_27\" value=\"\" class=\"gf-default-disabled\" \/><\/div>\n                        <input readonly='readonly' type='hidden' id='gforms_calendar_icon_input_6_27' class='gform_hidden' value='https:\/\/commongoodmedical.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_6_26\" class=\"gfield gfield--type-signature gfield--input-type-signature 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_6_26'>Patient \/ Guardian Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><input type='hidden' value='' name='input_26' id='input_6_26_signature_filename'\/><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_6_26_Container' class='gfield_signature_container ginput_container' style='height:180px; width:500px; ' ><canvas id='input_6_26' width='500' height='180' style='border-style: solid; border-width: 1px; border-color: #DDDDDD; background-color:#ffffff; cursor: url(https:\/\/commongoodmedical.org\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;'><\/canvas><\/div><div id='input_6_26_toolbar' style='margin:5px 0;position:relative;height:20px;width:500px;max-width:100%;'><img id = 'input_6_26_resetbutton' src='data:image\/png;base64,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' style='cursor:pointer;float:right;height:24px;width:24px;border:0px solid transparent' alt='Clear Signature' \/ ><\/div><input type='hidden' id='input_6_26_data' name='input_6_26_data' value=''><\/div><\/div><\/div><\/div>\n        <div class='gform-page-footer gform_page_footer top_label'><input type='submit' id='gform_previous_button_6' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='submit' id='gform_submit_button_6' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Submit'  \/> <button type='button'  id='gform_save_6_footer_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" 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