{"id":6185,"date":"2021-07-11T22:57:18","date_gmt":"2021-07-12T02:57:18","guid":{"rendered":"http:\/\/somnomed.gsqtest1.com\/en\/?page_id=6185"},"modified":"2022-03-09T10:00:07","modified_gmt":"2022-03-09T15:00:07","slug":"mcpay","status":"publish","type":"page","link":"https:\/\/somnomed.com\/en\/mcpay\/","title":{"rendered":"Managed Care Payment Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"6185\" class=\"elementor elementor-6185\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section data-particle_enable=\"false\" data-particle-mobile-disabled=\"false\" class=\"elementor-section elementor-top-section elementor-element elementor-element-0a75aa7 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"0a75aa7\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-93dbb59\" data-id=\"93dbb59\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-28a57ef elementor-widget elementor-widget-heading\" data-id=\"28a57ef\" 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<h2 class=\"elementor-heading-title elementor-size-default\">Managed Care Payment Form<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-a8c8a46 eael-gravity-form-button-custom elementor-widget elementor-widget-eael-gravity-form\" data-id=\"a8c8a46\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"eael-gravity-form.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t<div class=\"eael-contact-form eael-gravity-form eael-custom-radio-checkbox eael-contact-form-align-default\">\n\t\t        <script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_4' style='display:none'><div id='gf_4' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_4' id='gform_4'  action='\/en\/wp-json\/wp\/v2\/pages\/6185#gf_4' data-formid='4' novalidate>\n        <div id='gf_progressbar_wrapper_4' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<h3 class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>2<\/span><span class='gf_step_page_name'><\/span>\n        \t<\/h3>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_50' style='width:50%;'><span>50%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_4_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><ul id='gform_fields_4' class='gform_fields top_label form_sublabel_above description_below validation_below'><li id=\"field_4_20\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_above gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_20'>Comments<\/label><div class='ginput_container'><input name='input_20' id='input_4_20' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_4_20'>This field is for validation purposes and should be left unchanged.<\/div><\/li><li id=\"field_4_18\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><ul><li><h4><strong>NOTICE OF PATIENT FINANCIAL RESPONSIBILITY<\/strong><\/h4>\n<p>Thank you for allowing SomnoMed to be your Oral Appliance provider. We are committed to providing you with the highest quality products and services for the treatment of Obstructive Sleep Apnea (OSA).<\/p>\n<p>SomnoMed provides products and services in good faith, and it is important that you understand your medical insurance plan and its current benefits and coverage. Policies and coverage determinations may vary from year to year, so if you have questions, please contact your health plan administrator. Your SomnoMed oral device is billed under your medical insurance (not dental) as Durable Medical Equipment (DME) under treatment code E0486.<\/p>\n<p><strong><u>Patient Financial Responsibilities<\/u><\/strong><\/p>\n<ul>\n<li>As the patient, you are responsible for the payment of your treatment.<\/li>\n<li>SomnoMed will bill your insurance company. However, you are required to provide us with the correct and most updated information about your insurance plan. You are responsible for any charges incurred for incorrect or outdated information provided. <strong>Keep in mind that the co-insurance quoted to you at the time of connection is only an estimate and you are responsible for any additional amounts owed. Overpayments will be paid back to you once your account has been settled with your insurance company.<\/strong><\/li>\n<li>You are responsible for paying your co-pays, co-insurance, deductibles, and any add-on costs not covered by your insurance plan (i.e. compliance recorder, edentulous devices).<\/li>\n<li><strong>Co-pays and deductibles are non-refundable after IOS scans or impressions and\/or models have been completed by the sleep dentist,<\/strong> except if a SomnoMed device is deemed not clinically suitable by your sleep dentist during your initial evaluation. <\/li>\n<li><strong>You are responsible for the payment of additional charges at the discretion of SomnoMed.<\/strong> These charges may include (but are not limited to) a returned check, credit card payments, and any other penalties and collection costs incurred.<\/li>\n<li><strong>If you request a change in your selected DDS once impressions or IOS scans have been taken, or if the device has been manufactured and\/or delivered to you,<\/strong> you will be responsible for any additional cost resulting from the change.<\/li>\n<li>If you have questions or concerns you can contact a SomnoMed Patient Care Coordinator at 866.717.5337, option 6.<\/li>\n<\/ul><\/li><\/ul><\/li><li id=\"field_4_19\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_above gfield--has-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Agree terms<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_4_19'><li class='gchoice gchoice_4_19_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.1' type='checkbox'  value='I have read and agree to the &lt;a href=&quot;https:\/\/somnomed.com\/en\/mcpay\/&quot;&gt;Terms of Service&lt;\/a&gt;'  id='choice_4_19_1'   aria-describedby=\"gfield_description_4_19\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_4_19_1' id='label_4_19_1' class='gform-field-label gform-field-label--type-inline'>I have read and agree to the <a href=\"https:\/\/somnomed.com\/en\/mcpay\/\">Terms of Service<\/a><\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><div class='gfield_description' id='gfield_description_4_19'><b>Acknowledgment of Charges and Payment Terms<\/b>\n<p>By agreeing to the Terms of Service, the client acknowledges and accepts responsibility for all applicable charges incurred. Payment is due as outlined in the agreement, and disputes regarding charges must be raised within 3 days of payment. Failure to dispute charges within this timeframe constitutes acceptance of the charges in full.<p><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_4_17' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_4_2' class='gform_page' data-js='page-field-id-17' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_4_2' class='gform_fields top_label form_sublabel_above description_below validation_below'><li id=\"field_4_8\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Patient Information<\/h2><\/li><li id=\"field_4_1\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><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_4_1'>\n                            \n                            <span id='input_4_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_4_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                    <input type='text' name='input_1.3' id='input_4_1_3' value=''   aria-required='true'     \/>\n                                                <\/span>\n                            \n                            <span id='input_4_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_4_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                            <input type='text' name='input_1.6' id='input_4_1_6' value=''   aria-required='true'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/li><li id=\"field_4_2\" class=\"gfield gfield--type-address gfield--input-type-address gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Home Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_4_2' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_4_2_1_container' >\n                                        <label for='input_4_2_1' id='input_4_2_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                        <input type='text' name='input_2.1' id='input_4_2_1' value=''    aria-required='true'    \/>\n                                   <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_4_2_2_container' >\n                                        <label for='input_4_2_2' id='input_4_2_2_label' class='gform-field-label gform-field-label--type-sub '>Street Address 2<\/label>\n                                        <input type='text' name='input_2.2' id='input_4_2_2' value=''     aria-required='false'   \/>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_4_2_3_container' >\n                                    <label for='input_4_2_3' id='input_4_2_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                    <input type='text' name='input_2.3' id='input_4_2_3' value=''    aria-required='true'    \/>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_4_2_4_container' >\n                                        <label for='input_4_2_4' id='input_4_2_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                        <select name='input_2.4' id='input_4_2_4'     aria-required='true'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_4_2_5_container' >\n                                    <label for='input_4_2_5' id='input_4_2_5_label' class='gform-field-label gform-field-label--type-sub '>Zip<\/label>\n                                    <input type='text' name='input_2.5' id='input_4_2_5' value=''    aria-required='true'    \/>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_2.6' id='input_4_2_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_4_3\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_3'>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_3' id='input_4_3' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_4\" class=\"gfield gfield--type-email gfield--input-type-email gfield_contains_required field_sublabel_above gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container_email gform-grid-row' id='input_4_4_container'>\n                                <span id='input_4_4_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <label for='input_4_4' class='gform-field-label gform-field-label--type-sub '>Enter Email<\/label>\n                                    <input class='' type='email' name='input_4' id='input_4_4' value=''    aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_4_4\" \/>\n                                <\/span>\n                                <span id='input_4_4_2_container' class='ginput_right gform-grid-col gform-grid-col--size-auto'>\n                                    <label for='input_4_4_2' class='gform-field-label gform-field-label--type-sub '>Confirm Email<\/label>\n                                    <input class='' type='email' name='input_4_2' id='input_4_4_2' value=''    aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_4_4\" \/>\n                                <\/span>\n                                <div class='gf_clear gf_clear_complex'><\/div>\n                            <\/div><div class='gfield_description' id='gfield_description_4_4'>An receipt of payment will be sent to this email. <\/div><\/li><li id=\"field_4_7\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Payment Information<\/h2><\/li><li id=\"field_4_14\" class=\"gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_14'>Type of Payment<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_14' id='input_4_14' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Copay' >Copay<\/option><option value='Invoice' >Invoice<\/option><\/select><\/div><\/li><li id=\"field_4_15\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_15'>Invoice Number<\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_4_15' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_6\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_above gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_6'>Dentist SomnoMed ID<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_4_6' type='text' value='' class='medium'  aria-describedby=\"gfield_description_4_6\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_4_6'>Your Patient Care Coordinator provided you with this information in an email. <\/div><\/li><li id=\"field_4_5\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_above gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_5'>Dentist Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_5' id='input_4_5' type='text' value='' class='medium'  aria-describedby=\"gfield_description_4_5\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_4_5'>Your Patient Care Coordinator provided you with this information in an email. <\/div><\/li><li id=\"field_4_13\" class=\"gfield gfield--type-product gfield--input-type-price gfield_price gfield_price_4_13 gfield_product_4_13 gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_13'>Payment Amount<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_product_price'>\n\t\t\t\t\t<input name='input_13' id='input_4_13' type='text' value='' class='large ginput_amount'   aria-required=\"true\" aria-invalid=\"false\"  \/>\n\t\t\t\t<\/div><\/li><li id=\"field_4_11\" class=\"gfield gfield--type-creditcard gfield--input-type-creditcard field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' for='input_4_11_1'>Credit Card<\/label><div class='ginput_complex ginput_container ginput_container_creditcard gform-grid-row' id='input_4_11'><span class='ginput_full gform-grid-col' id='input_4_11_1_container' >\n                                    <div class='gform_card_icon_container'><div class='gform_card_icon gform_card_icon_amex' >American Express<\/div><div class='gform_card_icon gform_card_icon_discover' >Discover<\/div><div class='gform_card_icon gform_card_icon_mastercard' >MasterCard<\/div><div class='gform_card_icon gform_card_icon_visa' >Visa<\/div><span class='screen-reader-text' id='field_4_11_supported_creditcards'>Supported Credit Cards: American Express, Discover, MasterCard, Visa<\/span><\/div>\n                                    <label for='input_4_11_1' id='input_4_11_1_label' class='gform-field-label gform-field-label--type-sub '>Card Number<\/label>\n                                    <input type='text' name='input_11.1' id='input_4_11_1' value=''   onchange='gformMatchCard(\"input_4_11_1\");' onkeyup='gformMatchCard(\"input_4_11_1\");' autocomplete='off' pattern='[0-9]*' title='Only digits are allowed'  aria-required='false'  \/>\n                                 <\/span><span class='ginput_full ginput_cardextras gform-grid-col gform-grid-row' id='input_4_11_2_container'>\n                                            <span class='ginput_cardinfo_left gform-grid-col' id='input_4_11_2_cardinfo_left'>\n                                            <label for='input_4_11_2_month' class='gform-field-label gform-field-label--type-sub '>Expiration Date<\/label>\n                                                <span class='ginput_card_expiration_container ginput_card_field gform-grid-row'>\n                                                   \n                                                       \n                                                       <select name='input_11.2[]' id='input_4_11_2_month'   class='ginput_card_expiration ginput_card_expiration_month' aria-required='false'  >\n                                                           <option value=''>Month<\/option><option value='1' >01<\/option><option value='2' >02<\/option><option value='3' >03<\/option><option value='4' >04<\/option><option value='5' >05<\/option><option value='6' >06<\/option><option value='7' >07<\/option><option value='8' >08<\/option><option value='9' >09<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option>\n                                                       <\/select>\n                                                   \n                                                   \n                                                       \n                                                       <select name='input_11.2[]' id='input_4_11_2_year'   class='ginput_card_expiration ginput_card_expiration_year' aria-required='false'  >\n                                                           <option value=''>Year<\/option><option value='2026' >2026<\/option><option value='2027' >2027<\/option><option value='2028' >2028<\/option><option value='2029' >2029<\/option><option value='2030' >2030<\/option><option value='2031' >2031<\/option><option value='2032' >2032<\/option><option value='2033' >2033<\/option><option value='2034' >2034<\/option><option value='2035' >2035<\/option><option value='2036' >2036<\/option><option value='2037' >2037<\/option><option value='2038' >2038<\/option><option value='2039' >2039<\/option><option value='2040' >2040<\/option><option value='2041' >2041<\/option><option value='2042' >2042<\/option><option value='2043' >2043<\/option><option value='2044' >2044<\/option><option value='2045' >2045<\/option>\n                                                       <\/select>\n                                                   \n                                                <\/span>\n                                            <\/span><span class='ginput_cardinfo_right gform-grid-col' id='input_4_11_2_cardinfo_right'>\n                                                <label for='input_4_11_3' class='gform-field-label gform-field-label--type-sub '>Security Code<\/label>\n                                                <input type='text' name='input_11.3' id='input_4_11_3'   class='ginput_card_security_code' value='' autocomplete='off' pattern='[0-9]*' title='Only digits are allowed'  aria-required='false'  \/>\n                                                <span class='ginput_card_security_code_icon'>&nbsp;<\/span>\n                                             <\/span>\n                                        <\/span><span class='ginput_full gform-grid-col' id='input_4_11_5_container'>\n                                            <label for='input_4_11_5' id='input_4_11_5_label' class='gform-field-label gform-field-label--type-sub '>Cardholder Name<\/label>\n                                            <input type='text' name='input_11.5' id='input_4_11_5' value=''    aria-required='false'  \/>\n                                        <\/span> <\/div><\/li><li id=\"field_4_12\" class=\"gfield gfield--type-total gfield--input-type-total gfield_price gfield_price_4_ gfield_total gfield_total_4_ field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  aria-atomic=\"true\" aria-live=\"polite\" ><label class='gfield_label gform-field-label' for='input_4_12'>Total<\/label><div class='ginput_container ginput_container_total'>\n\t\t\t\t\t\t\t<span class='ginput_total ginput_total_4'>$0.00<\/span>\n\t\t\t\t\t\t\t<input type='hidden' name='input_12' id='input_4_12' class='gform_hidden'\/>\n\t\t\t\t\t\t<\/div><\/li><li 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We are committed to providing you with the highest quality products and services for the treatment of Obstructive Sleep Apnea (OSA). SomnoMed provides products &#8230;<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"footnotes":""},"class_list":["post-6185","page","type-page","status-publish","hentry"],"acf":[],"_links":{"self":[{"href":"https:\/\/somnomed.com\/en\/wp-json\/wp\/v2\/pages\/6185","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/somnomed.com\/en\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/somnomed.com\/en\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/somnomed.com\/en\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/somnomed.com\/en\/wp-json\/wp\/v2\/comments?post=6185"}],"version-history":[{"count":3,"href":"https:\/\/somnomed.com\/en\/wp-json\/wp\/v2\/pages\/6185\/revisions"}],"predecessor-version":[{"id":13243,"href":"https:\/\/somnomed.com\/en\/wp-json\/wp\/v2\/pages\/6185\/revisions\/13243"}],"wp:attachment":[{"href":"https:\/\/somnomed.com\/en\/wp-json\/wp\/v2\/media?parent=6185"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}