{"id":68091,"date":"2025-07-21T09:12:35","date_gmt":"2025-07-21T15:12:35","guid":{"rendered":"https:\/\/uat-internal.connectforhealthco.com\/?page_id=68091"},"modified":"2025-09-03T10:56:26","modified_gmt":"2025-09-03T16:56:26","slug":"escalation-form-for-authorized-broker","status":"publish","type":"page","link":"https:\/\/connectforhealthco.com\/es\/escalation-form-for-authorized-broker\/","title":{"rendered":"Escalation Form for Authorized Broker"},"content":{"rendered":"<div class=\"wp-bootstrap-blocks-row\">\n\t<div class=\"grid\">\n\t\t<div class=\"row\">\n\t\t\t\n\n<div class=\"col-12 col-sm-12 col-md-12 col-lg-12 col-xl-12\">\n\t<div class=\"\">\n\t\t\n\n<h2 class=\"wp-block-heading\" id=\"h-nbsp-nbsp-escalation-form-for-authorized-broker\"><img loading=\"lazy\" decoding=\"async\" width=\"36\" height=\"36\" class=\"wp-image-41426\" style=\"width: 36px;\" src=\"https:\/\/c4-media.s3.amazonaws.com\/wp-content\/uploads\/2019\/09\/09185320\/Icon-EnrollmentCenter.png\" alt=\"Enrollment Center icon\"><strong>&nbsp;&nbsp;Escalation Form for Authorized Broker<\/strong><\/h2>\n\n\n\n<p class=\"intro-text\">Customer account and\/or enrollment Escalation Form to be submitted by the authorized Broker of Record for that account. This form is to be used only after you have contacted the Service Center to escalate the problem and have not received resolution within the time frame allotted, 7-10 business days for normal priority or 3-5 business days for Medical Need. This form is not for Broker Portal, Training Portal, or BOR\/Commission issues. Please contact the Broker Team\u00a0<a href=\"mailto:BrokerTeam@c4hco.com\" target=\"_blank\" rel=\"noreferrer noopener\">BrokerTeam@c4hco.com<\/a>\u00a0for information on Broker specific issues.<\/p>\n\n\n<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 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Form<\/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; se\u00f1ala los campos obligatorios<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_37'  action='\/es\/wp-json\/wp\/v2\/pages\/68091' data-formid='37' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_37' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_37_1\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_37_1'>Broker 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_1' id='input_37_1' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_37_3\" class=\"gfield gfield--type-email gfield--input-type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_37_3'>Broker Email<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_3' id='input_37_3' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_37_4\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_37_4'>Broker Phone 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_4' id='input_37_4' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_37_6\" class=\"gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_37_6'>Account Type<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_6' id='input_37_6' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Marketplace' >Marketplace<\/option><option value='Colorado Connect' >Colorado Connect<\/option><\/select><\/div><\/div><div id=\"field_37_21\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_37_21'>Customer Last 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_21' id='input_37_21' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_37_7\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_37_7'>Customer Account #<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_37_7' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_37_8\" class=\"gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_37_8'>Enrollment type<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_8' id='input_37_8' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Medical' >Medical<\/option><option value='Dental' >Dental<\/option><option value='Both' >Both<\/option><\/select><\/div><\/div><div id=\"field_37_9\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_37_9'>Describe the error issue in a short summary (DO NOT INCLUDE PII):<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_9' id='input_37_9' class='textarea medium'   maxlength='700'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_37_22\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_37_22'>Desired Outcome<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_22' id='input_37_22' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_37_23\" 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_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Escalation Type<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_37_23'><div class='gchoice gchoice_37_23_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.1' type='checkbox'  value='Effective date change'  id='choice_37_23_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_37_23_1' id='label_37_23_1' class='gform-field-label gform-field-label--type-inline'>Effective date change<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_37_23_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.2' type='checkbox'  value='End date change'  id='choice_37_23_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_37_23_2' id='label_37_23_2' class='gform-field-label gform-field-label--type-inline'>End date change<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_37_23_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.3' type='checkbox'  value='Account error'  id='choice_37_23_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_37_23_3' id='label_37_23_3' class='gform-field-label gform-field-label--type-inline'>Account error<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_37_23_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.4' type='checkbox'  value='Issuer didn&#039;t receive enrollment files'  id='choice_37_23_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_37_23_4' id='label_37_23_4' class='gform-field-label gform-field-label--type-inline'>Issuer didn&#8217;t receive enrollment files<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_37_23_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.5' type='checkbox'  value='Reinstatement request'  id='choice_37_23_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_37_23_5' id='label_37_23_5' class='gform-field-label gform-field-label--type-inline'>Reinstatement request<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_37_23_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.6' type='checkbox'  value='1095-A'  id='choice_37_23_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_37_23_6' id='label_37_23_6' class='gform-field-label gform-field-label--type-inline'>1095-A<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_37_23_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.7' type='checkbox'  value='APTC Change'  id='choice_37_23_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_37_23_7' id='label_37_23_7' class='gform-field-label gform-field-label--type-inline'>APTC Change<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_37_23_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.8' type='checkbox'  value='Add\/Remove Dependent'  id='choice_37_23_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_37_23_8' id='label_37_23_8' class='gform-field-label gform-field-label--type-inline'>Add\/Remove Dependent<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_37_23_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.9' type='checkbox'  value='Issuer not accepting payment'  id='choice_37_23_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_37_23_9' id='label_37_23_9' class='gform-field-label gform-field-label--type-inline'>Issuer not accepting payment<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_37_23_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.11' type='checkbox'  value='Issuer didn&#039;t receive change files'  id='choice_37_23_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_37_23_11' id='label_37_23_11' class='gform-field-label gform-field-label--type-inline'>Issuer didn&#8217;t receive change files<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_37_25\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_37_25'>Urgency Level<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_25' id='input_37_25' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='P3 = Low urgency' >P3 = Low urgency<\/option><option value='P2 = Medium urgency' >P2 = Medium urgency<\/option><option value='P1 = Medical urgency' >P1 = Medical urgency<\/option><\/select><\/div><\/div><div id=\"field_37_12\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_37_12'>URL or website address of the error page<\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_37_12' type='text' value='' class='large'  aria-describedby=\"gfield_description_37_12\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_37_12'>If you need to provide screenshots of error, you can upload to the customer&#8217;s account via my documents<\/div><\/div><div id=\"field_37_13\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_37_13'>Customer Service Center Incident Case #<\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_37_13' type='text' value='' class='large'  aria-describedby=\"gfield_description_37_13\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_37_13'>If you called the customer service center<\/div><\/div><fieldset id=\"field_37_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_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Issuer<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_37_24'><div class='gchoice gchoice_37_24_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.1' type='checkbox'  value='Anthem'  id='choice_37_24_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_37_24_1' id='label_37_24_1' class='gform-field-label gform-field-label--type-inline'>Anthem<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_37_24_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.2' type='checkbox'  value='Cigna'  id='choice_37_24_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_37_24_2' id='label_37_24_2' class='gform-field-label gform-field-label--type-inline'>Cigna<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_37_24_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.3' type='checkbox'  value='Denver Health'  id='choice_37_24_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_37_24_3' id='label_37_24_3' class='gform-field-label gform-field-label--type-inline'>Denver Health<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_37_24_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.4' type='checkbox'  value='United'  id='choice_37_24_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_37_24_4' id='label_37_24_4' class='gform-field-label gform-field-label--type-inline'>United<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_37_24_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.5' type='checkbox'  value='Select'  id='choice_37_24_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_37_24_5' id='label_37_24_5' class='gform-field-label gform-field-label--type-inline'>Select<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_37_24_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.6' type='checkbox'  value='Kaiser'  id='choice_37_24_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_37_24_6' id='label_37_24_6' class='gform-field-label gform-field-label--type-inline'>Kaiser<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_37_24_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.7' type='checkbox'  value='Rocky Mountain'  id='choice_37_24_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_37_24_7' id='label_37_24_7' class='gform-field-label gform-field-label--type-inline'>Rocky Mountain<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_37_24_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.8' type='checkbox'  value='Solstice'  id='choice_37_24_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_37_24_8' id='label_37_24_8' class='gform-field-label gform-field-label--type-inline'>Solstice<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_37_24_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.9' type='checkbox'  value='VSP'  id='choice_37_24_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_37_24_9' id='label_37_24_9' class='gform-field-label gform-field-label--type-inline'>VSP<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_37_24_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.11' type='checkbox'  value='Eye Med'  id='choice_37_24_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_37_24_11' id='label_37_24_11' class='gform-field-label gform-field-label--type-inline'>Eye Med<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_37_24_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.12' type='checkbox'  value='Delta Dental'  id='choice_37_24_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_37_24_12' id='label_37_24_12' class='gform-field-label gform-field-label--type-inline'>Delta Dental<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_37_24_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.13' type='checkbox'  value='N\/A'  id='choice_37_24_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_37_24_13' id='label_37_24_13' class='gform-field-label gform-field-label--type-inline'>N\/A<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_37_16\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_37_16'>Has the issuer been contacted?<\/label><div class='ginput_container ginput_container_select'><select name='input_16' id='input_37_16' class='large gfield_select'     aria-invalid=\"false\" ><option value='Yes' >Yes<\/option><option value='No' selected='selected'>No<\/option><\/select><\/div><\/div><div id=\"field_37_17\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_37_17'>Contact Date<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_17' id='input_37_17' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/aaaa' aria-describedby=\"input_37_17_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_37_17_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_37_17' class='gform_hidden' value='https:\/\/connectforhealthco.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_37_18\" class=\"gfield gfield--type-time gfield--input-type-time gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Contact Time<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class=\"ginput_container ginput_complex gform-grid-row\">\n                        <div class='gfield_time_hour ginput_container ginput_container_time gform-grid-col' id='input_37_18'>\n                            <input type='number' name='input_18[]' id='input_37_18_1' value=''  min='0' max='12' step='1'  placeholder='HH' aria-required='true'   \/> \n                            <label class='gform-field-label gform-field-label--type-sub hour_label screen-reader-text' for='input_37_18_1'>Horas<\/label>\n                        <\/div>\n                        <div class=\"below hour_minute_colon gform-grid-col\">:<\/div>\n                        <div class='gfield_time_minute ginput_container ginput_container_time gform-grid-col'>\n                            <input type='number' name='input_18[]' id='input_37_18_2' value=''  min='0' max='59' step='1'  placeholder='MM' aria-required='true'  \/>\n                            <label class='gform-field-label gform-field-label--type-sub minute_label screen-reader-text' for='input_37_18_2'>Minutos<\/label>\n                        <\/div>\n                        <div class='gfield_time_ampm ginput_container ginput_container_time below gform-grid-col' >\n                                \n                                <select name='input_18[]' id='input_37_18_3'  >\n                                    <option value='am' >AM<\/option>\n                                    <option value='pm' >PM<\/option>\n                                <\/select> \n                                <label class='gform-field-label gform-field-label--type-sub am_pm_label screen-reader-text' for='input_37_18_3'>AM\/PM<\/label>                                \n                           <\/div>\n                    <\/div><\/fieldset><div id=\"field_37_19\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_37_19'>Agent 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_19' id='input_37_19' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_37_20\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_37_20'>Reference Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_37_20' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_37_15\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_37_15'>Enrollment Effective Date<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_15' id='input_37_15' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/aaaa' aria-describedby=\"input_37_15_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_37_15_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_37_15' class='gform_hidden' value='https:\/\/connectforhealthco.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_37' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Submit'  \/> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_37' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_37' id='gform_theme_37' value='orbital' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_37' id='gform_style_settings_37' value='{&quot;inputPrimaryColor&quot;:&quot;#204ce5&quot;}' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_37' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='37' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='USD' value='KyrZD7silRgumIB+HVX8OMJRmY01DUL7c4vmPim+oT6s25DJbKnYEhGItieGTps+jhqYufMG\/zJ8bOTttraT4IzqxElLVuvIaW7x1BP2qdeT1RM=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_37' value='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' 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