{"id":1835,"date":"2024-02-20T09:04:49","date_gmt":"2024-02-20T09:04:49","guid":{"rendered":"https:\/\/mzcustomfit.com\/?page_id=1835"},"modified":"2024-03-08T11:29:50","modified_gmt":"2024-03-08T11:29:50","slug":"insurance-for-compression","status":"publish","type":"page","link":"https:\/\/mzcustomfit.com\/insurance-for-compression\/","title":{"rendered":"Insurance for Compression"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"1835\" class=\"elementor elementor-1835\">\n\t\t\t\t\t\t<div class=\"elementor-inner\">\n\t\t\t\t<div class=\"elementor-section-wrap\">\n\t\t\t\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-3db5b432 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"3db5b432\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t\t\t<div class=\"elementor-row\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-5be1fb91\" data-id=\"5be1fb91\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-column-wrap elementor-element-populated\">\n\t\t\t\t\t\t\t<div class=\"elementor-widget-wrap\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-2cf599f1 elementor-widget elementor-widget-text-editor\" data-id=\"2cf599f1\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-text-editor elementor-clearfix\">\n\t\t\t\t<!-- wp:wpforms\/form-selector {\"formId\":\"1834\"} \/-->\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-374283b elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"374283b\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t\t\t<div class=\"elementor-row\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-ada476e\" data-id=\"ada476e\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-column-wrap elementor-element-populated\">\n\t\t\t\t\t\t\t<div class=\"elementor-widget-wrap\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-9ed3cf9 elementor-widget elementor-widget-wpforms\" data-id=\"9ed3cf9\" data-element_type=\"widget\" data-widget_type=\"wpforms.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<div class=\"wpforms-container wpforms-container-full\" id=\"wpforms-1831\"><form id=\"wpforms-form-1831\" class=\"wpforms-validate wpforms-form\" data-formid=\"1831\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/wp-json\/wp\/v2\/pages\/1835\" data-token=\"8b9ef528a6fd6eaf1db17619672424fd\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-page-indicator progress\" data-indicator=\"progress\" data-indicator-color=\"#72b239\" data-scroll=\"1\"><span class=\"wpforms-page-indicator-page-title\" ><\/span><span class=\"wpforms-page-indicator-page-title-sep\" style=\"display:none;\"> - <\/span><span class=\"wpforms-page-indicator-steps\">Step <span class=\"wpforms-page-indicator-steps-current\">1<\/span> of 2<\/span><div class=\"wpforms-page-indicator-page-progress-wrap\"><div class=\"wpforms-page-indicator-page-progress\" style=\"width:50%;background-color:#72b239;\"><\/div><\/div><\/div><div class=\"wpforms-field-container\"><div class=\"wpforms-page wpforms-page-1 \"><div id=\"wpforms-1831-field_9-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"9\"><\/div><div id=\"wpforms-1831-field_1-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"1\"><h3 id=\"wpforms-1831-field_1\" name=\"wpforms[fields][1]\">Eligibility<\/h3><\/div><div id=\"wpforms-1831-field_4-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-2-columns wpforms-conditional-trigger\" data-field-id=\"4\"><label class=\"wpforms-field-label\" for=\"wpforms-1831-field_4\">Do you currently have a medical diagnosis of lymphedema? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-1831-field_4\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1831-field_4_1\" name=\"wpforms[fields][4]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1831-field_4_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1831-field_4_2\" name=\"wpforms[fields][4]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1831-field_4_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-1831-field_5-container\" class=\"wpforms-field wpforms-field-html wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"5\" style=\"display:none;\"><div id=\"wpforms-1831-field_5\"><p>Medicare requires a medical diagnosis of lymphedema before they will provide coverage for lymphedema treatment supplies. Speak to your doctor if you believe you have lymphedema.<\/p><\/div><\/div><div id=\"wpforms-1831-field_6-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-2-columns wpforms-conditional-trigger\" data-field-id=\"6\"><label class=\"wpforms-field-label\" for=\"wpforms-1831-field_6\">Have you been seen by your Primary Care Physician or specialist in the last six months? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-1831-field_6\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1831-field_6_1\" name=\"wpforms[fields][6]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1831-field_6_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1831-field_6_2\" name=\"wpforms[fields][6]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1831-field_6_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-1831-field_7-container\" class=\"wpforms-field wpforms-field-html wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"7\" style=\"display:none;\"><div id=\"wpforms-1831-field_7\"><p>Medicare requires a medical diagnosis of lymphedema and a prescription for specific lymphedema treatment supplies dated within the last six months in order to provide coverage. See your Primary Care Physician or specialist to obtain an updated lymphedema diagnosis and prescription for treatment supplies.<\/p><\/div><\/div><div id=\"wpforms-1831-field_8-container\" class=\"wpforms-field wpforms-field-pagebreak customnextbutton\" data-field-id=\"8\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><button class=\"wpforms-page-button wpforms-page-next\" data-action=\"next\" data-page=\"1\" data-formid=\"1831\" disabled>Next<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-2 last customnextbutton\" style=\"display:none;\"><div id=\"wpforms-1831-field_11-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"11\"><h3 id=\"wpforms-1831-field_11\" name=\"wpforms[fields][11]\">Patient Information<\/h3><\/div><div id=\"wpforms-1831-field_12-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"12\"><label class=\"wpforms-field-label\" for=\"wpforms-1831-field_12\">Name <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-1831-field_12\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][12][first]\" required><label for=\"wpforms-1831-field_12\" class=\"wpforms-field-sublabel after \">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-1831-field_12-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][12][last]\" required><label for=\"wpforms-1831-field_12-last\" class=\"wpforms-field-sublabel after \">Last<\/label><\/div><\/div><\/div><div id=\"wpforms-1831-field_13-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"13\"><label class=\"wpforms-field-label\" for=\"wpforms-1831-field_13\">Date of Birth <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-1831-field_13\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-large\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][13][date]\" required><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-1831-field_14-container\" class=\"wpforms-field wpforms-field-address\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-1831-field_14\">Home Address <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-large\"><div ><input type=\"text\" id=\"wpforms-1831-field_14\" class=\"wpforms-field-address-address1 wpforms-field-required\" name=\"wpforms[fields][14][address1]\" required><label for=\"wpforms-1831-field_14\" class=\"wpforms-field-sublabel after \">Address Line 1<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-1831-field_14-city\" class=\"wpforms-field-address-city wpforms-field-required\" name=\"wpforms[fields][14][city]\" required><label for=\"wpforms-1831-field_14-city\" class=\"wpforms-field-sublabel after \">City<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><select id=\"wpforms-1831-field_14-state\" class=\"wpforms-field-address-state wpforms-field-required\" name=\"wpforms[fields][14][state]\" required><option value=\"AL\" >Alabama<\/option><option value=\"AK\" >Alaska<\/option><option value=\"AZ\" >Arizona<\/option><option value=\"AR\" >Arkansas<\/option><option value=\"CA\" >California<\/option><option value=\"CO\" >Colorado<\/option><option value=\"CT\" >Connecticut<\/option><option value=\"DE\" >Delaware<\/option><option value=\"DC\" >District of Columbia<\/option><option value=\"FL\" >Florida<\/option><option value=\"GA\" >Georgia<\/option><option value=\"HI\" >Hawaii<\/option><option value=\"ID\" >Idaho<\/option><option value=\"IL\" >Illinois<\/option><option value=\"IN\" >Indiana<\/option><option value=\"IA\" >Iowa<\/option><option value=\"KS\" >Kansas<\/option><option value=\"KY\" >Kentucky<\/option><option value=\"LA\" >Louisiana<\/option><option value=\"ME\" >Maine<\/option><option value=\"MD\" >Maryland<\/option><option value=\"MA\" >Massachusetts<\/option><option value=\"MI\" >Michigan<\/option><option value=\"MN\" >Minnesota<\/option><option value=\"MS\" >Mississippi<\/option><option value=\"MO\" >Missouri<\/option><option value=\"MT\" >Montana<\/option><option value=\"NE\" >Nebraska<\/option><option value=\"NV\" >Nevada<\/option><option value=\"NH\" >New Hampshire<\/option><option value=\"NJ\" >New Jersey<\/option><option value=\"NM\" >New Mexico<\/option><option value=\"NY\" >New York<\/option><option value=\"NC\" >North Carolina<\/option><option value=\"ND\" >North Dakota<\/option><option value=\"OH\" >Ohio<\/option><option value=\"OK\" >Oklahoma<\/option><option value=\"OR\" >Oregon<\/option><option value=\"PA\" >Pennsylvania<\/option><option value=\"RI\" >Rhode Island<\/option><option value=\"SC\" >South Carolina<\/option><option value=\"SD\" >South Dakota<\/option><option value=\"TN\" >Tennessee<\/option><option value=\"TX\" >Texas<\/option><option value=\"UT\" >Utah<\/option><option value=\"VT\" >Vermont<\/option><option value=\"VA\" >Virginia<\/option><option value=\"WA\" >Washington<\/option><option value=\"WV\" >West Virginia<\/option><option value=\"WI\" >Wisconsin<\/option><option value=\"WY\" >Wyoming<\/option><\/select><label for=\"wpforms-1831-field_14-state\" class=\"wpforms-field-sublabel after \">State<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-1831-field_14-postal\" class=\"wpforms-field-address-postal wpforms-field-required wpforms-masked-input\" data-inputmask-mask=\"99999[-9999]\" data-inputmask-greedy=\"false\" data-rule-empty-blanks=\"1\" name=\"wpforms[fields][14][postal]\" required><label for=\"wpforms-1831-field_14-postal\" class=\"wpforms-field-sublabel after \">Zip Code<\/label><\/div><\/div><\/div><div id=\"wpforms-1831-field_15-container\" class=\"wpforms-field wpforms-field-address\" data-field-id=\"15\"><label class=\"wpforms-field-label\" for=\"wpforms-1831-field_15\">Ship Address<\/label><div class=\"wpforms-field-row wpforms-field-large\"><div ><input type=\"text\" id=\"wpforms-1831-field_15\" class=\"wpforms-field-address-address1\" name=\"wpforms[fields][15][address1]\" ><label for=\"wpforms-1831-field_15\" class=\"wpforms-field-sublabel after \">Address Line 1<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-1831-field_15-city\" class=\"wpforms-field-address-city\" name=\"wpforms[fields][15][city]\" ><label for=\"wpforms-1831-field_15-city\" class=\"wpforms-field-sublabel after \">City<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><select id=\"wpforms-1831-field_15-state\" class=\"wpforms-field-address-state\" name=\"wpforms[fields][15][state]\" ><option value=\"AL\" >Alabama<\/option><option value=\"AK\" >Alaska<\/option><option value=\"AZ\" >Arizona<\/option><option value=\"AR\" >Arkansas<\/option><option value=\"CA\" >California<\/option><option value=\"CO\" >Colorado<\/option><option value=\"CT\" >Connecticut<\/option><option value=\"DE\" >Delaware<\/option><option value=\"DC\" >District of Columbia<\/option><option value=\"FL\" >Florida<\/option><option value=\"GA\" >Georgia<\/option><option value=\"HI\" >Hawaii<\/option><option value=\"ID\" >Idaho<\/option><option value=\"IL\" >Illinois<\/option><option value=\"IN\" >Indiana<\/option><option value=\"IA\" >Iowa<\/option><option value=\"KS\" >Kansas<\/option><option value=\"KY\" >Kentucky<\/option><option value=\"LA\" >Louisiana<\/option><option value=\"ME\" >Maine<\/option><option value=\"MD\" >Maryland<\/option><option value=\"MA\" >Massachusetts<\/option><option value=\"MI\" >Michigan<\/option><option value=\"MN\" >Minnesota<\/option><option value=\"MS\" >Mississippi<\/option><option value=\"MO\" >Missouri<\/option><option value=\"MT\" >Montana<\/option><option value=\"NE\" >Nebraska<\/option><option value=\"NV\" >Nevada<\/option><option value=\"NH\" >New Hampshire<\/option><option value=\"NJ\" >New Jersey<\/option><option value=\"NM\" >New Mexico<\/option><option value=\"NY\" >New York<\/option><option value=\"NC\" >North Carolina<\/option><option value=\"ND\" >North Dakota<\/option><option value=\"OH\" >Ohio<\/option><option value=\"OK\" >Oklahoma<\/option><option value=\"OR\" >Oregon<\/option><option value=\"PA\" >Pennsylvania<\/option><option value=\"RI\" >Rhode Island<\/option><option value=\"SC\" >South Carolina<\/option><option value=\"SD\" >South Dakota<\/option><option value=\"TN\" >Tennessee<\/option><option value=\"TX\" >Texas<\/option><option value=\"UT\" >Utah<\/option><option value=\"VT\" >Vermont<\/option><option value=\"VA\" >Virginia<\/option><option value=\"WA\" >Washington<\/option><option value=\"WV\" >West Virginia<\/option><option value=\"WI\" >Wisconsin<\/option><option value=\"WY\" >Wyoming<\/option><\/select><label for=\"wpforms-1831-field_15-state\" class=\"wpforms-field-sublabel after \">State<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-1831-field_15-postal\" class=\"wpforms-field-address-postal wpforms-masked-input\" data-inputmask-mask=\"99999[-9999]\" data-inputmask-greedy=\"false\" data-rule-empty-blanks=\"1\" name=\"wpforms[fields][15][postal]\" ><label for=\"wpforms-1831-field_15-postal\" class=\"wpforms-field-sublabel after \">Zip Code<\/label><\/div><\/div><\/div><div id=\"wpforms-1831-field_16-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"16\"><label class=\"wpforms-field-label\" for=\"wpforms-1831-field_16\">Daytime Phone<\/label><input type=\"tel\" id=\"wpforms-1831-field_16\" class=\"wpforms-field-large wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][16]\" ><\/div><div id=\"wpforms-1831-field_42-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"42\"><label class=\"wpforms-field-label\" for=\"wpforms-1831-field_42\">Mobile Phone <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-1831-field_42\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][42]\" value=\"N\/A\" placeholder=\"N\/A\" required><\/div><div id=\"wpforms-1831-field_18-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"18\"><label class=\"wpforms-field-label\" for=\"wpforms-1831-field_18\">Email <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"email\" id=\"wpforms-1831-field_18\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][18]\" required><\/div><div id=\"wpforms-1831-field_19-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"19\"><h3 id=\"wpforms-1831-field_19\" name=\"wpforms[fields][19]\">Insurance Information<\/h3><\/div><div id=\"wpforms-1831-field_20-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"20\"><label class=\"wpforms-field-label\" for=\"wpforms-1831-field_20\">Medicare Number <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-1831-field_20\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][20]\" value=\"N\/A\" placeholder=\"N\/A\" required><\/div><div id=\"wpforms-1831-field_47-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"47\"><label class=\"wpforms-field-label\" for=\"wpforms-1831-field_47\">Primary Insurance Provider<\/label><input type=\"text\" id=\"wpforms-1831-field_47\" class=\"wpforms-field-large\" name=\"wpforms[fields][47]\" ><\/div><div id=\"wpforms-1831-field_48-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"48\"><label class=\"wpforms-field-label\" for=\"wpforms-1831-field_48\">Primary Insurance Member ID #<\/label><input type=\"text\" id=\"wpforms-1831-field_48\" class=\"wpforms-field-large\" name=\"wpforms[fields][48]\" ><\/div><div id=\"wpforms-1831-field_49-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"49\"><label class=\"wpforms-field-label\" for=\"wpforms-1831-field_49\">Primary Insurance Group #<\/label><input type=\"text\" id=\"wpforms-1831-field_49\" class=\"wpforms-field-large\" name=\"wpforms[fields][49]\" ><\/div><div id=\"wpforms-1831-field_50-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"50\"><label class=\"wpforms-field-label\" for=\"wpforms-1831-field_50\">Primary Insurance Phone<\/label><input type=\"tel\" id=\"wpforms-1831-field_50\" class=\"wpforms-field-large wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][50]\" ><\/div><div id=\"wpforms-1831-field_21-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"21\"><label class=\"wpforms-field-label\" for=\"wpforms-1831-field_21\">Secondary Insurance Provider<\/label><input type=\"text\" id=\"wpforms-1831-field_21\" class=\"wpforms-field-large\" name=\"wpforms[fields][21]\" ><\/div><div id=\"wpforms-1831-field_22-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"22\"><label class=\"wpforms-field-label\" for=\"wpforms-1831-field_22\">Secondary Insurance Member ID #<\/label><input type=\"text\" id=\"wpforms-1831-field_22\" class=\"wpforms-field-large\" name=\"wpforms[fields][22]\" ><\/div><div id=\"wpforms-1831-field_23-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"23\"><label class=\"wpforms-field-label\" for=\"wpforms-1831-field_23\">Secondary Insurance Group #<\/label><input type=\"text\" id=\"wpforms-1831-field_23\" class=\"wpforms-field-large\" name=\"wpforms[fields][23]\" ><\/div><div id=\"wpforms-1831-field_24-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"24\"><label class=\"wpforms-field-label\" for=\"wpforms-1831-field_24\">Secondary Insurance Phone<\/label><input type=\"tel\" id=\"wpforms-1831-field_24\" class=\"wpforms-field-large wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][24]\" ><\/div><div id=\"wpforms-1831-field_25-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"25\"><h3 id=\"wpforms-1831-field_25\" name=\"wpforms[fields][25]\">Treatment Information<\/h3><\/div><div id=\"wpforms-1831-field_26-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"26\"><label class=\"wpforms-field-label\" for=\"wpforms-1831-field_26\">Doctor Name <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-1831-field_26\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][26]\" required><\/div><div id=\"wpforms-1831-field_27-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"27\"><label class=\"wpforms-field-label\" for=\"wpforms-1831-field_27\">Doctor Phone <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-1831-field_27\" class=\"wpforms-field-large wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][27]\" required><\/div><div id=\"wpforms-1831-field_28-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"28\"><label class=\"wpforms-field-label\" for=\"wpforms-1831-field_28\">Therapist Name<\/label><input type=\"text\" id=\"wpforms-1831-field_28\" class=\"wpforms-field-large\" name=\"wpforms[fields][28]\" ><\/div><div id=\"wpforms-1831-field_29-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"29\"><label class=\"wpforms-field-label\" for=\"wpforms-1831-field_29\">Therapist Phone<\/label><input type=\"tel\" id=\"wpforms-1831-field_29\" class=\"wpforms-field-large wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][29]\" ><\/div><div id=\"wpforms-1831-field_30-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"30\"><label class=\"wpforms-field-label\" for=\"wpforms-1831-field_30\">Diagnosis Code 1<\/label><input type=\"text\" id=\"wpforms-1831-field_30\" class=\"wpforms-field-large\" name=\"wpforms[fields][30]\" ><\/div><div id=\"wpforms-1831-field_31-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"31\"><label class=\"wpforms-field-label\" for=\"wpforms-1831-field_31\">Diagnosis Code 2<\/label><input type=\"text\" id=\"wpforms-1831-field_31\" class=\"wpforms-field-large\" name=\"wpforms[fields][31]\" ><\/div><div id=\"wpforms-1831-field_32-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"32\"><label class=\"wpforms-field-label\" for=\"wpforms-1831-field_32\">Diagnosis Code Other<\/label><input type=\"text\" id=\"wpforms-1831-field_32\" class=\"wpforms-field-large\" name=\"wpforms[fields][32]\" ><\/div><div id=\"wpforms-1831-field_33-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"33\"><h3 id=\"wpforms-1831-field_33\" name=\"wpforms[fields][33]\">Product Information<\/h3><\/div><div id=\"wpforms-1831-field_34-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"34\"><label class=\"wpforms-field-label\" for=\"wpforms-1831-field_34\">List or Describe Products Being Ordered <span class=\"wpforms-required-label\">*<\/span><\/label><textarea id=\"wpforms-1831-field_34\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][34]\" required><\/textarea><\/div><div id=\"wpforms-1831-field_35-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"35\"><label class=\"wpforms-field-label\" for=\"wpforms-1831-field_35\">Sizing Classification<\/label><select id=\"wpforms-1831-field_35\" class=\"wpforms-field-large\" name=\"wpforms[fields][35]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>Please select...<\/option><option value=\"Off-The-Shelf\" >Off-The-Shelf<\/option><option value=\"(OTS) Custom\" >(OTS) Custom<\/option><\/select><\/div><div id=\"wpforms-1831-field_36-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"36\"><label class=\"wpforms-field-label\" for=\"wpforms-1831-field_36\">Product Category<\/label><select id=\"wpforms-1831-field_36\" class=\"wpforms-field-large\" name=\"wpforms[fields][36]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>Please select...<\/option><option value=\"Daytime Compression Garment\" >Daytime Compression Garment<\/option><option value=\"Nighttime Compression Wrap\" >Nighttime Compression Wrap<\/option><option value=\"Other\" >Other<\/option><\/select><\/div><div id=\"wpforms-1831-field_44-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"44\"><label class=\"wpforms-field-label\" for=\"wpforms-1831-field_44\">Laterality <span class=\"wpforms-required-label\">*<\/span><\/label><select id=\"wpforms-1831-field_44\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][44]\" required=\"required\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>Please select...<\/option><option value=\"Right\" >Right<\/option><option value=\"Left\" >Left<\/option><option value=\"Bilateral\" >Bilateral<\/option><\/select><\/div><div id=\"wpforms-1831-field_43-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"43\"><label class=\"wpforms-field-label\" for=\"wpforms-1831-field_43\">Anatomical Region<\/label><textarea id=\"wpforms-1831-field_43\" class=\"wpforms-field-medium\" name=\"wpforms[fields][43]\" ><\/textarea><\/div><div id=\"wpforms-1831-field_38-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"38\"><label class=\"wpforms-field-label\" for=\"wpforms-1831-field_38\">Compression Level<\/label><select id=\"wpforms-1831-field_38\" class=\"wpforms-field-large\" name=\"wpforms[fields][38]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>Please select...<\/option><option value=\"Class 1 (20-30 mmHg)\" >Class 1 (20-30 mmHg)<\/option><option value=\"Class 2 (30-40 mmHg)\" >Class 2 (30-40 mmHg)<\/option><option value=\"Class 3 (40-50 mmHg)\" >Class 3 (40-50 mmHg)<\/option><option value=\"Other\" >Other<\/option><\/select><\/div><div id=\"wpforms-1831-field_39-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"39\"><div id=\"wpforms-1831-field_39\"><p style=\"text-align: center;\">NOTE: Fields marked with an asterisk are required.<\/p><\/div><\/div><div id=\"wpforms-1831-field_10-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"10\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><button class=\"wpforms-page-button wpforms-page-prev\" data-action=\"prev\" data-page=\"2\" data-formid=\"1831\" disabled>Previous<\/button><\/div><\/div><\/div><\/div><div class=\"wpforms-submit-container\" style=\"display:none;\"><input type=\"hidden\" name=\"wpforms[id]\" value=\"1831\"><input type=\"hidden\" name=\"wpforms[author]\" value=\"3\"><button type=\"submit\" name=\"wpforms[submit]\" class=\"wpforms-submit \" id=\"wpforms-submit-1831\" value=\"wpforms-submit\" aria-live=\"assertive\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\">Submit<\/button><\/div><\/form><\/div>  <!-- .wpforms-container -->\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"","protected":false},"author":3,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":[],"_links":{"self":[{"href":"https:\/\/mzcustomfit.com\/wp-json\/wp\/v2\/pages\/1835"}],"collection":[{"href":"https:\/\/mzcustomfit.com\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/mzcustomfit.com\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/mzcustomfit.com\/wp-json\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/mzcustomfit.com\/wp-json\/wp\/v2\/comments?post=1835"}],"version-history":[{"count":78,"href":"https:\/\/mzcustomfit.com\/wp-json\/wp\/v2\/pages\/1835\/revisions"}],"predecessor-version":[{"id":1937,"href":"https:\/\/mzcustomfit.com\/wp-json\/wp\/v2\/pages\/1835\/revisions\/1937"}],"wp:attachment":[{"href":"https:\/\/mzcustomfit.com\/wp-json\/wp\/v2\/media?parent=1835"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}