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fbConfigScript.type = "text/javascript";
fbRequireJSScript.type = "text/javascript";
fbInstaMedJSScript.type = "text/javascript";
fbGeoCaptchaCallback.type = "text/javascript";
fbGeoReCaptchaCallback.type = "text/javascript";
fbFormulateRenderer.type = "text/javascript";
fbRenderedIntegrations.type = "text/javascript";
fbRenderedScripts.type = "text/javascript";
fbAutoPopulateFromQueryString.type = "text/javascript";

fbRequireJSScript.src = "https://formulate.geonetric.com/Scripts/require.min.js";
fbInstaMedJSScript.src = "https://formulate.geonetric.com/Scripts/vendor/instamed/token.js";
fbInstaMedJSScript.id = "instamed-sdk";
fbGeoCaptchaCallback.src = "https://formulate.geonetric.com/Scripts/geo-captcha-callback.js";
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<input type=\'hidden\' name=\'formId\' id=\'formId\' value=\'bc6530f4-120c-422d-a345-1efda047fe2a\' />\
<input type=\'hidden\' name=\'formName\' id=\'formName\' value=\'Patient Request for Estimate\' />\
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\
\
                        <fieldset class=\'fb-fieldset \'>\
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                    <div >\
                        <input class=\'fb-name-field form-control input-medium\' id=\'FormField1_bc6530f4-120c-422d-a345-1efda047fe2aLast\' name=\'FormField1_bc6530f4-120c-422d-a345-1efda047fe2aLast\' type=\'text\' data-export-label=\'Patient_Name_Last_Name\'  integration-export-label=\'\' placeholder=\'\' required data-msg-required=\'Last Name is required.\' />\
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<input type=\'text\' name=\'FormField4_bc6530f4-120c-422d-a345-1efda047fe2a\' id=\'FormField4_bc6530f4-120c-422d-a345-1efda047fe2a\' class=\'form-control input-medium \' value=\'\'   data-export-label=\'Patient_Address\'  placeholder=\'\'  />\
</div></div><div class=\'form-group\'><label for=\'FormField5_bc6530f4-120c-422d-a345-1efda047fe2a\' class=\'control-label  \'>City</label><div>\
<input type=\'text\' name=\'FormField5_bc6530f4-120c-422d-a345-1efda047fe2a\' id=\'FormField5_bc6530f4-120c-422d-a345-1efda047fe2a\' class=\'form-control input-medium \' value=\'\'   data-export-label=\'City\'  placeholder=\'\'  />\
</div></div><div class=\'form-group\'><label for=\'FormField6_bc6530f4-120c-422d-a345-1efda047fe2a\' class=\'control-label  \'>State</label><div>\
<input type=\'text\' name=\'FormField6_bc6530f4-120c-422d-a345-1efda047fe2a\' id=\'FormField6_bc6530f4-120c-422d-a345-1efda047fe2a\' class=\'form-control input-medium \' value=\'\'   data-export-label=\'State\'  placeholder=\'\'  />\
</div></div><div class=\'form-group\'><label for=\'FormField7_bc6530f4-120c-422d-a345-1efda047fe2a\' class=\'control-label  \'>Zip Code</label><div>\
<input type=\'text\' name=\'FormField7_bc6530f4-120c-422d-a345-1efda047fe2a\' id=\'FormField7_bc6530f4-120c-422d-a345-1efda047fe2a\' class=\'form-control input-medium \' value=\'\'   data-export-label=\'Zip_Code\'  placeholder=\'\'  />\
</div></div><div class=\'form-group\'><label for=\'FormField10_bc6530f4-120c-422d-a345-1efda047fe2a\' class=\'control-label  \'>Patient Email Address</label><div><input type=\'email\' name=\'FormField10_bc6530f4-120c-422d-a345-1efda047fe2a\' id=\'FormField10_bc6530f4-120c-422d-a345-1efda047fe2a\' class=\'form-control input-medium \' value=\'\'  data-export-label=\'Patient_Email_Address\'  data-msg-email=\'Please specify a valid email.\' />\
</div></div><div class=\'form-group\'><label for=\'FormField8_bc6530f4-120c-422d-a345-1efda047fe2a\' class=\'control-label  \'>Patient Phone Number<span class=\'fb-required\'>*</span></label><div><input type=\'text\' name=\'FormField8_bc6530f4-120c-422d-a345-1efda047fe2a\' id=\'FormField8_bc6530f4-120c-422d-a345-1efda047fe2a\' class=\'form-control input-medium \' value=\'\' required data-msg-required=\'Patient Phone Number is required.\' data-export-label=\'Patient_Phone_Number\'  data-rule-phoneUS=\'true\' data-msg-phoneUS=\'Please specify a valid phone number.\' />\
</div></div><div class=\'form-group\'><label  class=\'control-label  hidden-label\'>Patient Voicemail permission</label><div><div><div class=\'flow Chkbx\'><input type=\'checkbox\' value=\'Permission to leave a detailed message on this phone number\'  name=\'e5b6dd0c-6f22-4699-8c3f-a0f7c76a09c9_FormField9_bc6530f4-120c-422d-a345-1efda047fe2a_checkbox_9\' id=\'FormField9_bc6530f4-120c-422d-a345-1efda047fe2a_1\' class=\'fo-right-margin-5\' data-export-label=\'Patient_Voicemail_permission\' ><label for=\'FormField9_bc6530f4-120c-422d-a345-1efda047fe2a_1\'>Permission to leave a detailed message on this phone number</label></div></div></div></div><div class=\'form-group\'><label  class=\'control-label  \'>Is the person completing the form the patient?<span class=\'fb-required\'>*</span></label><div class=\'Chkbx\'><div><fieldset class=\'RadioGroup\'><div class=\'flow\'><input type=\'radio\' value=\'Yes\' required data-msg-required=\'Is the person completing the form the patient? is required.\' name=\'checkbox32\' id=\'FormField32_bc6530f4-120c-422d-a345-1efda047fe2a_1\' class=\'right\' data-export-label=\'Completing_form_the_patient\' ><label for=\'FormField32_bc6530f4-120c-422d-a345-1efda047fe2a_1\'>Yes</label></div><div class=\'flow\'><input type=\'radio\' value=\'No\' required data-msg-required=\'Is the person completing the form the patient? is required.\' name=\'checkbox32\' id=\'FormField32_bc6530f4-120c-422d-a345-1efda047fe2a_2\' class=\'right\' data-export-label=\'Completing_form_the_patient\' ><label for=\'FormField32_bc6530f4-120c-422d-a345-1efda047fe2a_2\'>No</label></div></fieldset></div></div></div><div class=\'fb-section\' style=\'display: none;\' id=\'FormField37_bc6530f4-120c-422d-a345-1efda047fe2a\'>\
                        <fieldset class=\'fb-fieldset \'>\
                            <legend class=\'fb-legend \'>Name of the person filling out the form (if not the patient)</legend>\
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                <div class=\'form-group fb-form-group\'>\
                    <label class=\'control-label  \' for=\'FormField12_bc6530f4-120c-422d-a345-1efda047fe2aFirst\'>First Name<span class=\'fb-required\'>*</span></label>\
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                        <input class=\'fb-name-field form-control input-medium\' id=\'FormField12_bc6530f4-120c-422d-a345-1efda047fe2aFirst\' name=\'FormField12_bc6530f4-120c-422d-a345-1efda047fe2aFirst\' type=\'text\' data-export-label=\'Name_of_person_filling_out_the_form_First_Name\'  integration-export-label=\'\' placeholder=\'\' required data-msg-required=\'First Name is required.\' />\
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                <div class=\'form-group fb-form-group\'>\
                    <label class=\'control-label  \' for=\'FormField12_bc6530f4-120c-422d-a345-1efda047fe2aLast\'>Last Name<span class=\'fb-required\'>*</span></label>\
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                    </div>\
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                        </fieldset><div class=\'form-group\'><label for=\'FormField11_bc6530f4-120c-422d-a345-1efda047fe2a\' class=\'control-label  \'>Relationship to the patient</label><div>\
<input type=\'text\' name=\'FormField11_bc6530f4-120c-422d-a345-1efda047fe2a\' id=\'FormField11_bc6530f4-120c-422d-a345-1efda047fe2a\' class=\'form-control input-medium \' value=\'\'   data-export-label=\'Relationship_to_the_patient\'  placeholder=\'\'  />\
</div></div><div class=\'form-group\'><label for=\'FormField14_bc6530f4-120c-422d-a345-1efda047fe2a\' class=\'control-label  \'>Date of Birth</label><div><div class=\'clearfix\'><input type=\'text\' name=\'FormField14_bc6530f4-120c-422d-a345-1efda047fe2a\' id=\'FormField14_bc6530f4-120c-422d-a345-1efda047fe2a\' class=\'form-control input-medium isDatePicker\'  data-format=\'mm/dd/yy\' data-export-label=\'Date_of_Birth\'  data-rule-dateFormat=\'MM/DD/YYYY\' style=\'float: left;\' /></div></div></div><div class=\'form-group\'><label for=\'FormField17_bc6530f4-120c-422d-a345-1efda047fe2a\' class=\'control-label  \'>Email Address</label><div><input type=\'email\' name=\'FormField17_bc6530f4-120c-422d-a345-1efda047fe2a\' id=\'FormField17_bc6530f4-120c-422d-a345-1efda047fe2a\' class=\'form-control input-medium \' value=\'\'  data-export-label=\'Email_Address\'  data-msg-email=\'Please specify a valid email.\' />\
</div></div><div class=\'form-group\'><label for=\'FormField15_bc6530f4-120c-422d-a345-1efda047fe2a\' class=\'control-label  \'>Phone Number</label><div><input type=\'text\' name=\'FormField15_bc6530f4-120c-422d-a345-1efda047fe2a\' id=\'FormField15_bc6530f4-120c-422d-a345-1efda047fe2a\' class=\'form-control input-medium \' value=\'\'  data-export-label=\'Phone_Number\'  data-rule-phoneUS=\'true\' data-msg-phoneUS=\'Please specify a valid phone number.\' />\
</div></div><div class=\'form-group\'><label  class=\'control-label  hidden-label\'>Voicemail permission</label><div><div><div class=\'flow Chkbx\'><input type=\'checkbox\' value=\'Permission to leave a detailed message on this phone number\'  name=\'e5b6dd0c-6f22-4699-8c3f-a0f7c76a09c9_FormField16_bc6530f4-120c-422d-a345-1efda047fe2a_checkbox_16\' id=\'FormField16_bc6530f4-120c-422d-a345-1efda047fe2a_1\' class=\'fo-right-margin-5\' data-export-label=\'Voicemail_permission\' ><label for=\'FormField16_bc6530f4-120c-422d-a345-1efda047fe2a_1\'>Permission to leave a detailed message on this phone number</label></div></div></div></div></div><div class=\'form-group\'><label for=\'FormField18_bc6530f4-120c-422d-a345-1efda047fe2a\' class=\'control-label  \'>Date of Service if scheduled</label><div><div class=\'clearfix\'><input type=\'text\' name=\'FormField18_bc6530f4-120c-422d-a345-1efda047fe2a\' id=\'FormField18_bc6530f4-120c-422d-a345-1efda047fe2a\' class=\'form-control input-medium isDatePicker\'  data-format=\'mm/dd/yy\' data-export-label=\'Date_of_Service_if_scheduled\'  data-rule-dateFormat=\'MM/DD/YYYY\' style=\'float: left;\' /></div></div></div><div class=\'form-group\'><label for=\'FormField19_bc6530f4-120c-422d-a345-1efda047fe2a\' class=\'control-label  \'>Description of Services or Procedure<span class=\'fb-required\'>*</span></label><div>\
<input type=\'text\' name=\'FormField19_bc6530f4-120c-422d-a345-1efda047fe2a\' id=\'FormField19_bc6530f4-120c-422d-a345-1efda047fe2a\' class=\'form-control input-medium \' value=\'\'  required data-msg-required=\'Description of Services or Procedure is required.\' data-export-label=\'Service_Description\'  placeholder=\'\'  />\
</div></div><div class=\'form-group\'><label  class=\'control-label  \'>Patient Type<span class=\'fb-required\'>*</span></label><div class=\'Chkbx\'><div><fieldset class=\'RadioGroup\'><div class=\'flow\'><input type=\'radio\' value=\'Inpatient\' required data-msg-required=\'Patient Type is required.\' name=\'checkbox20\' id=\'FormField20_bc6530f4-120c-422d-a345-1efda047fe2a_1\' class=\'right\' data-export-label=\'Patient_Type\' ><label for=\'FormField20_bc6530f4-120c-422d-a345-1efda047fe2a_1\'>Inpatient</label></div><div class=\'flow\'><input type=\'radio\' value=\'Outpatient\' required data-msg-required=\'Patient Type is required.\' name=\'checkbox20\' id=\'FormField20_bc6530f4-120c-422d-a345-1efda047fe2a_2\' class=\'right\' data-export-label=\'Patient_Type\' ><label for=\'FormField20_bc6530f4-120c-422d-a345-1efda047fe2a_2\'>Outpatient</label></div></fieldset></div></div></div><div class=\'form-group\'><label for=\'FormField31_bc6530f4-120c-422d-a345-1efda047fe2a\' class=\'control-label  \'>Location where services will be provided<span class=\'fb-required\'>*</span></label><div><select  name=\'FormField31_bc6530f4-120c-422d-a345-1efda047fe2a\' id=\'FormField31_bc6530f4-120c-422d-a345-1efda047fe2a\' class=\'form-control \' style=\'width: auto\' required data-msg-required=\'Location where services will be provided is required.\' data-export-label=\'Service_location\' ><option value=\'\' selected>( Please Select )</option><option value=\'Ridgeview Medical Center (Waconia)\'>Ridgeview Medical Center (Waconia)</option><option value=\'Ridgeview Clinics\'>Ridgeview Clinics</option><option value=\'Ridgeview Two Twelve Medical Center (Chaska)\'>Ridgeview Two Twelve Medical Center (Chaska)</option></select></div></div><div class=\'form-group\'><label for=\'FormField22_bc6530f4-120c-422d-a345-1efda047fe2a\' class=\'control-label  \'>CPT or DRG code(s) if known (request from Provider)</label><div>\
<input type=\'text\' name=\'FormField22_bc6530f4-120c-422d-a345-1efda047fe2a\' id=\'FormField22_bc6530f4-120c-422d-a345-1efda047fe2a\' class=\'form-control input-medium \' value=\'\'   data-export-label=\'Codes\'  placeholder=\'\'  />\
</div></div>\
                        <fieldset class=\'fb-fieldset \'>\
                            <legend class=\'fb-legend \'>Provider\'s Name</legend>\
                            \
                <div class=\'form-group fb-form-group\'>\
                    <label class=\'control-label  \' for=\'FormField23_bc6530f4-120c-422d-a345-1efda047fe2aFirst\'>First Name</label>\
                    <div >\
                        <input class=\'fb-name-field form-control input-medium\' id=\'FormField23_bc6530f4-120c-422d-a345-1efda047fe2aFirst\' name=\'FormField23_bc6530f4-120c-422d-a345-1efda047fe2aFirst\' type=\'text\' data-export-label=\'Provider_Name_First_Name\'  integration-export-label=\'\' placeholder=\'\'  />\
                        \
                    </div>\
                </div>\
                <div class=\'form-group fb-form-group\'>\
                    <label class=\'control-label  \' for=\'FormField23_bc6530f4-120c-422d-a345-1efda047fe2aLast\'>Last Name</label>\
                    <div >\
                        <input class=\'fb-name-field form-control input-medium\' id=\'FormField23_bc6530f4-120c-422d-a345-1efda047fe2aLast\' name=\'FormField23_bc6530f4-120c-422d-a345-1efda047fe2aLast\' type=\'text\' data-export-label=\'Provider_Name_Last_Name\'  integration-export-label=\'\' placeholder=\'\'  />\
                        \
                    </div>\
                </div>\
                        </fieldset><div class=\'form-group\'><label  class=\'control-label  \'>Insured?<span class=\'fb-required\'>*</span></label><div class=\'Chkbx\'><div><fieldset class=\'RadioGroup\'><div class=\'flow\'><input type=\'radio\' value=\'Yes\' required data-msg-required=\'Insured? is required.\' name=\'checkbox24\' id=\'FormField24_bc6530f4-120c-422d-a345-1efda047fe2a_1\' class=\'right\' data-export-label=\'Insured\' ><label for=\'FormField24_bc6530f4-120c-422d-a345-1efda047fe2a_1\'>Yes</label></div><div class=\'flow\'><input type=\'radio\' value=\'No\' required data-msg-required=\'Insured? is required.\' name=\'checkbox24\' id=\'FormField24_bc6530f4-120c-422d-a345-1efda047fe2a_2\' class=\'right\' data-export-label=\'Insured\' ><label for=\'FormField24_bc6530f4-120c-422d-a345-1efda047fe2a_2\'>No</label></div></fieldset></div></div></div><div class=\'fb-section\' style=\'display: none;\' id=\'FormField28_bc6530f4-120c-422d-a345-1efda047fe2a\'><p>If insured, please complete the following:</p><div class=\'form-group\'><label for=\'FormField26_bc6530f4-120c-422d-a345-1efda047fe2a\' class=\'control-label  \'>Insurance Health Plan<span class=\'fb-required\'>*</span></label><div>\
<input type=\'text\' name=\'FormField26_bc6530f4-120c-422d-a345-1efda047fe2a\' id=\'FormField26_bc6530f4-120c-422d-a345-1efda047fe2a\' class=\'form-control input-medium \' value=\'\'  required data-msg-required=\'Insurance Health Plan is required.\' data-export-label=\'Insurance_Health_Plan\'  placeholder=\'\'  />\
</div></div><div class=\'form-group\'><label for=\'FormField27_bc6530f4-120c-422d-a345-1efda047fe2a\' class=\'control-label  \'>Insurance Health Plan Group Number<span class=\'fb-required\'>*</span></label><div>\
<input type=\'text\' name=\'FormField27_bc6530f4-120c-422d-a345-1efda047fe2a\' id=\'FormField27_bc6530f4-120c-422d-a345-1efda047fe2a\' class=\'form-control input-medium \' value=\'\'  required data-msg-required=\'Insurance Health Plan Group Number is required.\' data-export-label=\'Plan_Group_Number\'  placeholder=\'\'  />\
</div></div><div class=\'form-group\'><label for=\'FormField29_bc6530f4-120c-422d-a345-1efda047fe2a\' class=\'control-label  \'>Insurance Health Plan ID Number<span class=\'fb-required\'>*</span></label><div>\
<input type=\'text\' name=\'FormField29_bc6530f4-120c-422d-a345-1efda047fe2a\' id=\'FormField29_bc6530f4-120c-422d-a345-1efda047fe2a\' class=\'form-control input-medium \' value=\'\'  required data-msg-required=\'Insurance Health Plan ID Number is required.\' data-export-label=\'ID_Number\'  placeholder=\'\'  />\
</div></div></div><p>Requests for price estimates are reviewed by Ridgeview&apos;s Patient Access Department during normal business hours and are generally responded to within five business days.</p><p>If you have other inquiries or would like to speak with someone regarding your request, please call <strong>952-442-8087</strong> and select Option 3. Thank you for considering Ridgeview.</p><div class=\'validationSummary\'><p><i class=\'fa fa-exclamation-triangle\'></i> The following fields are required or invalid.</p><ul></ul></div>\
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<div id=\'form-errors\' class=\'alert alert-danger fade in\' role=\'alert\' style=\'display:none\'></div>\
<div class=\'form-group ignore\'><div class=\'form-group ButtonHolder\'><div class=\'col-sm-4 col-sm-offset-2\'><button id=\'fb-submitButton\' type=\'button\' class=\'btn btn-primary Button\' value=\'Submit\'>Submit</button></div></div></div>\
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