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Generic Short Term Disability eForm html

Updated June 8th to include x boxes, default values assigned in the header, and the list of disability insurance providers that have agreed to accept the form. The subject line is now filled out with the primary diagnosis.

HTML icon ShortTermDisabilityForm.html — HTML, 31 kB (32058 bytes)

File contents

<HTML>
<head>

<link rel="stylesheet" type="text/css" media="print" href="${oscar_image_path}JSMPC.css" />

<title>Master Short Term Disability eform</title>

<style type="text/css" media="print">
 .DoNotPrint {
	 display: none;
 }
 .noborder {
	 border : 0px;
	 background: transparent;
	 scrollbar-3dlight-color: transparent;
	 scrollbar-3dlight-color: transparent;
	 scrollbar-arrow-color: transparent;
	 scrollbar-base-color: transparent;
	 scrollbar-darkshadow-color: transparent;
	 scrollbar-face-color: transparent;
	 scrollbar-highlight-color: transparent;
	 scrollbar-shadow-color: transparent;
	 scrollbar-track-color: transparent;
	 background: transparent;
	 overflow: hidden;
 }
 </style>
 
 <script language="javascript" type="text/javascript">
		/****************************
		startup functions 
		****************************/
		function startUp()
		{			
			// shows the forms on development machine from notepad ++ - saves you from uploading to the server to input alignments
			var strLoc = window.location.href.toLowerCase();
			if(strLoc.indexOf("https") == -1)
			{
				//page1
				var src = document.getElementById('BGImage1').src;				
				document.getElementById('BGImage1').src = src.replace('$%7Boscar_image_path%7D','');
				//page2
				var src = document.getElementById('BGImage2').src;				
				document.getElementById('BGImage2').src = src.replace('$%7Boscar_image_path%7D','');
			}
			setDocumentTitle('Master Short Term Disability eform',document.getElementById('patient_name').value);
			setDefaults();	
					
		}
		
		function setDocumentTitle(Title,patient_name)
		{
			// set document title
			document.title = Title + ' - ' + patient_name;					
							
		}
		function setDefaults()
		{	            
			// check the newform flag to ensure this is the initial load of the form
			if (document.getElementById("newForm").value == 'True')
			{
				document.getElementById("RTWDate").value = 'Unknown';	
				document.getElementById("Other2").value = 'pro re nata';	
				document.getElementById("Prognosis2").value = 'See above';	
	
			}   
		}
	
		/****************************
			submit and print functions 
		****************************/
		function printSubmit()
		{
			printLetter();
			releaseDirtyFlag();			
			submission();
		}

		function printLetter()
		{
			// hide the bottom buttons
			if (document.getElementById('BottomButtons').style.display == '')
				document.getElementById('BottomButtons').style.display = 'none';
			// print the letter
			window.print();
		} 

		function submission()
		{
			setFlag();
			setTimeout('document.FormName.submit()',1000);			
		}

		function setFlag()
		{
		// indicate that the form has been submitted
		if (document.getElementById("newForm").value == 'True')
			document.getElementById("newForm").value = 'False';
		}
		
		function showButtons()
		{
			//show the bottom buttons if they are hidden
			if (document.getElementById('BottomButtons').style.display == 'none')
				document.getElementById('BottomButtons').style.display = '';
		}
		
		/****************************
			checkbox functions 
		****************************/
		function changeValue(x)
		{
			if (document.getElementById(x).value == '')
				document.getElementById(x).value = 'X';
			else
				document.getElementById(x).value = '';
		}

		function displayKeyCode(evt,x)
		{
			var charCode = (evt.which) ? evt.which : event.keyCode
			// any key press except tab will constitute a value change to the checkbox
			if (charCode != 9)
			{
				changeValue(x);
				return false;
			}
		}
		</script>

<!-------Script to optimize window on loading----------->
<script language="JavaScript">
top.window.moveTo(0,0);
if (document.all) {
top.window.resizeTo(screen.availWidth,screen.availHeight);
}
else if (document.layers||document.getElementById) {
if (top.window.outerHeight<screen.availHeight||top.window.outerWidth<screen.availWidth){
top.window.outerHeight = screen.availHeight;
<!-- top.window.outerWidth = 1120; -->
top.window.outerWidth = 1400;
}
}
</script>
<!----------End optimize window script---------->

<!-- scripts to confirm closing of window if it hadn't been saved yet -->
<script language="javascript">
//keypress events trigger dirty flag
var needToConfirm = false;
document.onkeyup=setDirtyFlag;
function setDirtyFlag(){
		needToConfirm = false;
}
function releaseDirtyFlag(){
		needToConfirm = false; //Call this function if doesn't requires an alert.
//this could be called when save button is clicked
}
window.onbeforeunload = confirmExit;
function confirmExit(){
	 if (needToConfirm){
		 return "You have attempted to leave this page. If you have made any changes to the fields without clicking the Save button, your changes will be lost. Are you sure you want to exit this page?";
	 }
}
</script>

<script type="text/javascript" language="javascript">
function checkGender(){
	 if (document.getElementById('PatientGender').value == 'M'){
	 document.getElementById('Male').value = 'X';
	 }else if (document.getElementById('PatientGender').value == 'F'){
	 document.getElementById('Female').value = 'X';
	}
 }
</script>

</head>

<body onLoad="startUp(); checkGender();">
<form method="post" action="" name="twoPageForm">



<!-- PAGE 1 ----------------------------------------------------------------------------------------------- -->
<div id="page1" style="page-break-after:always;position:relative;" >
<img id='BGImage1'src="${oscar_image_path}Page1STD.png" style="position: relative; left: 0px; top: 0px; width:750px">
<input name="patient_name" id="patient_name" type="text" class="noborder" style="position:absolute; left:45px; top:129px; width:254px; height:17px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;"  oscarDB=patient_name>


<input name="phone" id="phone" type="text" class="noborder" style="position:absolute; left:376px; top:129px; width:145px; height:17px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;"  oscarDB=phone>


<input name="cell" id="cell" type="text" class="noborder" style="position:absolute; left:533px; top:129px; width:153px; height:17px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;"  oscarDB=cell>


<input name="addressline" id="addressline" type="text" class="noborder" style="position:absolute; left:229px; top:148px; width:458px; height:26px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;"  oscarDB=addressline>


<input name="m$HT#value" id="m$HT#value" type="text" class="noborder" style="position:absolute; left:79px; top:207px; width:99px; height:22px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;"  oscarDB=m$HT#value>


<input name="m$WT#value" id="m$WT#value" type="text" class="noborder" style="position:absolute; left:227px; top:206px; width:134px; height:21px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;"  oscarDB=m$WT#value>


<input name="dob" id="dob" type="text" class="noborder" style="position:absolute; left:479px; top:207px; width:165px; height:22px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:white;"  oscarDB=dob>


<input name="LastWorked" id="LastWorked" type="text" class="noborder" style="position:absolute; left:140px; top:232px; width:170px; height:30px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;" value="">


<input name="RTWDate" id="RTWDate" type="text" class="noborder" style="position:absolute; left:461px; top:244px; width:226px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;" value="">


<input name="Dx1" id="Dx1" type="text" class="noborder" style="position:absolute; left:147px; top:486px; width:538px; height:34px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;" onblur="subject.value+=Dx1.value">


<textarea name="Dx2Complications" id="Dx2Complications" class="noborder" style="position:absolute; left:212px; top:529px; width:473px; height:81px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;" ></textarea>


<input name="EDD" id="EDD" type="text" class="noborder" style="position:absolute; left:323px; top:615px; width:132px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;" value="">


<input name="Vaginal" id="Vaginal" type="text" style="position:absolute; left:523px; top:618px;  width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);"  >


<input name="CSection" id="CSection" type="text" style="position:absolute; left:596px; top:618px;  width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);"  >


<input name="OccupationalYes" id="OccupationalYes" type="text" style="position:absolute; left:209px; top:640px;  width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);"  >


<input name="OccupationalNo" id="OccupationalNo" type="text" style="position:absolute; left:252px; top:640px;  width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);"  >


<input name="OccupationalDate" id="OccupationalDate" type="text" class="noborder" style="position:absolute; left:193px; top:657px; width:151px; height:17px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;" value="">


<input name="MVAYes" id="MVAYes" type="text" style="position:absolute; left:476px; top:641px;  width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);"  >


<input name="MVANo" id="MVANo" type="text" style="position:absolute; left:522px; top:641px;  width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);"  >


<input name="MVADate" id="MVADate" type="text" class="noborder" style="position:absolute; left:503px; top:656px; width:184px; height:19px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;" value="">


<input name="FirstVisitDate" id="FirstVisitDate" type="text" class="noborder" style="position:absolute; left:90px; top:692px; width:246px; height:17px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:white;" value="">


<input name="OffWorkDate" id="OffWorkDate" type="text" class="noborder" style="position:absolute; left:399px; top:691px; width:287px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;" value="">


<input name="HospitalYes" id="HospitalYes" type="text" style="position:absolute; left:305px; top:714px;  width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);"  >


<input name="DaySurgeryYes" id="DaySurgeryYes" type="text" style="position:absolute; left:416px; top:715px;  width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);"  >


<input name="AdmitDate" id="AdmitDate" type="text" class="noborder" style="position:absolute; left:45px; top:751px; width:149px; height:19px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;" value="">


<input name="DischargeDate" id="DischargeDate" type="text" class="noborder" style="position:absolute; left:243px; top:750px; width:152px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;" value="">


<input name="HospitalName" id="HospitalName" type="text" class="noborder" style="position:absolute; left:405px; top:750px; width:281px; height:22px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;" value="">


<input name="SurgeryDate" id="SurgeryDate" type="text" class="noborder" style="position:absolute; left:117px; top:794px; width:142px; height:19px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;" value="">


<input name="SurgeryType" id="SurgeryType" type="text" class="noborder" style="position:absolute; left:327px; top:793px; width:359px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;" value="">


<textarea name="Treatments" id="Treatments" class="noborder" style="position:absolute; left:39px; top:831px; width:646px; height:43px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;" ></textarea>


<textarea name="Prognosis1" id="Prognosis1" class="noborder" style="position:absolute; left:39px; top:894px; width:646px; height:49px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;" ></textarea>


<input name="PatientGender" id="PatientGender" type="hidden" oscarDB=sex>
<input name="Male" id="Male" type="text" style="position:absolute; left: 304px; top: 115px;   width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);"  >
<input name="Female" id="Female" type="text"  style="position:absolute; left: 304px; top: 131px;  width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);"  >


</div>

<!-- PAGE 2 ----------------------------------------------------------------------------------------------- -->
<div id="page2" style="page-break-after:always;position:relative;" >
<img id='BGImage2' src="${oscar_image_path}Page2STD.png" width="750">
<input name="patient_name1" id="patient_name1" type="text" class="noborder" style="position:absolute; left:333px; top:54px; width:197px; height:19px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;"  oscarDB=patient_name>


<input name="today" id="today" type="text" class="noborder" style="position:absolute; left:550px; top:56px; width:122px; height:17px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;"  oscarDB=today>


<input name="AutoName-2" id="AutoName-2" type="text" style="position:absolute; left:433px; top:102px;  width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);"  >


<input name="AutoName-1" id="AutoName-1" type="text" style="position:absolute; left:477px; top:102px;  width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);"  >


<input name="PreviousTxDate" id="PreviousTxDate" type="text" class="noborder" style="position:absolute; left:156px; top:120px; width:113px; height:17px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;" value="">


<input name="PreviousTxProvider" id="PreviousTxProvider" type="text" class="noborder" style="position:absolute; left:432px; top:120px; width:247px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;" value="">


<textarea name="Symptoms" id="Symptoms" class="noborder" style="position:absolute; left:45px; top:165px; width:636px; height:65px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;" ></textarea>


<input name="Weekly" id="Weekly" type="text" style="position:absolute; left:157px; top:238px;  width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);"  >


<input name="Monthly" id="Monthly" type="text" style="position:absolute; left:224px; top:238px;  width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);"  >


<input name="Other" id="Other" type="text" style="position:absolute; left:297px; top:237px;  width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);"  >


<input name="Other2" id="Other2" type="text" class="noborder" style="position:absolute; left:346px; top:239px; width:336px; height:16px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;" value="">


<input name="Specialist" id="Specialist" type="text" class="noborder" style="position:absolute; left:144px; top:331px; width:166px; height:17px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;" value="">


<input name="Speciality" id="Speciality" type="text" class="noborder" style="position:absolute; left:367px; top:331px; width:150px; height:17px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;" value="">


<input name="SpDate" id="SpDate" type="text" class="noborder" style="position:absolute; left:588px; top:330px; width:96px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;" value="">


<textarea name="CurrentStatus" id="CurrentStatus" class="noborder" style="position:absolute; left:42px; top:383px; width:642px; height:82px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;" ></textarea>


<textarea name="Complications" id="Complications" class="noborder" style="position:absolute; left:43px; top:502px; width:640px; height:70px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;" ></textarea>


<input name="FollowingYes" id="FollowingYes" type="text" style="position:absolute; left:494px; top:579px;  width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);"  >


<input name="FollowingNo" id="FollowingNo" type="text" style="position:absolute; left:539px; top:579px;  width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);"  >


<input name="FollowingComment" id="FollowingComment" type="text" class="noborder" style="position:absolute; left:557px; top:581px; width:128px; height:15px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;" value="">


<input name="ConcernsYes" id="ConcernsYes" type="text" style="position:absolute; left:496px; top:600px;  width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);"  >


<input name="ConcernsNo" id="ConcernsNo" type="text" style="position:absolute; left:540px; top:600px;  width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);"  >


<textarea name="Prognosis2" id="Prognosis2" class="noborder" style="position:absolute; left:41px; top:634px; width:644px; height:46px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;" ></textarea>


<input name="MDName" id="MDName" type="text" class="noborder" style="position:absolute; left:40px; top:766px; width:211px; height:24px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;"  oscarDB=doctor>


<input name="MDSpecialty" id="MDSpecialty" type="text" class="noborder" style="position:absolute; left:265px; top:767px; width:199px; height:22px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;" value="">


<input name="clinic_addressLineFull" id="clinic_addressLineFull" type="text" class="noborder" style="position:absolute; left:39px; top:806px; width:429px; height:22px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;"  oscarDB=clinic_addressLineFull>


<input name="doctor_work_phone" id="doctor_work_phone" type="text" class="noborder" style="position:absolute; left:41px; top:843px; width:210px; height:24px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;"  oscarDB=doctor_work_phone>


<input name="clinic_fax" id="clinic_fax" type="text" class="noborder" style="position:absolute; left:259px; top:844px; width:210px; height:23px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;"  oscarDB=clinic_fax>


<input name="today1" id="today1" type="text" class="noborder" style="position:absolute; left:260px; top:881px; width:209px; height:24px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;"  oscarDB=today>


<textarea name="clinic_label1" id="clinic_label1" class="noborder" style="position:absolute; left:476px; top:766px; width:209px; height:137px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;"  oscarDB=clinic_label></textarea>

</div>




 <!-- The submit/print/reset buttons ------------------------------------------------------------->
<div class="DoNotPrint" id="BottomButtons" >
		<table style="position: absolute; left:20px; top:1900px;text-align: left; width: 90%;   font-size:12px; font-family:Arial;" border="0" cellpadding="0" cellspacing="0">
		<tr><td>
		<input type="hidden" id="newForm" name="newForm" value="True" />				
		Subject: <input name="subject" size="40" type="text" >
		<input value="Submit" name="SubmitButton" id="SubmitButton" type="submit" onclick="releaseDirtyFlag();document.FormName.submit();SubmitImage(); document.forms[0].submit();">
		<input value="Reset" name="ResetButton" id="ResetButton" type="reset"> 
		<input value="Print" name="PrintButton" id="PrintButton" type="button" onclick="printLetter()"> 			
		<input value="Print and Submit" name="PrintSubmitButton" type="button" onClick="printLetter(); releaseDirtyFlag(); setTimeout('SubmitButton.click()',1000);"> 
		</td></tr>
		</table>
</div>
<!-- ------End of submit/print/reset buttons----------------------------------------------------->

<div class='DoNotPrint' id='CLHIAMembers' style='position: absolute; top:20px; left:800px; width:750px;'>
<b><u>  CLHIA Members </u></b><br>

<table style='border:.75pt solid black; background:transparent; text-align:center;'>
   <tr>
	<td></td>
   </tr>
	<tr>Acadia Life <br>
ACE INA Life Insurance<br>
Actra Fraternal Benefit Society<br>
Aetna Life Insurance Company<br>
Alberta Blue Cross<br>
Allianz Life Insurance Company of North America<br>
American Health and Life Insurance Company<br>
     Triton Insurance Company 1<br>
Assumption Mutual Life Insurance Company<br>
Assurant Solutions 2<br>
     American Bankers Insurance Company of Florida 1<br>
     American Bankers Life Assurance Company of Florida 1<br>
     Assurant Life of Canada 1<br>
Aurigen Reinsurance Company<br>
BMO Life Assurance Company<br>
BMO Life Insurance Company<br>
CAA Insurance Company (Ontario)<br>
The Canada Life Assurance Company<br>
Canadian Premier Life Insurance Company<br>
     Legacy General Insurance Company 1<br>
CIBC Life Insurance Company Limited<br>
CIGNA Life Insurance Company of Canada<br>
     Connecticut General Life Insurance Company 1<br>
     Life Insurance Company of North America 1<br>
Combined Insurance Company of America<br>
Co-operators Life Insurance Company<br>
     Co-operators General Insurance Company 1 <br>
     TIC Travel Insurance Coordinators Ltd. 1<br>
CUMIS Life Insurance Company<br>
The Empire Life Insurance Company<br>
Employers Reassurance Corporation<br>
The Equitable Life Insurance Company of Canada<br>
FaithLife Financial<br>
First Canadian Insurance Corporation<br>
Foresters 2<br>
     The Independent Order of Foresters <br>
Foresters Life Insurance Company<br>
Gerber Life Insurance Company<br>
The Great-West Life Assurance Company / <br>
London Life Insurance Company / <br>
The Canada Life Assurance Company<br>
     The Canada Life Insurance Company of Canada 1<br>
Green Shield Canada<br>
Group Medical Services<br>
     GMS Insurance Inc. 1<br>
Hartford Life Insurance Company<br>
Household Life Insurance Company<br>
Industrial Alliance Insurance and Financial Services Inc.<br>
     MD Life Insurance Company 1<br>
     The Excellence Life Insurance Company 1<br>
Knights of Columbus<br>
London Life Insurance Company<br>
Liberty Life Assurance Company of Boston<br>
Manitoba Blue Cross<br>
Manulife Financial<br>
     First North American Insurance Company 1<br>
     The Manufacturers Life Insurance Company 1<br>
     Manulife Canada Ltd. 1<br>
Medavie Blue Cross<br>
     Blue Cross Life Insurance Company of Canada 1<br>
Munich Reinsurance Company<br>
National Bank Life Insurance Company<br>
New York Life Insurance Company<br>
Optimum Reassurance Inc.<br>
Pacific Blue Cross<br>
     British Columbia Life & Casualty Company (BC Life) 1<br>
Pacific Life Insurance Company<br>
Partner Reinsurance Europe Public Limited Company (Life Branch)<br>
Penncorp Life Insurance Company<br>
Primerica Life Insurance Company of Canada<br>
Principal Life Insurance Company<br>
RBC Life Insurance Company<br>
     RBC General Insurance Company 1<br>
     RBC Insurance Company of Canada 1<br>
Regroupement des assureurs de personnes � charte du Qu�bec (RACQ)<br>
     Canassurance Insurance Company <br>
         Canassurance Hospital Service Association 1<br>
     Desjardins Financial Security Life Assurance Company<br>
     Humania Assurance Inc.<br>
         LS-Travel, Insurance Company 1<br>
     La Capitale Insurance and Financial Services Inc.<br>
     La Capitale Civil Service Insurer Inc.<br>
     SSQ Financial Group 2<br>
         SSQ, Life Insurance Company Inc. 1<br>
     The Union Life, A Mutual Assurance Company / UL Mutual<br>
Reliable Life Insurance Company<br>
RGA Life Reinsurance Company of Canada<br>
     General American Life Insurance Company 1<br>
Saskatchewan Blue Cross<br>
SCOR Global Life<br>
Scotia Life Insurance Company<br>
SSQ Insurance Company Inc.<br>
The Standard Life Assurance Company of Canada<br>
     Standard Life Assurance Limited 1<br>
     The Standard Life Assurance Company 2006 1<br>
     Standard Life Trust Company 1<br>
State Farm International Life Insurance Company Ltd.<br>
Sun Life Assurance Company of Canada<br>
      Sun Life Insurance (Canada) Limited 1<br>
Swiss Reinsurance Company Ltd<br>
     Reassure America Life Insurance Company 1<br>
TD Life Insurance Company<br>
     CT Financial Assurance Company 1<br>
Teachers Life Insurance Society (Fraternal)<br>
Transamerica Life Canada<br>
VSP Canada Vision Care Insurance
<br>The Wawanesa Life Insurance Company
<br>Western Life Assurance Company
<br>Zurich Insurance Company Ltd

	</tr>


</table>


</div>
</body>
</html>

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