{"id":15939,"date":"2023-02-27T07:01:57","date_gmt":"2023-02-27T12:01:57","guid":{"rendered":"https:\/\/southernregional.org\/?page_id=15939"},"modified":"2023-03-02T13:32:16","modified_gmt":"2023-03-02T18:32:16","slug":"financial-assistance-application-form","status":"publish","type":"page","link":"https:\/\/southernregional.org\/financial-assistance-application-form\/","title":{"rendered":"Financial assistance Application form"},"content":{"rendered":"<p>[et_pb_section fb_built=&#8221;1&#8243; _builder_version=&#8221;4.16&#8243; global_colors_info=&#8221;{}&#8221;][et_pb_row _builder_version=&#8221;4.19.5&#8243; _module_preset=&#8221;default&#8221; custom_padding=&#8221;||0px||false|false&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;4.19.5&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_text _builder_version=&#8221;4.19.5&#8243; _module_preset=&#8221;default&#8221; 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header_5_text_shadow_vertical_length_tablet=&#8221;0px&#8221; header_5_text_shadow_blur_strength_tablet=&#8221;1px&#8221; header_6_text_shadow_horizontal_length_tablet=&#8221;0px&#8221; header_6_text_shadow_vertical_length_tablet=&#8221;0px&#8221; header_6_text_shadow_blur_strength_tablet=&#8221;1px&#8221; box_shadow_horizontal_tablet=&#8221;0px&#8221; box_shadow_vertical_tablet=&#8221;0px&#8221; box_shadow_blur_tablet=&#8221;40px&#8221; box_shadow_spread_tablet=&#8221;0px&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<div class='fluentform ff-default fluentform_wrapper_6 ffs_default_wrap'><form data-form_id=\"6\" id=\"fluentform_6\" class=\"frm-fluent-form fluent_form_6 ff-el-form-top ff_form_instance_6_1 ff-form-loading ff-form-has-steps ff_has_v3_recptcha ffs_default\" data-form_instance=\"ff_form_instance_6_1\" method=\"POST\" data-recptcha_key=\"6Ld1FskkAAAAAH3knkrVS97NLuSEstHetTy_MM2i\" ><fieldset  style=\"border: none!important;margin: 0!important;padding: 0!important;background-color: transparent!important;box-shadow: none!important;outline: none!important; min-inline-size: 100%;\">\n                    <legend class=\"ff_screen_reader_title\" style=\"display: block; margin: 0!important;padding: 0!important;height: 0!important;text-indent: -999999px;width: 0!important;overflow:hidden;\">Latest financial assistance Application form (#6)<\/legend>        <span style=\"display: none !important;\"><input type=\"checkbox\"\n                name=\"item__6__fluent_checkme_\"\n                value=\"1\" style=\"display:none !important;\" tabindex=\"-1\" aria-hidden=\"true\"><\/span>\n        <input type='hidden' name='__fluent_form_embded_post_id' value='15939' \/><input type=\"hidden\" id=\"_fluentform_6_fluentformnonce\" name=\"_fluentform_6_fluentformnonce\" value=\"50f9bd1ee0\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/wp-json\/wp\/v2\/pages\/15939\" \/><div class='ff-step-container' data-name=\"step_start-6_7\" data-disable_auto_focus=\"no\" data-enable_auto_slider=\"no\" data-enable_step_data_persistency=\"yes\" data-enable_step_page_resume=\"yes\" data-animation_type=\"slide\" ><span class='ff_step_start'><\/span><div class='ff-step-body'><div class=\"fluentform-step active\" data-name=\"step_start-6_7\" data-disable_auto_focus=\"no\" data-enable_auto_slider=\"no\" data-enable_step_data_persistency=\"yes\" data-enable_step_page_resume=\"yes\" data-animation_type=\"slide\" ><div data-name=\"ff_cn_id_1\"  class='ff-t-container ff-column-container ff_columns_total_2  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_input_text_1' aria-label=\"Application Date\">Application Date<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_1\" class=\"ff-el-form-control\" data-name=\"input_text_1\" id=\"ff_6_input_text_1\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_input_text' aria-label=\"Date of Service\">Date of Service<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text\" class=\"ff-el-form-control\" data-name=\"input_text\" id=\"ff_6_input_text\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_2\"  class='ff-t-container ff-column-container ff_columns_total_2  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div data-type=\"name-element\" data-name=\"names\" class=\" ff-field_container ff-name-field-wrapper\" ><div class='ff-t-container'><div class='ff-t-cell '><div class='ff-el-group  ff-el-form-top'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_names_first_name_' aria-label=\"Patient Name\">Patient Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names[first_name]\" id=\"ff_6_names_first_name_\" class=\"ff-el-form-control\" placeholder=\"Full Name\" aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_ssn' aria-label=\"Account Number\">Account Number<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"ssn\" class=\"ff-el-form-control\" data-name=\"ssn\" id=\"ff_6_ssn\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_3\"  class='ff-t-container ff-column-container ff_columns_total_3  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_numeric-field' aria-label=\"Phone\/Mobile\">Phone\/Mobile<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"numeric-field\" id=\"ff_6_numeric-field\" class=\"ff-el-form-control\" data-name=\"numeric-field\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_datetime' aria-label=\"Patient Date of Birth\">Patient Date of Birth<\/label><\/div><div class='ff-el-input--content'><input data-type-datepicker data-format='d\/m\/Y' type=\"text\" name=\"datetime\" value=\"25\/04\/1991\" id=\"ff_6_datetime\" class=\"ff-el-form-control ff-el-datepicker\" data-name=\"datetime\"  aria-invalid='false' aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_input_text_22' aria-label=\"Social Security Number\">Social Security Number<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_22\" class=\"ff-el-form-control\" data-name=\"input_text_22\" id=\"ff_6_input_text_22\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_4\"  class='ff-t-container ff-column-container ff_columns_total_2  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><\/div><\/div><div class=\"ff-name-address-wrapper fluent-address\" data-type=\"address-element\" data-name=\"address_1\" ><div class='ff-el-input--label'><label aria-label=Address>Address<\/label><\/div><div class='ff-el-input--content'><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_address_1_address_line_1_' aria-label=\"street address line 1\">street address line 1<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_1[address_line_1]\" id=\"ff_6_address_1_address_line_1_\" class=\"ff-el-form-control\" placeholder=\"street address line 1\" data-key_name=\"address_line_1\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_address_1_address_line_2_' aria-label=\"street address line 2\">street address line 2<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_1[address_line_2]\" id=\"ff_6_address_1_address_line_2_\" class=\"ff-el-form-control\" placeholder=\"street address line 2\" data-key_name=\"address_line_2\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_address_1_city_' aria-label=\"City\">City<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_1[city]\" id=\"ff_6_address_1_city_\" class=\"ff-el-form-control\" placeholder=\"City\" data-key_name=\"city\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_address_1_state_' aria-label=\"State\">State<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_1[state]\" id=\"ff_6_address_1_state_\" class=\"ff-el-form-control\" placeholder=\"State\" data-key_name=\"state\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_address_1_zip_' aria-label=\"Zip Code\">Zip Code<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_1[zip]\" id=\"ff_6_address_1_zip_\" class=\"ff-el-form-control\" placeholder=\"Zip\" data-key_name=\"zip\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label  aria-label=\"Was the patient a resident of Georgia at the time of service?\">Was the patient a resident of Georgia at the time of service?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=patient_a_resident_of_Georgia_0e622798f45968bff779276416661dff><input  type=\"radio\" name=\"patient_a_resident_of_Georgia\" data-name=\"patient_a_resident_of_Georgia\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='patient_a_resident_of_Georgia_0e622798f45968bff779276416661dff' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=patient_a_resident_of_Georgia_777db83c1849ad675511206451a3a59e><input  type=\"radio\" name=\"patient_a_resident_of_Georgia\" data-name=\"patient_a_resident_of_Georgia\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='patient_a_resident_of_Georgia_777db83c1849ad675511206451a3a59e' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><div data-name=\"ff_cn_id_5\"  class='ff-t-container ff-column-container ff_columns_total_2  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label  aria-label=\"Did the patient have medical insurance at the time of service?\">Did the patient have medical insurance at the time of service?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=patient_have_medical_insurance_8a63f952427ccfb0fa1ecd7fa27960d0><input  type=\"radio\" name=\"patient_have_medical_insurance\" data-name=\"patient_have_medical_insurance\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='patient_have_medical_insurance_8a63f952427ccfb0fa1ecd7fa27960d0' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=patient_have_medical_insurance_bc104fe807c475828d07724352a42184><input  type=\"radio\" name=\"patient_have_medical_insurance\" data-name=\"patient_have_medical_insurance\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='patient_have_medical_insurance_bc104fe807c475828d07724352a42184' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label  aria-label=\"Was the patient an active Medicaid recipient at the time of service?\">Was the patient an active Medicaid recipient at the time of service?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=patient_an_active_Medicaid_recipient_e9c35955beb2873adddc38ee8ccdbfd1><input  type=\"radio\" name=\"patient_an_active_Medicaid_recipient\" data-name=\"patient_an_active_Medicaid_recipient\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='patient_an_active_Medicaid_recipient_e9c35955beb2873adddc38ee8ccdbfd1' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=patient_an_active_Medicaid_recipient_f8910853bf09a7d138b152e2b71c5c4e><input  type=\"radio\" name=\"patient_an_active_Medicaid_recipient\" data-name=\"patient_an_active_Medicaid_recipient\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='patient_an_active_Medicaid_recipient_f8910853bf09a7d138b152e2b71c5c4e' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_file-upload_1' aria-label=\"Please attach a copy of your insurance or Medicaid card to this application.\">Please attach a copy of your insurance or Medicaid card to this application.<\/label><\/div><div class='ff-el-input--content'><label for='ff_6_file-upload_1' class='ff_file_upload_holder'><span class='ff_upload_btn ff-btn'>Choose File<\/span> <input type=\"file\" name=\"file-upload\" id=\"ff_6_file-upload_1\" class=\"ff-el-form-control  ff-screen-reader-element\" data-name=\"file-upload\" multiple=\"1\"  aria-invalid='false' aria-required=false><\/label><\/div><\/div><div class='step-nav ff_step_nav_last'><button  type='button' data-action='prev' class='ff-btn ff-btn-prev ff-btn-secondary'>Previous<\/button><button  type='button' data-action='next' class='ff-float-right ff-btn ff-btn-next ff-btn-secondary'>Next<\/button><\/div><\/div><div class=\" fluentform-step\" data-name=\"form_step-6_1\" ><div class='ff-el-group  ff-custom_html' data-name=\"custom_html-6_2\" ><p><strong><u>INCOME:<\/u><\/strong><\/p>\n<ul>\n<li><strong>All adult family members' income must be <\/strong>Income includes gross (before taxes) wages, rental income, unemployment compensation, social security benefits, public assistance, dividends and interest, etc.<\/li>\n<li>\"Family\" is defined as follows:<\/li>\n<li>(i) for persons 18 years of age and older, family means spouse, domestic partner and dependent children under 21 years of age, whether living at home or not;<\/li>\n<li>(ii) for persons under 18 years of age, family means parents, caretakers, relatives, and other children under 21 years of age of the parent or caretaker relative. If the patient is a minor, the \"family\" is defined as the patient, the patient's natural or adoptive parents and the parent's other children (natural or adoptive) who live in the patient's home.<\/li>\n<\/ul><\/div><div data-name=\"ff_cn_id_6\"  class='ff-t-container ff-column-container ff_columns_total_4  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 25%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_Family_Member_s_Name1' aria-label=\"Family Member&#039;s Name\">Family Member's Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Family_Member_s_Name1\" class=\"ff-el-form-control\" data-name=\"Family_Member_s_Name1\" id=\"ff_6_Family_Member_s_Name1\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 25%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_Age1' aria-label=\"Age\">Age<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"Age1\" id=\"ff_6_Age1\" class=\"ff-el-form-control\" data-name=\"Age1\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 25%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_Date_of_Birth1' aria-label=\"Date of Birth\">Date of Birth<\/label><\/div><div class='ff-el-input--content'><input data-type-datepicker data-format='d\/m\/Y' type=\"text\" name=\"Date_of_Birth1\" id=\"ff_6_Date_of_Birth1\" class=\"ff-el-form-control ff-el-datepicker\" data-name=\"Date_of_Birth1\"  aria-invalid='false' aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-4' style='flex-basis: 25%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_Relationship_to_Parent1' aria-label=\"Relationship to Parent\">Relationship to Parent<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Relationship_to_Parent1\" class=\"ff-el-form-control\" data-name=\"Relationship_to_Parent1\" id=\"ff_6_Relationship_to_Parent1\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_7\"  class='ff-t-container ff-column-container ff_columns_total_3  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.18%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_Source_of_Income_or_Employer_Name1' aria-label=\"Source of Income or Employer Name\">Source of Income or Employer Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Source_of_Income_or_Employer_Name1\" class=\"ff-el-form-control\" data-name=\"Source_of_Income_or_Employer_Name1\" id=\"ff_6_Source_of_Income_or_Employer_Name1\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.49%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_Income_for_3_months_prior_to_date_of_service1' aria-label=\"Income for 3 months prior to date of service\">Income for 3 months prior to date of service<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Income_for_3_months_prior_to_date_of_service1\" class=\"ff-el-form-control\" data-name=\"Income_for_3_months_prior_to_date_of_service1\" id=\"ff_6_Income_for_3_months_prior_to_date_of_service1\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_Income_for_12_months_prior_to_date_of_service1' aria-label=\"Income for 12 months prior to date of service\">Income for 12 months prior to date of service<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Income_for_12_months_prior_to_date_of_service1\" class=\"ff-el-form-control\" data-name=\"Income_for_12_months_prior_to_date_of_service1\" id=\"ff_6_Income_for_12_months_prior_to_date_of_service1\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-el-group ff-el-form-hide_label'><div class=\"ff-el-input--label asterisk-right\"><label  aria-label=\"add-more1\">add-more1<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=add_more1_e216c6cf7256c029a517008a431bc21b><input  type=\"checkbox\" name=\"add_more1[]\" data-name=\"add_more1\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Add More\"  id='add_more1_e216c6cf7256c029a517008a431bc21b' aria-label='Add More' aria-invalid='false' aria-required=false> <span>Add More<\/span><\/label><\/div><\/div><\/div><div data-name=\"ff_cn_id_8\"  class='ff-t-container ff-column-container ff_columns_total_4  has-conditions '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 25%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_Family_Member_s_Name2' aria-label=\"Family Member&#039;s Name\">Family Member's Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Family_Member_s_Name2\" class=\"ff-el-form-control\" data-name=\"Family_Member_s_Name2\" id=\"ff_6_Family_Member_s_Name2\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 25%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_Age2' aria-label=\"Age\">Age<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"Age2\" id=\"ff_6_Age2\" class=\"ff-el-form-control\" data-name=\"Age2\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 25%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_Date_of_Birth2' aria-label=\"Date of Birth\">Date of Birth<\/label><\/div><div class='ff-el-input--content'><input data-type-datepicker data-format='d\/m\/Y' type=\"text\" name=\"Date_of_Birth2\" id=\"ff_6_Date_of_Birth2\" class=\"ff-el-form-control ff-el-datepicker\" data-name=\"Date_of_Birth2\"  aria-invalid='false' aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-4' style='flex-basis: 25%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_Relationship_to_Parent2' aria-label=\"Relationship to Parent\">Relationship to Parent<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Relationship_to_Parent2\" class=\"ff-el-form-control\" data-name=\"Relationship_to_Parent2\" id=\"ff_6_Relationship_to_Parent2\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_9\"  class='ff-t-container ff-column-container ff_columns_total_3  has-conditions '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_Source_of_Income_or_Employer_Name2' aria-label=\"Source of Income or Employer Name\">Source of Income or Employer Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Source_of_Income_or_Employer_Name2\" class=\"ff-el-form-control\" data-name=\"Source_of_Income_or_Employer_Name2\" id=\"ff_6_Source_of_Income_or_Employer_Name2\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_Income_for_13_months_prior_to_date_of_service2' aria-label=\"Income for 3 months prior to date of service\">Income for 3 months prior to date of service<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Income_for_13_months_prior_to_date_of_service2\" class=\"ff-el-form-control\" data-name=\"Income_for_13_months_prior_to_date_of_service2\" id=\"ff_6_Income_for_13_months_prior_to_date_of_service2\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_Income_for_14_months_prior_to_date_of_service2' aria-label=\"Income for 12 months prior to date of service\">Income for 12 months prior to date of service<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Income_for_14_months_prior_to_date_of_service2\" class=\"ff-el-form-control\" data-name=\"Income_for_14_months_prior_to_date_of_service2\" id=\"ff_6_Income_for_14_months_prior_to_date_of_service2\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label  aria-label=\"add-more2\">add-more2<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=add_more2_6934b129dd791de5fbea3846c87454f5><input  type=\"checkbox\" name=\"add_more2[]\" data-name=\"add_more2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Add More\"  id='add_more2_6934b129dd791de5fbea3846c87454f5' aria-label='Add More' aria-invalid='false' aria-required=false> <span>Add More<\/span><\/label><\/div><\/div><\/div><div data-name=\"ff_cn_id_10\"  class='ff-t-container ff-column-container ff_columns_total_4  has-conditions '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 25%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_Family_Member_s_Name3' aria-label=\"Family Member&#039;s Name\">Family Member's Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Family_Member_s_Name3\" class=\"ff-el-form-control\" data-name=\"Family_Member_s_Name3\" id=\"ff_6_Family_Member_s_Name3\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 25%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_Age3' aria-label=\"Age\">Age<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"Age3\" id=\"ff_6_Age3\" class=\"ff-el-form-control\" data-name=\"Age3\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 25%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_Date_of_Birth3' aria-label=\"Date of Birth\">Date of Birth<\/label><\/div><div class='ff-el-input--content'><input data-type-datepicker data-format='d\/m\/Y' type=\"text\" name=\"Date_of_Birth3\" id=\"ff_6_Date_of_Birth3\" class=\"ff-el-form-control ff-el-datepicker\" data-name=\"Date_of_Birth3\"  aria-invalid='false' aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-4' style='flex-basis: 25%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_Relationship_to_Parent3' aria-label=\"Relationship to Parent\">Relationship to Parent<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Relationship_to_Parent3\" class=\"ff-el-form-control\" data-name=\"Relationship_to_Parent3\" id=\"ff_6_Relationship_to_Parent3\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_11\"  class='ff-t-container ff-column-container ff_columns_total_3  has-conditions '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_Source_of_Income_or_Employer_Name3' aria-label=\"Source of Income or Employer Name\">Source of Income or Employer Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Source_of_Income_or_Employer_Name3\" class=\"ff-el-form-control\" data-name=\"Source_of_Income_or_Employer_Name3\" id=\"ff_6_Source_of_Income_or_Employer_Name3\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_Income_for_15_months_prior_to_date_of_service3' aria-label=\"Income for 3 months prior to date of service\">Income for 3 months prior to date of service<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Income_for_15_months_prior_to_date_of_service3\" class=\"ff-el-form-control\" data-name=\"Income_for_15_months_prior_to_date_of_service3\" id=\"ff_6_Income_for_15_months_prior_to_date_of_service3\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_Income_for_16_months_prior_to_date_of_service3' aria-label=\"Income for 12 months prior to date of service\">Income for 12 months prior to date of service<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Income_for_16_months_prior_to_date_of_service3\" class=\"ff-el-form-control\" data-name=\"Income_for_16_months_prior_to_date_of_service3\" id=\"ff_6_Income_for_16_months_prior_to_date_of_service3\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label  aria-label=\"add-more3\">add-more3<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=add_more3_9315a69f1588b137d67de51e79ba15a7><input  type=\"checkbox\" name=\"add_more3[]\" data-name=\"add_more3\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Add More\"  id='add_more3_9315a69f1588b137d67de51e79ba15a7' aria-label='Add More' aria-invalid='false' aria-required=false> <span>Add More<\/span><\/label><\/div><\/div><\/div><div data-name=\"ff_cn_id_12\"  class='ff-t-container ff-column-container ff_columns_total_4  has-conditions '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 25%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_Family_Member_s_Name4' aria-label=\"Family Member&#039;s Name\">Family Member's Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Family_Member_s_Name4\" class=\"ff-el-form-control\" data-name=\"Family_Member_s_Name4\" id=\"ff_6_Family_Member_s_Name4\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 25%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_Age4' aria-label=\"Age\">Age<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"Age4\" id=\"ff_6_Age4\" class=\"ff-el-form-control\" data-name=\"Age4\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 25%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_Date_of_Birth4' aria-label=\"Date of Birth\">Date of Birth<\/label><\/div><div class='ff-el-input--content'><input data-type-datepicker data-format='d\/m\/Y' type=\"text\" name=\"Date_of_Birth4\" id=\"ff_6_Date_of_Birth4\" class=\"ff-el-form-control ff-el-datepicker\" data-name=\"Date_of_Birth4\"  aria-invalid='false' aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-4' style='flex-basis: 25%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_Relationship_to_Parent4' aria-label=\"Relationship to Parent\">Relationship to Parent<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Relationship_to_Parent4\" class=\"ff-el-form-control\" data-name=\"Relationship_to_Parent4\" id=\"ff_6_Relationship_to_Parent4\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_13\"  class='ff-t-container ff-column-container ff_columns_total_3  has-conditions '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_Source_of_Income_or_Employer_Name4' aria-label=\"Source of Income or Employer Name\">Source of Income or Employer Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Source_of_Income_or_Employer_Name4\" class=\"ff-el-form-control\" data-name=\"Source_of_Income_or_Employer_Name4\" id=\"ff_6_Source_of_Income_or_Employer_Name4\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_Income_for_17_months_prior_to_date_of_service4' aria-label=\"Income for 3 months prior to date of service\">Income for 3 months prior to date of service<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Income_for_17_months_prior_to_date_of_service4\" class=\"ff-el-form-control\" data-name=\"Income_for_17_months_prior_to_date_of_service4\" id=\"ff_6_Income_for_17_months_prior_to_date_of_service4\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_Income_for_18_months_prior_to_date_of_service4' aria-label=\"Income for 12 months prior to date of service\">Income for 12 months prior to date of service<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Income_for_18_months_prior_to_date_of_service4\" class=\"ff-el-form-control\" data-name=\"Income_for_18_months_prior_to_date_of_service4\" id=\"ff_6_Income_for_18_months_prior_to_date_of_service4\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label  aria-label=\"Add More4\">Add More4<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=Add_More4_903fcef924bae307c2a0283599e2b5f9><input  type=\"checkbox\" name=\"Add_More4[]\" data-name=\"Add_More4\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Add More\"  id='Add_More4_903fcef924bae307c2a0283599e2b5f9' aria-label='Add More' aria-invalid='false' aria-required=false> <span>Add More<\/span><\/label><\/div><\/div><\/div><div data-name=\"ff_cn_id_14\"  class='ff-t-container ff-column-container ff_columns_total_4  has-conditions '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 25%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_Family_Member_s_Name5' aria-label=\"Family Member&#039;s Name\">Family Member's Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Family_Member_s_Name5\" class=\"ff-el-form-control\" data-name=\"Family_Member_s_Name5\" id=\"ff_6_Family_Member_s_Name5\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 25%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_Age5' aria-label=\"Age\">Age<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"Age5\" id=\"ff_6_Age5\" class=\"ff-el-form-control\" data-name=\"Age5\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 25%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_Date_of_Birth5' aria-label=\"Date of Birth\">Date of Birth<\/label><\/div><div class='ff-el-input--content'><input data-type-datepicker data-format='d\/m\/Y' type=\"text\" name=\"Date_of_Birth5\" id=\"ff_6_Date_of_Birth5\" class=\"ff-el-form-control ff-el-datepicker\" data-name=\"Date_of_Birth5\"  aria-invalid='false' aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-4' style='flex-basis: 25%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_Relationship_to_Parent5' aria-label=\"Relationship to Parent\">Relationship to Parent<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Relationship_to_Parent5\" class=\"ff-el-form-control\" data-name=\"Relationship_to_Parent5\" id=\"ff_6_Relationship_to_Parent5\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_15\"  class='ff-t-container ff-column-container ff_columns_total_3  has-conditions '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_Source_of_Income_or_Employer_Name5' aria-label=\"Source of Income or Employer Name\">Source of Income or Employer Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Source_of_Income_or_Employer_Name5\" class=\"ff-el-form-control\" data-name=\"Source_of_Income_or_Employer_Name5\" id=\"ff_6_Source_of_Income_or_Employer_Name5\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_Income_for_19_months_prior_to_date_of_service5' aria-label=\"Income for 3 months prior to date of service\">Income for 3 months prior to date of service<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Income_for_19_months_prior_to_date_of_service5\" class=\"ff-el-form-control\" data-name=\"Income_for_19_months_prior_to_date_of_service5\" id=\"ff_6_Income_for_19_months_prior_to_date_of_service5\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_Income_for_20_months_prior_to_date_of_service5' aria-label=\"Income for 12 months prior to date of service\">Income for 12 months prior to date of service<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Income_for_20_months_prior_to_date_of_service5\" class=\"ff-el-form-control\" data-name=\"Income_for_20_months_prior_to_date_of_service5\" id=\"ff_6_Income_for_20_months_prior_to_date_of_service5\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_Proof_of_income_1' aria-label=\"Proof of income must be supplied at the time of application (e.g., three months of pay stubs, most recent tax return (IRS Form 1040), etc.).\">Proof of income must be supplied at the time of application (e.g., three months of pay stubs, most recent tax return (IRS Form 1040), etc.).<\/label><\/div><div class='ff-el-input--content'><label for='ff_6_Proof_of_income_1' class='ff_file_upload_holder'><span class='ff_upload_btn ff-btn'>Choose File<\/span> <input type=\"file\" name=\"Proof_of_income\" id=\"ff_6_Proof_of_income_1\" class=\"ff-el-form-control  ff-screen-reader-element\" data-name=\"Proof_of_income\" multiple=\"1\"  aria-invalid='false' aria-required=false><\/label><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_report__0_income_1' aria-label=\"If you report $0 income, please provide a written statement of how you (or the patient) are surviving financially, including who provides food, shelter, transportation, etc. and how long you have been without income.\">If you report $0 income, please provide a written statement of how you (or the patient) are surviving financially, including who provides food, shelter, transportation, etc. and how long you have been without income.<\/label><\/div><div class='ff-el-input--content'><label for='ff_6_report__0_income_1' class='ff_file_upload_holder'><span class='ff_upload_btn ff-btn'>Choose File<\/span> <input type=\"file\" name=\"report__0_income\" id=\"ff_6_report__0_income_1\" class=\"ff-el-form-control  ff-screen-reader-element\" data-name=\"report__0_income\" multiple=\"1\"  aria-invalid='false' aria-required=false><\/label><\/div><\/div><div class='step-nav ff_step_nav_last'><button  type='button' data-action='prev' class='ff-btn ff-btn-prev ff-btn-secondary'>Previous<\/button><button  type='button' data-action='next' class='ff-float-right ff-btn ff-btn-next ff-btn-secondary'>Next<\/button><\/div><\/div><div class=\" fluentform-step\" data-name=\"form_step-6_3\" ><div class='ff-el-group  ff-custom_html' data-name=\"custom_html-6_4\" ><h3 style=\"margin-top: 20px;padding-bottom: 0px;text-align: left\">Monthly Expenses<\/h3><\/div><div data-name=\"ff_cn_id_16\"  class='ff-t-container ff-column-container ff_columns_total_3  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_Monthly_Rent_Mortgage' aria-label=\"Monthly Rent \/ Mortgage\">Monthly Rent \/ Mortgage<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Monthly_Rent_Mortgage\" class=\"ff-el-form-control\" placeholder=\"$\" data-name=\"Monthly_Rent_Mortgage\" id=\"ff_6_Monthly_Rent_Mortgage\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_Car_Payment' aria-label=\"Car Payment\">Car Payment<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Car_Payment\" class=\"ff-el-form-control\" placeholder=\"$\" data-name=\"Car_Payment\" id=\"ff_6_Car_Payment\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_Insurance_premiums_' aria-label=\"Insurance premiums {life, home, car, medical)\">Insurance premiums {life, home, car, medical)<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Insurance_premiums_\" class=\"ff-el-form-control\" placeholder=\"$\" data-name=\"Insurance_premiums_\" id=\"ff_6_Insurance_premiums_\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_17\"  class='ff-t-container ff-column-container ff_columns_total_3  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_Clothing__Grocieries__Household_Goods' aria-label=\"Clothing, Grocieries, Household Goods\">Clothing, Grocieries, Household Goods<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Clothing__Grocieries__Household_Goods\" class=\"ff-el-form-control\" placeholder=\"$\" data-name=\"Clothing__Grocieries__Household_Goods\" id=\"ff_6_Clothing__Grocieries__Household_Goods\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_Utilities' aria-label=\"Utilities\">Utilities<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Utilities\" class=\"ff-el-form-control\" placeholder=\"$\" data-name=\"Utilities\" id=\"ff_6_Utilities\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_Medical_Expenses' aria-label=\"Medical Expenses\">Medical Expenses<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Medical_Expenses\" class=\"ff-el-form-control\" placeholder=\"$\" data-name=\"Medical_Expenses\" id=\"ff_6_Medical_Expenses\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_input_text_21' aria-label=\"Other Debts \/ Expenses (e.g., child support, loans, other)\">Other Debts \/ Expenses (e.g., child support, loans, other)<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_21\" class=\"ff-el-form-control\" placeholder=\"$\" data-name=\"input_text_21\" id=\"ff_6_input_text_21\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group  ff-custom_html' data-name=\"custom_html-6_5\" ><h3 style=\"margin-top: 20px;padding-bottom: 0px;text-align: left\">Assets<\/h3>\n<p>This information may be used if your income is above 200% of Federal Poverty Level guidelines to determine whether you may be eligible for discounted care.<\/p><\/div><div data-name=\"ff_cn_id_18\"  class='ff-t-container ff-column-container ff_columns_total_3  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_Checking_Account_' aria-label=\"Checking Account \">Checking Account <\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Checking_Account_\" class=\"ff-el-form-control\" placeholder=\"$\" data-name=\"Checking_Account_\" id=\"ff_6_Checking_Account_\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_Business_Ownership' aria-label=\"Business Ownership\">Business Ownership<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Business_Ownership\" class=\"ff-el-form-control\" placeholder=\"$\" data-name=\"Business_Ownership\" id=\"ff_6_Business_Ownership\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_SSI_Disability_' aria-label=\"SSI \/ Disability?\">SSI \/ Disability?<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"SSI_Disability_\" class=\"ff-el-form-control\" placeholder=\"$\" data-name=\"SSI_Disability_\" id=\"ff_6_SSI_Disability_\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_19\"  class='ff-t-container ff-column-container ff_columns_total_3  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_Child_Support' aria-label=\"Child Support\">Child Support<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Child_Support\" class=\"ff-el-form-control\" placeholder=\"$\" data-name=\"Child_Support\" id=\"ff_6_Child_Support\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_Savings_Account_' aria-label=\"Savings Account \">Savings Account <\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Savings_Account_\" class=\"ff-el-form-control\" placeholder=\"$\" data-name=\"Savings_Account_\" id=\"ff_6_Savings_Account_\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_Stocks_and_Bonds' aria-label=\"Stocks and Bonds\">Stocks and Bonds<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Stocks_and_Bonds\" class=\"ff-el-form-control\" placeholder=\"$\" data-name=\"Stocks_and_Bonds\" id=\"ff_6_Stocks_and_Bonds\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_Real_Estate__Excluding_Primary_Residence_' aria-label=\"Real Estate (Excluding Primary Residence)\">Real Estate (Excluding Primary Residence)<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Real_Estate__Excluding_Primary_Residence_\" class=\"ff-el-form-control\" placeholder=\"$\" data-name=\"Real_Estate__Excluding_Primary_Residence_\" id=\"ff_6_Real_Estate__Excluding_Primary_Residence_\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group  ff-custom_html' data-name=\"custom_html-6_6\" ><p><em>My signature below certifies that everything I have stated on this application is correct and subject to review under audit. I understand that if the information I provide is determined to be false, financial assistance may be denied and I may be responsible to pay for services provided.<\/em><\/p><\/div><div data-name=\"ff_cn_id_20\"  class='ff-t-container ff-column-container ff_columns_total_2  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_6_Applicant_s_Signature' aria-label=\"Applicant&#039;s Signature\">Applicant's Signature<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Applicant_s_Signature\" class=\"ff-el-form-control\" data-name=\"Applicant_s_Signature\" id=\"ff_6_Applicant_s_Signature\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_6_Applicant_date' aria-label=\"Date\">Date<\/label><\/div><div class='ff-el-input--content'><input data-type-datepicker data-format='d\/m\/Y' type=\"text\" name=\"Applicant_date\" id=\"ff_6_Applicant_date\" class=\"ff-el-form-control ff-el-datepicker\" data-name=\"Applicant_date\"  aria-invalid='false' aria-required=true><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_21\"  class='ff-t-container ff-column-container ff_columns_total_2  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_6_Spouse_s_Signature' aria-label=\"Spouse&#039;s Signature\">Spouse's Signature<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Spouse_s_Signature\" class=\"ff-el-form-control\" data-name=\"Spouse_s_Signature\" id=\"ff_6_Spouse_s_Signature\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_6_Spouse_date' aria-label=\"Date \">Date <\/label><\/div><div class='ff-el-input--content'><input data-type-datepicker data-format='d\/m\/Y' type=\"text\" name=\"Spouse_date\" id=\"ff_6_Spouse_date\" class=\"ff-el-form-control ff-el-datepicker\" data-name=\"Spouse_date\"  aria-invalid='false' aria-required=true><\/div><\/div><\/div><\/div>        <div class=\"ff-step-t-container ff-inner_submit_container ff-column-container ff_columns_total_2\">\n            <div class=\"ff-t-cell ff-t-column-1\"><div class='step-nav ff_step_nav_last'><button  type='button' data-action='prev' class='ff-btn ff-btn-prev ff-btn-secondary'>Previous<\/button><\/div><\/div>\n            <div class=\"ff-t-cell ff-t-column-2\">\n                <div class='ff-el-group ff-text-left ff_submit_btn_wrapper'><button type=\"submit\" class=\"ff-btn ff-btn-submit ff-btn-md ff_btn_style\" >Submit<\/button><\/div>            <\/div>\n        <\/div>\n        <\/div><\/div><\/div>\n        <\/fieldset><\/form><div id='fluentform_6_errors' class='ff-errors-in-stack ff_form_instance_6_1 ff-form-loading_errors ff_form_instance_6_1_errors'><\/div><\/div>        <script type=\"text\/javascript\">\n            window.fluent_form_ff_form_instance_6_1 = {\"id\":\"6\",\"settings\":{\"layout\":{\"labelPlacement\":\"top\",\"helpMessagePlacement\":\"with_label\",\"errorMessagePlacement\":\"inline\",\"cssClassName\":\"\",\"asteriskPlacement\":\"asterisk-right\"},\"restrictions\":{\"denyEmptySubmission\":{\"enabled\":false}}},\"form_instance\":\"ff_form_instance_6_1\",\"form_id_selector\":\"fluentform_6\",\"rules\":{\"input_text_1\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"input_text\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"names[first_name]\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"names[middle_name]\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"names[last_name]\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"ssn\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"numeric-field\":{\"required\":{\"value\":false,\"message\":\"This field is required\"},\"numeric\":{\"value\":true,\"message\":\"This field must contain numeric value\"},\"min\":{\"value\":\"\",\"message\":\"Minimum value is \"},\"max\":{\"value\":\"\",\"message\":\"Maximum value is \"},\"digits\":{\"value\":\"\",\"message\":\"The number of digits has to be \"}},\"datetime\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"input_text_22\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"address_1[address_line_1]\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"address_1[address_line_2]\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"address_1[city]\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"address_1[state]\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"address_1[zip]\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"address_1[country]\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"patient_a_resident_of_Georgia\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"patient_have_medical_insurance\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"patient_an_active_Medicaid_recipient\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"file-upload\":{\"required\":{\"value\":false,\"message\":\"This field is required\"},\"max_file_size\":{\"value\":10485760,\"_valueFrom\":\"MB\",\"message\":\"Maximum file size limit is 10MB\"},\"max_file_count\":{\"value\":1,\"message\":\"You can upload maximum 1 file\"},\"allowed_file_types\":{\"value\":[\"pdf\",\"doc|ppt|pps|xls|mdb|docx|xlsx|pptx|odt|odp|ods|odg|odc|odb|odf|rtf|txt\"],\"message\":\"Invalid file type\"}},\"Family_Member_s_Name1\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"Age1\":{\"required\":{\"value\":false,\"message\":\"This field is required\"},\"numeric\":{\"value\":true,\"message\":\"This field must contain numeric value\"},\"min\":{\"value\":\"\",\"message\":\"Minimum value is \"},\"max\":{\"value\":\"\",\"message\":\"Maximum value is \"},\"digits\":{\"value\":\"\",\"message\":\"The number of digits has to be \"}},\"Date_of_Birth1\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"Relationship_to_Parent1\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"Source_of_Income_or_Employer_Name1\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"Income_for_3_months_prior_to_date_of_service1\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"Income_for_12_months_prior_to_date_of_service1\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"add_more1\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"Family_Member_s_Name2\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"Age2\":{\"required\":{\"value\":false,\"message\":\"This field is required\"},\"numeric\":{\"value\":true,\"message\":\"This field must contain numeric value\"},\"min\":{\"value\":\"\",\"message\":\"Minimum value is \"},\"max\":{\"value\":\"\",\"message\":\"Maximum value is \"},\"digits\":{\"value\":\"\",\"message\":\"The number of digits has to be \"}},\"Date_of_Birth2\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"Relationship_to_Parent2\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"Source_of_Income_or_Employer_Name2\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"Income_for_13_months_prior_to_date_of_service2\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"Income_for_14_months_prior_to_date_of_service2\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"add_more2\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"Family_Member_s_Name3\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"Age3\":{\"required\":{\"value\":false,\"message\":\"This field is required\"},\"numeric\":{\"value\":true,\"message\":\"This field must contain numeric value\"},\"min\":{\"value\":\"\",\"message\":\"Minimum value is \"},\"max\":{\"value\":\"\",\"message\":\"Maximum value is \"},\"digits\":{\"value\":\"\",\"message\":\"The number of digits has to be \"}},\"Date_of_Birth3\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"Relationship_to_Parent3\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"Source_of_Income_or_Employer_Name3\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"Income_for_15_months_prior_to_date_of_service3\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"Income_for_16_months_prior_to_date_of_service3\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"add_more3\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"Family_Member_s_Name4\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"Age4\":{\"required\":{\"value\":false,\"message\":\"This field is required\"},\"numeric\":{\"value\":true,\"message\":\"This field must contain numeric value\"},\"min\":{\"value\":\"\",\"message\":\"Minimum value is \"},\"max\":{\"value\":\"\",\"message\":\"Maximum value is \"},\"digits\":{\"value\":\"\",\"message\":\"The number of digits has to be \"}},\"Date_of_Birth4\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"Relationship_to_Parent4\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"Source_of_Income_or_Employer_Name4\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"Income_for_17_months_prior_to_date_of_service4\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"Income_for_18_months_prior_to_date_of_service4\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"Add_More4\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"Family_Member_s_Name5\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"Age5\":{\"required\":{\"value\":false,\"message\":\"This field is required\"},\"numeric\":{\"value\":true,\"message\":\"This field must contain numeric value\"},\"min\":{\"value\":\"\",\"message\":\"Minimum value is \"},\"max\":{\"value\":\"\",\"message\":\"Maximum value is \"},\"digits\":{\"value\":\"\",\"message\":\"The number of digits has to be \"}},\"Date_of_Birth5\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"Relationship_to_Parent5\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"Source_of_Income_or_Employer_Name5\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"Income_for_19_months_prior_to_date_of_service5\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"Income_for_20_months_prior_to_date_of_service5\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"Proof_of_income\":{\"required\":{\"value\":false,\"message\":\"This field is required\"},\"max_file_size\":{\"value\":1048576,\"_valueFrom\":\"MB\",\"message\":\"Maximum file size limit is 1MB\"},\"max_file_count\":{\"value\":1,\"message\":\"You can upload maximum 1 file\"},\"allowed_file_types\":{\"value\":[\"pdf\",\"doc|ppt|pps|xls|mdb|docx|xlsx|pptx|odt|odp|ods|odg|odc|odb|odf|rtf|txt\"],\"message\":\"Invalid file type\"}},\"report__0_income\":{\"required\":{\"value\":false,\"message\":\"This field is required\"},\"max_file_size\":{\"value\":1048576,\"_valueFrom\":\"MB\",\"message\":\"Maximum file size limit is 1MB\"},\"max_file_count\":{\"value\":1,\"message\":\"You can upload maximum 1 file\"},\"allowed_file_types\":{\"value\":[\"pdf\",\"doc|ppt|pps|xls|mdb|docx|xlsx|pptx|odt|odp|ods|odg|odc|odb|odf|rtf|txt\"],\"message\":\"Invalid file type\"}},\"Monthly_Rent_Mortgage\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"Car_Payment\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"Insurance_premiums_\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"Clothing__Grocieries__Household_Goods\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"Utilities\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"Medical_Expenses\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"input_text_21\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"Checking_Account_\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"Business_Ownership\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"SSI_Disability_\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"Child_Support\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"Savings_Account_\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"Stocks_and_Bonds\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"Real_Estate__Excluding_Primary_Residence_\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"Applicant_s_Signature\":{\"required\":{\"value\":true,\"message\":\"This field is required\"}},\"Applicant_date\":{\"required\":{\"value\":true,\"message\":\"This field is required\"}},\"Spouse_s_Signature\":{\"required\":{\"value\":true,\"message\":\"This field is required\"}},\"Spouse_date\":{\"required\":{\"value\":true,\"message\":\"This field is required\"}},\"g-recaptcha-response\":[]},\"conditionals\":{\"file-upload\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"patient_have_medical_insurance\",\"value\":\"yes\",\"operator\":\"=\"},{\"field\":\"patient_an_active_Medicaid_recipient\",\"value\":\"yes\",\"operator\":\"=\"}]},\"ff_cn_id_8\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"add_more1\",\"value\":\"Add More\",\"operator\":\"=\"}]},\"Family_Member_s_Name2\":{\"conditions\":[],\"status\":false,\"type\":\"any\",\"container_condition\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"add_more1\",\"value\":\"Add More\",\"operator\":\"=\"}]}},\"Age2\":{\"conditions\":[],\"status\":false,\"type\":\"any\",\"container_condition\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"add_more1\",\"value\":\"Add More\",\"operator\":\"=\"}]}},\"Date_of_Birth2\":{\"conditions\":[],\"status\":false,\"type\":\"any\",\"container_condition\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"add_more1\",\"value\":\"Add More\",\"operator\":\"=\"}]}},\"Relationship_to_Parent2\":{\"conditions\":[],\"status\":false,\"type\":\"any\",\"container_condition\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"add_more1\",\"value\":\"Add More\",\"operator\":\"=\"}]}},\"ff_cn_id_9\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"add_more1\",\"value\":\"Add More\",\"operator\":\"=\"}]},\"Source_of_Income_or_Employer_Name2\":{\"conditions\":[],\"status\":false,\"type\":\"any\",\"container_condition\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"add_more1\",\"value\":\"Add More\",\"operator\":\"=\"}]}},\"Income_for_13_months_prior_to_date_of_service2\":{\"conditions\":[],\"status\":false,\"type\":\"any\",\"container_condition\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"add_more1\",\"value\":\"Add More\",\"operator\":\"=\"}]}},\"Income_for_14_months_prior_to_date_of_service2\":{\"conditions\":[],\"status\":false,\"type\":\"any\",\"container_condition\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"add_more1\",\"value\":\"Add More\",\"operator\":\"=\"}]}},\"add_more2\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"add_more1\",\"value\":\"Add 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More\",\"operator\":\"=\"}]}},\"Relationship_to_Parent3\":{\"conditions\":[],\"status\":false,\"type\":\"any\",\"container_condition\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"add_more2\",\"value\":\"Add More\",\"operator\":\"=\"}]}},\"ff_cn_id_11\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"add_more2\",\"value\":\"Add More\",\"operator\":\"=\"}]},\"Source_of_Income_or_Employer_Name3\":{\"conditions\":[],\"status\":false,\"type\":\"any\",\"container_condition\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"add_more2\",\"value\":\"Add More\",\"operator\":\"=\"}]}},\"Income_for_15_months_prior_to_date_of_service3\":{\"conditions\":[],\"status\":false,\"type\":\"any\",\"container_condition\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"add_more2\",\"value\":\"Add More\",\"operator\":\"=\"}]}},\"Income_for_16_months_prior_to_date_of_service3\":{\"conditions\":[],\"status\":false,\"type\":\"any\",\"container_condition\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"add_more2\",\"value\":\"Add More\",\"operator\":\"=\"}]}},\"add_more3\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"add_more2\",\"value\":\"Add More\",\"operator\":\"=\"}]},\"ff_cn_id_12\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"add_more3\",\"value\":\"Add More\",\"operator\":\"=\"}]},\"Family_Member_s_Name4\":{\"conditions\":[],\"status\":false,\"type\":\"any\",\"container_condition\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"add_more3\",\"value\":\"Add More\",\"operator\":\"=\"}]}},\"Age4\":{\"conditions\":[],\"status\":false,\"type\":\"any\",\"container_condition\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"add_more3\",\"value\":\"Add More\",\"operator\":\"=\"}]}},\"Date_of_Birth4\":{\"conditions\":[],\"status\":false,\"type\":\"any\",\"container_condition\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"add_more3\",\"value\":\"Add More\",\"operator\":\"=\"}]}},\"Relationship_to_Parent4\":{\"conditions\":[],\"status\":false,\"type\":\"any\",\"container_condition\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"add_more3\",\"value\":\"Add More\",\"operator\":\"=\"}]}},\"ff_cn_id_13\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"add_more3\",\"value\":\"Add More\",\"operator\":\"=\"}]},\"Source_of_Income_or_Employer_Name4\":{\"conditions\":[],\"status\":false,\"type\":\"any\",\"container_condition\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"add_more3\",\"value\":\"Add More\",\"operator\":\"=\"}]}},\"Income_for_17_months_prior_to_date_of_service4\":{\"conditions\":[],\"status\":false,\"type\":\"any\",\"container_condition\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"add_more3\",\"value\":\"Add More\",\"operator\":\"=\"}]}},\"Income_for_18_months_prior_to_date_of_service4\":{\"conditions\":[],\"status\":false,\"type\":\"any\",\"container_condition\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"add_more3\",\"value\":\"Add More\",\"operator\":\"=\"}]}},\"Add_More4\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"add_more3\",\"value\":\"Add More\",\"operator\":\"=\"}]},\"ff_cn_id_14\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"Add_More4\",\"value\":\"Add More\",\"operator\":\"=\"}]},\"Family_Member_s_Name5\":{\"conditions\":[],\"status\":false,\"type\":\"any\",\"container_condition\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"Add_More4\",\"value\":\"Add More\",\"operator\":\"=\"}]}},\"Age5\":{\"conditions\":[],\"status\":false,\"type\":\"any\",\"container_condition\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"Add_More4\",\"value\":\"Add More\",\"operator\":\"=\"}]}},\"Date_of_Birth5\":{\"conditions\":[],\"status\":false,\"type\":\"any\",\"container_condition\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"Add_More4\",\"value\":\"Add More\",\"operator\":\"=\"}]}},\"Relationship_to_Parent5\":{\"conditions\":[],\"status\":false,\"type\":\"any\",\"container_condition\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"Add_More4\",\"value\":\"Add More\",\"operator\":\"=\"}]}},\"ff_cn_id_15\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"Add_More4\",\"value\":\"Add More\",\"operator\":\"=\"}]},\"Source_of_Income_or_Employer_Name5\":{\"conditions\":[],\"status\":false,\"type\":\"any\",\"container_condition\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"Add_More4\",\"value\":\"Add More\",\"operator\":\"=\"}]}},\"Income_for_19_months_prior_to_date_of_service5\":{\"conditions\":[],\"status\":false,\"type\":\"any\",\"container_condition\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"Add_More4\",\"value\":\"Add More\",\"operator\":\"=\"}]}},\"Income_for_20_months_prior_to_date_of_service5\":{\"conditions\":[],\"status\":false,\"type\":\"any\",\"container_condition\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"Add_More4\",\"value\":\"Add More\",\"operator\":\"=\"}]}}}};\n                    <\/script>\n        \n<p>[\/et_pb_text][\/et_pb_column][\/et_pb_row][et_pb_row _builder_version=&#8221;4.19.5&#8243; _module_preset=&#8221;default&#8221; custom_padding=&#8221;0px||0px||true|false&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;4.19.5&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_text _builder_version=&#8221;4.19.5&#8243; _module_preset=&#8221;default&#8221; text_text_color=&#8221;#262626&#8243; text_font_size=&#8221;18px&#8221; custom_padding=&#8221;||||true&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<p>Please call <strong>(770) 991-8600<\/strong> for any questions about filling out this form.<\/p>\n<p>[\/et_pb_text][\/et_pb_column][\/et_pb_row][\/et_pb_section]<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Financial Assistance Application FormSelect Spanish or other langauges to translate the application form to your preferred language<div class=\"gtranslate_wrapper\" id=\"gt-wrapper-33706049\"><\/div><div class='fluentform ff-default fluentform_wrapper_6 ffs_default_wrap'><form data-form_id=\"6\" id=\"fluentform_6\" class=\"frm-fluent-form fluent_form_6 ff-el-form-top ff_form_instance_6_2 ff-form-loading ff-form-has-steps ff_has_v3_recptcha ff_has_v3_recptcha ffs_default\" data-form_instance=\"ff_form_instance_6_2\" method=\"POST\" data-recptcha_key=\"6Ld1FskkAAAAAH3knkrVS97NLuSEstHetTy_MM2i\" ><fieldset  style=\"border: none!important;margin: 0!important;padding: 0!important;background-color: transparent!important;box-shadow: none!important;outline: none!important; min-inline-size: 100%;\">\n                    <legend class=\"ff_screen_reader_title\" style=\"display: block; margin: 0!important;padding: 0!important;height: 0!important;text-indent: -999999px;width: 0!important;overflow:hidden;\">Latest financial assistance Application form (#6)<\/legend>        <span style=\"display: none !important;\"><input type=\"checkbox\"\n                name=\"item__6__fluent_checkme_\"\n                value=\"1\" style=\"display:none !important;\" tabindex=\"-1\" aria-hidden=\"true\"><\/span>\n        <input type='hidden' name='__fluent_form_embded_post_id' value='15939' \/><input type=\"hidden\" id=\"_fluentform_6_fluentformnonce\" name=\"_fluentform_6_fluentformnonce\" value=\"50f9bd1ee0\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/wp-json\/wp\/v2\/pages\/15939\" \/><div class='ff-step-container' data-name=\"step_start-6_7\" data-disable_auto_focus=\"no\" data-enable_auto_slider=\"no\" data-enable_step_data_persistency=\"yes\" data-enable_step_page_resume=\"yes\" data-animation_type=\"slide\" ><span class='ff_step_start'><\/span><div class='ff-step-body'><div class=\"fluentform-step active\" data-name=\"step_start-6_7\" data-disable_auto_focus=\"no\" data-enable_auto_slider=\"no\" data-enable_step_data_persistency=\"yes\" data-enable_step_page_resume=\"yes\" data-animation_type=\"slide\" ><div data-name=\"ff_cn_id_1\"  class='ff-t-container ff-column-container ff_columns_total_2  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_2_input_text_1' aria-label=\"Application Date\">Application Date<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_1\" class=\"ff-el-form-control\" data-name=\"input_text_1\" id=\"ff_6_2_input_text_1\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_2_input_text' aria-label=\"Date of Service\">Date of Service<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text\" class=\"ff-el-form-control\" data-name=\"input_text\" id=\"ff_6_2_input_text\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_2\"  class='ff-t-container ff-column-container ff_columns_total_2  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div data-type=\"name-element\" data-name=\"names\" class=\" ff-field_container ff-name-field-wrapper\" ><div class='ff-t-container'><div class='ff-t-cell '><div class='ff-el-group  ff-el-form-top'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_2_names_first_name_' aria-label=\"Patient Name\">Patient Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names[first_name]\" id=\"ff_6_2_names_first_name_\" class=\"ff-el-form-control\" placeholder=\"Full Name\" aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_2_ssn' aria-label=\"Account Number\">Account Number<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"ssn\" class=\"ff-el-form-control\" data-name=\"ssn\" id=\"ff_6_2_ssn\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_3\"  class='ff-t-container ff-column-container ff_columns_total_3  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_2_numeric-field' aria-label=\"Phone\/Mobile\">Phone\/Mobile<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"numeric-field\" id=\"ff_6_2_numeric-field\" class=\"ff-el-form-control\" data-name=\"numeric-field\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_2_datetime' aria-label=\"Patient Date of Birth\">Patient Date of Birth<\/label><\/div><div class='ff-el-input--content'><input data-type-datepicker data-format='d\/m\/Y' type=\"text\" name=\"datetime\" value=\"25\/04\/1991\" id=\"ff_6_2_datetime\" class=\"ff-el-form-control ff-el-datepicker\" data-name=\"datetime\"  aria-invalid='false' aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_2_input_text_22' aria-label=\"Social Security Number\">Social Security Number<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_22\" class=\"ff-el-form-control\" data-name=\"input_text_22\" id=\"ff_6_2_input_text_22\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_4\"  class='ff-t-container ff-column-container ff_columns_total_2  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><\/div><\/div><div class=\"ff-name-address-wrapper fluent-address\" data-type=\"address-element\" data-name=\"address_1\" ><div class='ff-el-input--label'><label aria-label=Address>Address<\/label><\/div><div class='ff-el-input--content'><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_2_address_1_address_line_1_' aria-label=\"street address line 1\">street address line 1<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_1[address_line_1]\" id=\"ff_6_2_address_1_address_line_1_\" class=\"ff-el-form-control\" placeholder=\"street address line 1\" data-key_name=\"address_line_1\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_2_address_1_address_line_2_' aria-label=\"street address line 2\">street address line 2<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_1[address_line_2]\" id=\"ff_6_2_address_1_address_line_2_\" class=\"ff-el-form-control\" placeholder=\"street address line 2\" data-key_name=\"address_line_2\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_2_address_1_city_' aria-label=\"City\">City<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_1[city]\" id=\"ff_6_2_address_1_city_\" class=\"ff-el-form-control\" placeholder=\"City\" data-key_name=\"city\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_2_address_1_state_' aria-label=\"State\">State<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_1[state]\" id=\"ff_6_2_address_1_state_\" class=\"ff-el-form-control\" placeholder=\"State\" data-key_name=\"state\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_2_address_1_zip_' aria-label=\"Zip Code\">Zip Code<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_1[zip]\" id=\"ff_6_2_address_1_zip_\" class=\"ff-el-form-control\" placeholder=\"Zip\" data-key_name=\"zip\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label  aria-label=\"Was the patient a resident of Georgia at the time of service?\">Was the patient a resident of Georgia at the time of service?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=patient_a_resident_of_Georgia_36ed354ce7a9bbb21a09c141f00f08fc><input  type=\"radio\" name=\"patient_a_resident_of_Georgia\" data-name=\"patient_a_resident_of_Georgia\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='patient_a_resident_of_Georgia_36ed354ce7a9bbb21a09c141f00f08fc' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=patient_a_resident_of_Georgia_6f955859239f6074185fb90156bd9d18><input  type=\"radio\" name=\"patient_a_resident_of_Georgia\" data-name=\"patient_a_resident_of_Georgia\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='patient_a_resident_of_Georgia_6f955859239f6074185fb90156bd9d18' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><div data-name=\"ff_cn_id_5\"  class='ff-t-container ff-column-container ff_columns_total_2  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label  aria-label=\"Did the patient have medical insurance at the time of service?\">Did the patient have medical insurance at the time of service?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=patient_have_medical_insurance_a9f986734bdfa5450dc07f4561e41d3a><input  type=\"radio\" name=\"patient_have_medical_insurance\" data-name=\"patient_have_medical_insurance\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='patient_have_medical_insurance_a9f986734bdfa5450dc07f4561e41d3a' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=patient_have_medical_insurance_f3073c3aa90c6491307b83ef1a0ad87f><input  type=\"radio\" name=\"patient_have_medical_insurance\" data-name=\"patient_have_medical_insurance\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='patient_have_medical_insurance_f3073c3aa90c6491307b83ef1a0ad87f' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label  aria-label=\"Was the patient an active Medicaid recipient at the time of service?\">Was the patient an active Medicaid recipient at the time of service?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=patient_an_active_Medicaid_recipient_685378fab6c47f7387fcd861724e7343><input  type=\"radio\" name=\"patient_an_active_Medicaid_recipient\" data-name=\"patient_an_active_Medicaid_recipient\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='patient_an_active_Medicaid_recipient_685378fab6c47f7387fcd861724e7343' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=patient_an_active_Medicaid_recipient_d749862558a0336a456a5dc8813c001f><input  type=\"radio\" name=\"patient_an_active_Medicaid_recipient\" data-name=\"patient_an_active_Medicaid_recipient\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='patient_an_active_Medicaid_recipient_d749862558a0336a456a5dc8813c001f' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_2_file-upload_2' aria-label=\"Please attach a copy of your insurance or Medicaid card to this application.\">Please attach a copy of your insurance or Medicaid card to this application.<\/label><\/div><div class='ff-el-input--content'><label for='ff_6_2_file-upload_2' class='ff_file_upload_holder'><span class='ff_upload_btn ff-btn'>Choose File<\/span> <input type=\"file\" name=\"file-upload\" id=\"ff_6_2_file-upload_2\" class=\"ff-el-form-control  ff-screen-reader-element\" data-name=\"file-upload\" multiple=\"1\"  aria-invalid='false' aria-required=false><\/label><\/div><\/div><div class='step-nav ff_step_nav_last'><button  type='button' data-action='prev' class='ff-btn ff-btn-prev ff-btn-secondary'>Previous<\/button><button  type='button' data-action='next' class='ff-float-right ff-btn ff-btn-next ff-btn-secondary'>Next<\/button><\/div><\/div><div class=\" fluentform-step\" data-name=\"form_step-6_1\" ><div class='ff-el-group  ff-custom_html' data-name=\"custom_html-6_2\" ><p><strong><u>INCOME:<\/u><\/strong><\/p>\n<ul>\n<li><strong>All adult family members' income must be <\/strong>Income includes gross (before taxes) wages, rental income, unemployment compensation, social security benefits, public assistance, dividends and interest, etc.<\/li>\n<li>\"Family\" is defined as follows:<\/li>\n<li>(i) for persons 18 years of age and older, family means spouse, domestic partner and dependent children under 21 years of age, whether living at home or not;<\/li>\n<li>(ii) for persons under 18 years of age, family means parents, caretakers, relatives, and other children under 21 years of age of the parent or caretaker relative. If the patient is a minor, the \"family\" is defined as the patient, the patient's natural or adoptive parents and the parent's other children (natural or adoptive) who live in the patient's home.<\/li>\n<\/ul><\/div><div data-name=\"ff_cn_id_6\"  class='ff-t-container ff-column-container ff_columns_total_4  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 25%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_2_Family_Member_s_Name1' aria-label=\"Family Member&#039;s Name\">Family Member's Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Family_Member_s_Name1\" class=\"ff-el-form-control\" data-name=\"Family_Member_s_Name1\" id=\"ff_6_2_Family_Member_s_Name1\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 25%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_2_Age1' aria-label=\"Age\">Age<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"Age1\" id=\"ff_6_2_Age1\" class=\"ff-el-form-control\" data-name=\"Age1\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 25%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_2_Date_of_Birth1' aria-label=\"Date of Birth\">Date of Birth<\/label><\/div><div class='ff-el-input--content'><input data-type-datepicker data-format='d\/m\/Y' type=\"text\" name=\"Date_of_Birth1\" id=\"ff_6_2_Date_of_Birth1\" class=\"ff-el-form-control ff-el-datepicker\" data-name=\"Date_of_Birth1\"  aria-invalid='false' aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-4' style='flex-basis: 25%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_2_Relationship_to_Parent1' aria-label=\"Relationship to Parent\">Relationship to Parent<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Relationship_to_Parent1\" class=\"ff-el-form-control\" data-name=\"Relationship_to_Parent1\" id=\"ff_6_2_Relationship_to_Parent1\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_7\"  class='ff-t-container ff-column-container ff_columns_total_3  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.18%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_2_Source_of_Income_or_Employer_Name1' aria-label=\"Source of Income or Employer Name\">Source of Income or Employer Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Source_of_Income_or_Employer_Name1\" class=\"ff-el-form-control\" data-name=\"Source_of_Income_or_Employer_Name1\" id=\"ff_6_2_Source_of_Income_or_Employer_Name1\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.49%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_2_Income_for_3_months_prior_to_date_of_service1' aria-label=\"Income for 3 months prior to date of service\">Income for 3 months prior to date of service<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Income_for_3_months_prior_to_date_of_service1\" class=\"ff-el-form-control\" data-name=\"Income_for_3_months_prior_to_date_of_service1\" id=\"ff_6_2_Income_for_3_months_prior_to_date_of_service1\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_2_Income_for_12_months_prior_to_date_of_service1' aria-label=\"Income for 12 months prior to date of service\">Income for 12 months prior to date of service<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Income_for_12_months_prior_to_date_of_service1\" class=\"ff-el-form-control\" data-name=\"Income_for_12_months_prior_to_date_of_service1\" id=\"ff_6_2_Income_for_12_months_prior_to_date_of_service1\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-el-group ff-el-form-hide_label'><div class=\"ff-el-input--label asterisk-right\"><label  aria-label=\"add-more1\">add-more1<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=add_more1_6a5ad848b1208ae957fb06caac6b1f26><input  type=\"checkbox\" name=\"add_more1[]\" data-name=\"add_more1\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Add More\"  id='add_more1_6a5ad848b1208ae957fb06caac6b1f26' aria-label='Add More' aria-invalid='false' aria-required=false> <span>Add More<\/span><\/label><\/div><\/div><\/div><div data-name=\"ff_cn_id_8\"  class='ff-t-container ff-column-container ff_columns_total_4  has-conditions '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 25%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_2_Family_Member_s_Name2' aria-label=\"Family Member&#039;s Name\">Family Member's Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Family_Member_s_Name2\" class=\"ff-el-form-control\" data-name=\"Family_Member_s_Name2\" id=\"ff_6_2_Family_Member_s_Name2\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 25%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_2_Age2' aria-label=\"Age\">Age<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"Age2\" id=\"ff_6_2_Age2\" class=\"ff-el-form-control\" data-name=\"Age2\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 25%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_2_Date_of_Birth2' aria-label=\"Date of Birth\">Date of Birth<\/label><\/div><div class='ff-el-input--content'><input data-type-datepicker data-format='d\/m\/Y' type=\"text\" name=\"Date_of_Birth2\" id=\"ff_6_2_Date_of_Birth2\" class=\"ff-el-form-control ff-el-datepicker\" data-name=\"Date_of_Birth2\"  aria-invalid='false' aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-4' style='flex-basis: 25%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_2_Relationship_to_Parent2' aria-label=\"Relationship to Parent\">Relationship to Parent<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Relationship_to_Parent2\" class=\"ff-el-form-control\" data-name=\"Relationship_to_Parent2\" id=\"ff_6_2_Relationship_to_Parent2\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_9\"  class='ff-t-container ff-column-container ff_columns_total_3  has-conditions '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_2_Source_of_Income_or_Employer_Name2' aria-label=\"Source of Income or Employer Name\">Source of Income or Employer Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Source_of_Income_or_Employer_Name2\" class=\"ff-el-form-control\" data-name=\"Source_of_Income_or_Employer_Name2\" id=\"ff_6_2_Source_of_Income_or_Employer_Name2\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_2_Income_for_13_months_prior_to_date_of_service2' aria-label=\"Income for 3 months prior to date of service\">Income for 3 months prior to date of service<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Income_for_13_months_prior_to_date_of_service2\" class=\"ff-el-form-control\" data-name=\"Income_for_13_months_prior_to_date_of_service2\" id=\"ff_6_2_Income_for_13_months_prior_to_date_of_service2\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_2_Income_for_14_months_prior_to_date_of_service2' aria-label=\"Income for 12 months prior to date of service\">Income for 12 months prior to date of service<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Income_for_14_months_prior_to_date_of_service2\" class=\"ff-el-form-control\" data-name=\"Income_for_14_months_prior_to_date_of_service2\" id=\"ff_6_2_Income_for_14_months_prior_to_date_of_service2\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label  aria-label=\"add-more2\">add-more2<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=add_more2_d72dc07d903de9410b86a4412ed7e445><input  type=\"checkbox\" name=\"add_more2[]\" data-name=\"add_more2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Add More\"  id='add_more2_d72dc07d903de9410b86a4412ed7e445' aria-label='Add More' aria-invalid='false' aria-required=false> <span>Add More<\/span><\/label><\/div><\/div><\/div><div data-name=\"ff_cn_id_10\"  class='ff-t-container ff-column-container ff_columns_total_4  has-conditions '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 25%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_2_Family_Member_s_Name3' aria-label=\"Family Member&#039;s Name\">Family Member's Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Family_Member_s_Name3\" class=\"ff-el-form-control\" data-name=\"Family_Member_s_Name3\" id=\"ff_6_2_Family_Member_s_Name3\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 25%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_2_Age3' aria-label=\"Age\">Age<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"Age3\" id=\"ff_6_2_Age3\" class=\"ff-el-form-control\" data-name=\"Age3\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 25%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_2_Date_of_Birth3' aria-label=\"Date of Birth\">Date of Birth<\/label><\/div><div class='ff-el-input--content'><input data-type-datepicker data-format='d\/m\/Y' type=\"text\" name=\"Date_of_Birth3\" id=\"ff_6_2_Date_of_Birth3\" class=\"ff-el-form-control ff-el-datepicker\" data-name=\"Date_of_Birth3\"  aria-invalid='false' aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-4' style='flex-basis: 25%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_2_Relationship_to_Parent3' aria-label=\"Relationship to Parent\">Relationship to Parent<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Relationship_to_Parent3\" class=\"ff-el-form-control\" data-name=\"Relationship_to_Parent3\" id=\"ff_6_2_Relationship_to_Parent3\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_11\"  class='ff-t-container ff-column-container ff_columns_total_3  has-conditions '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_2_Source_of_Income_or_Employer_Name3' aria-label=\"Source of Income or Employer Name\">Source of Income or Employer Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Source_of_Income_or_Employer_Name3\" class=\"ff-el-form-control\" data-name=\"Source_of_Income_or_Employer_Name3\" id=\"ff_6_2_Source_of_Income_or_Employer_Name3\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_2_Income_for_15_months_prior_to_date_of_service3' aria-label=\"Income for 3 months prior to date of service\">Income for 3 months prior to date of service<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Income_for_15_months_prior_to_date_of_service3\" class=\"ff-el-form-control\" data-name=\"Income_for_15_months_prior_to_date_of_service3\" id=\"ff_6_2_Income_for_15_months_prior_to_date_of_service3\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_2_Income_for_16_months_prior_to_date_of_service3' aria-label=\"Income for 12 months prior to date of service\">Income for 12 months prior to date of service<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Income_for_16_months_prior_to_date_of_service3\" class=\"ff-el-form-control\" data-name=\"Income_for_16_months_prior_to_date_of_service3\" id=\"ff_6_2_Income_for_16_months_prior_to_date_of_service3\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label  aria-label=\"add-more3\">add-more3<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=add_more3_c3e6689deb316b85a70ad0a35c5754a3><input  type=\"checkbox\" name=\"add_more3[]\" data-name=\"add_more3\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Add More\"  id='add_more3_c3e6689deb316b85a70ad0a35c5754a3' aria-label='Add More' aria-invalid='false' aria-required=false> <span>Add More<\/span><\/label><\/div><\/div><\/div><div data-name=\"ff_cn_id_12\"  class='ff-t-container ff-column-container ff_columns_total_4  has-conditions '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 25%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_2_Family_Member_s_Name4' aria-label=\"Family Member&#039;s Name\">Family Member's Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Family_Member_s_Name4\" class=\"ff-el-form-control\" data-name=\"Family_Member_s_Name4\" id=\"ff_6_2_Family_Member_s_Name4\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 25%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_2_Age4' aria-label=\"Age\">Age<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"Age4\" id=\"ff_6_2_Age4\" class=\"ff-el-form-control\" data-name=\"Age4\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 25%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_2_Date_of_Birth4' aria-label=\"Date of Birth\">Date of Birth<\/label><\/div><div class='ff-el-input--content'><input data-type-datepicker data-format='d\/m\/Y' type=\"text\" name=\"Date_of_Birth4\" id=\"ff_6_2_Date_of_Birth4\" class=\"ff-el-form-control ff-el-datepicker\" data-name=\"Date_of_Birth4\"  aria-invalid='false' aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-4' style='flex-basis: 25%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_2_Relationship_to_Parent4' aria-label=\"Relationship to Parent\">Relationship to Parent<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Relationship_to_Parent4\" class=\"ff-el-form-control\" data-name=\"Relationship_to_Parent4\" id=\"ff_6_2_Relationship_to_Parent4\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_13\"  class='ff-t-container ff-column-container ff_columns_total_3  has-conditions '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_2_Source_of_Income_or_Employer_Name4' aria-label=\"Source of Income or Employer Name\">Source of Income or Employer Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Source_of_Income_or_Employer_Name4\" class=\"ff-el-form-control\" data-name=\"Source_of_Income_or_Employer_Name4\" id=\"ff_6_2_Source_of_Income_or_Employer_Name4\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_2_Income_for_17_months_prior_to_date_of_service4' aria-label=\"Income for 3 months prior to date of service\">Income for 3 months prior to date of service<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Income_for_17_months_prior_to_date_of_service4\" class=\"ff-el-form-control\" data-name=\"Income_for_17_months_prior_to_date_of_service4\" id=\"ff_6_2_Income_for_17_months_prior_to_date_of_service4\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_2_Income_for_18_months_prior_to_date_of_service4' aria-label=\"Income for 12 months prior to date of service\">Income for 12 months prior to date of service<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Income_for_18_months_prior_to_date_of_service4\" class=\"ff-el-form-control\" data-name=\"Income_for_18_months_prior_to_date_of_service4\" id=\"ff_6_2_Income_for_18_months_prior_to_date_of_service4\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label  aria-label=\"Add More4\">Add More4<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=Add_More4_3b7445e017d22c1067354bd71667c4ed><input  type=\"checkbox\" name=\"Add_More4[]\" data-name=\"Add_More4\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Add More\"  id='Add_More4_3b7445e017d22c1067354bd71667c4ed' aria-label='Add More' aria-invalid='false' aria-required=false> <span>Add More<\/span><\/label><\/div><\/div><\/div><div data-name=\"ff_cn_id_14\"  class='ff-t-container ff-column-container ff_columns_total_4  has-conditions '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 25%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_2_Family_Member_s_Name5' aria-label=\"Family Member&#039;s Name\">Family Member's Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Family_Member_s_Name5\" class=\"ff-el-form-control\" data-name=\"Family_Member_s_Name5\" id=\"ff_6_2_Family_Member_s_Name5\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 25%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_2_Age5' aria-label=\"Age\">Age<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"Age5\" id=\"ff_6_2_Age5\" class=\"ff-el-form-control\" data-name=\"Age5\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 25%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_2_Date_of_Birth5' aria-label=\"Date of Birth\">Date of Birth<\/label><\/div><div class='ff-el-input--content'><input data-type-datepicker data-format='d\/m\/Y' type=\"text\" name=\"Date_of_Birth5\" id=\"ff_6_2_Date_of_Birth5\" class=\"ff-el-form-control ff-el-datepicker\" data-name=\"Date_of_Birth5\"  aria-invalid='false' aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-4' style='flex-basis: 25%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_2_Relationship_to_Parent5' aria-label=\"Relationship to Parent\">Relationship to Parent<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Relationship_to_Parent5\" class=\"ff-el-form-control\" data-name=\"Relationship_to_Parent5\" id=\"ff_6_2_Relationship_to_Parent5\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_15\"  class='ff-t-container ff-column-container ff_columns_total_3  has-conditions '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_2_Source_of_Income_or_Employer_Name5' aria-label=\"Source of Income or Employer Name\">Source of Income or Employer Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Source_of_Income_or_Employer_Name5\" class=\"ff-el-form-control\" data-name=\"Source_of_Income_or_Employer_Name5\" id=\"ff_6_2_Source_of_Income_or_Employer_Name5\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_2_Income_for_19_months_prior_to_date_of_service5' aria-label=\"Income for 3 months prior to date of service\">Income for 3 months prior to date of service<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Income_for_19_months_prior_to_date_of_service5\" class=\"ff-el-form-control\" data-name=\"Income_for_19_months_prior_to_date_of_service5\" id=\"ff_6_2_Income_for_19_months_prior_to_date_of_service5\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_2_Income_for_20_months_prior_to_date_of_service5' aria-label=\"Income for 12 months prior to date of service\">Income for 12 months prior to date of service<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Income_for_20_months_prior_to_date_of_service5\" class=\"ff-el-form-control\" data-name=\"Income_for_20_months_prior_to_date_of_service5\" id=\"ff_6_2_Income_for_20_months_prior_to_date_of_service5\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_2_Proof_of_income_2' aria-label=\"Proof of income must be supplied at the time of application (e.g., three months of pay stubs, most recent tax return (IRS Form 1040), etc.).\">Proof of income must be supplied at the time of application (e.g., three months of pay stubs, most recent tax return (IRS Form 1040), etc.).<\/label><\/div><div class='ff-el-input--content'><label for='ff_6_2_Proof_of_income_2' class='ff_file_upload_holder'><span class='ff_upload_btn ff-btn'>Choose File<\/span> <input type=\"file\" name=\"Proof_of_income\" id=\"ff_6_2_Proof_of_income_2\" class=\"ff-el-form-control  ff-screen-reader-element\" data-name=\"Proof_of_income\" multiple=\"1\"  aria-invalid='false' aria-required=false><\/label><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_2_report__0_income_2' aria-label=\"If you report $0 income, please provide a written statement of how you (or the patient) are surviving financially, including who provides food, shelter, transportation, etc. and how long you have been without income.\">If you report $0 income, please provide a written statement of how you (or the patient) are surviving financially, including who provides food, shelter, transportation, etc. and how long you have been without income.<\/label><\/div><div class='ff-el-input--content'><label for='ff_6_2_report__0_income_2' class='ff_file_upload_holder'><span class='ff_upload_btn ff-btn'>Choose File<\/span> <input type=\"file\" name=\"report__0_income\" id=\"ff_6_2_report__0_income_2\" class=\"ff-el-form-control  ff-screen-reader-element\" data-name=\"report__0_income\" multiple=\"1\"  aria-invalid='false' aria-required=false><\/label><\/div><\/div><div class='step-nav ff_step_nav_last'><button  type='button' data-action='prev' class='ff-btn ff-btn-prev ff-btn-secondary'>Previous<\/button><button  type='button' data-action='next' class='ff-float-right ff-btn ff-btn-next ff-btn-secondary'>Next<\/button><\/div><\/div><div class=\" fluentform-step\" data-name=\"form_step-6_3\" ><div class='ff-el-group  ff-custom_html' data-name=\"custom_html-6_4\" ><h3 style=\"margin-top: 20px;padding-bottom: 0px;text-align: left\">Monthly Expenses<\/h3><\/div><div data-name=\"ff_cn_id_16\"  class='ff-t-container ff-column-container ff_columns_total_3  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_2_Monthly_Rent_Mortgage' aria-label=\"Monthly Rent \/ Mortgage\">Monthly Rent \/ Mortgage<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Monthly_Rent_Mortgage\" class=\"ff-el-form-control\" placeholder=\"$\" data-name=\"Monthly_Rent_Mortgage\" id=\"ff_6_2_Monthly_Rent_Mortgage\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_2_Car_Payment' aria-label=\"Car Payment\">Car Payment<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Car_Payment\" class=\"ff-el-form-control\" placeholder=\"$\" data-name=\"Car_Payment\" id=\"ff_6_2_Car_Payment\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_2_Insurance_premiums_' aria-label=\"Insurance premiums {life, home, car, medical)\">Insurance premiums {life, home, car, medical)<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Insurance_premiums_\" class=\"ff-el-form-control\" placeholder=\"$\" data-name=\"Insurance_premiums_\" id=\"ff_6_2_Insurance_premiums_\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_17\"  class='ff-t-container ff-column-container ff_columns_total_3  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_2_Clothing__Grocieries__Household_Goods' aria-label=\"Clothing, Grocieries, Household Goods\">Clothing, Grocieries, Household Goods<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Clothing__Grocieries__Household_Goods\" class=\"ff-el-form-control\" placeholder=\"$\" data-name=\"Clothing__Grocieries__Household_Goods\" id=\"ff_6_2_Clothing__Grocieries__Household_Goods\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_2_Utilities' aria-label=\"Utilities\">Utilities<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Utilities\" class=\"ff-el-form-control\" placeholder=\"$\" data-name=\"Utilities\" id=\"ff_6_2_Utilities\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_2_Medical_Expenses' aria-label=\"Medical Expenses\">Medical Expenses<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Medical_Expenses\" class=\"ff-el-form-control\" placeholder=\"$\" data-name=\"Medical_Expenses\" id=\"ff_6_2_Medical_Expenses\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_2_input_text_21' aria-label=\"Other Debts \/ Expenses (e.g., child support, loans, other)\">Other Debts \/ Expenses (e.g., child support, loans, other)<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_21\" class=\"ff-el-form-control\" placeholder=\"$\" data-name=\"input_text_21\" id=\"ff_6_2_input_text_21\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group  ff-custom_html' data-name=\"custom_html-6_5\" ><h3 style=\"margin-top: 20px;padding-bottom: 0px;text-align: left\">Assets<\/h3>\n<p>This information may be used if your income is above 200% of Federal Poverty Level guidelines to determine whether you may be eligible for discounted care.<\/p><\/div><div data-name=\"ff_cn_id_18\"  class='ff-t-container ff-column-container ff_columns_total_3  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_2_Checking_Account_' aria-label=\"Checking Account \">Checking Account <\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Checking_Account_\" class=\"ff-el-form-control\" placeholder=\"$\" data-name=\"Checking_Account_\" id=\"ff_6_2_Checking_Account_\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_2_Business_Ownership' aria-label=\"Business Ownership\">Business Ownership<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Business_Ownership\" class=\"ff-el-form-control\" placeholder=\"$\" data-name=\"Business_Ownership\" id=\"ff_6_2_Business_Ownership\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_2_SSI_Disability_' aria-label=\"SSI \/ Disability?\">SSI \/ Disability?<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"SSI_Disability_\" class=\"ff-el-form-control\" placeholder=\"$\" data-name=\"SSI_Disability_\" id=\"ff_6_2_SSI_Disability_\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_19\"  class='ff-t-container ff-column-container ff_columns_total_3  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_2_Child_Support' aria-label=\"Child Support\">Child Support<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Child_Support\" class=\"ff-el-form-control\" placeholder=\"$\" data-name=\"Child_Support\" id=\"ff_6_2_Child_Support\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_2_Savings_Account_' aria-label=\"Savings Account \">Savings Account <\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Savings_Account_\" class=\"ff-el-form-control\" placeholder=\"$\" data-name=\"Savings_Account_\" id=\"ff_6_2_Savings_Account_\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_2_Stocks_and_Bonds' aria-label=\"Stocks and Bonds\">Stocks and Bonds<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Stocks_and_Bonds\" class=\"ff-el-form-control\" placeholder=\"$\" data-name=\"Stocks_and_Bonds\" id=\"ff_6_2_Stocks_and_Bonds\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_2_Real_Estate__Excluding_Primary_Residence_' aria-label=\"Real Estate (Excluding Primary Residence)\">Real Estate (Excluding Primary Residence)<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Real_Estate__Excluding_Primary_Residence_\" class=\"ff-el-form-control\" placeholder=\"$\" data-name=\"Real_Estate__Excluding_Primary_Residence_\" id=\"ff_6_2_Real_Estate__Excluding_Primary_Residence_\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group  ff-custom_html' data-name=\"custom_html-6_6\" ><p><em>My signature below certifies that everything I have stated on this application is correct and subject to review under audit. I understand that if the information I provide is determined to be false, financial assistance may be denied and I may be responsible to pay for services provided.<\/em><\/p><\/div><div data-name=\"ff_cn_id_20\"  class='ff-t-container ff-column-container ff_columns_total_2  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_6_2_Applicant_s_Signature' aria-label=\"Applicant&#039;s Signature\">Applicant's Signature<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Applicant_s_Signature\" class=\"ff-el-form-control\" data-name=\"Applicant_s_Signature\" id=\"ff_6_2_Applicant_s_Signature\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_6_2_Applicant_date' aria-label=\"Date\">Date<\/label><\/div><div class='ff-el-input--content'><input data-type-datepicker data-format='d\/m\/Y' type=\"text\" name=\"Applicant_date\" id=\"ff_6_2_Applicant_date\" class=\"ff-el-form-control ff-el-datepicker\" data-name=\"Applicant_date\"  aria-invalid='false' aria-required=true><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_21\"  class='ff-t-container ff-column-container ff_columns_total_2  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_6_2_Spouse_s_Signature' aria-label=\"Spouse&#039;s Signature\">Spouse's Signature<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Spouse_s_Signature\" class=\"ff-el-form-control\" data-name=\"Spouse_s_Signature\" id=\"ff_6_2_Spouse_s_Signature\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_6_2_Spouse_date' aria-label=\"Date \">Date <\/label><\/div><div class='ff-el-input--content'><input data-type-datepicker data-format='d\/m\/Y' type=\"text\" name=\"Spouse_date\" id=\"ff_6_2_Spouse_date\" class=\"ff-el-form-control ff-el-datepicker\" data-name=\"Spouse_date\"  aria-invalid='false' aria-required=true><\/div><\/div><\/div><\/div>        <div class=\"ff-step-t-container ff-inner_submit_container ff-column-container ff_columns_total_2\">\n            <div class=\"ff-t-cell ff-t-column-1\"><div class='step-nav ff_step_nav_last'><button  type='button' data-action='prev' class='ff-btn ff-btn-prev ff-btn-secondary'>Previous<\/button><\/div><\/div>\n            <div class=\"ff-t-cell ff-t-column-2\">\n                <div class='ff-el-group ff-text-left ff_submit_btn_wrapper'><button type=\"submit\" class=\"ff-btn ff-btn-submit ff-btn-md ff_btn_style\" >Submit<\/button><\/div>            <\/div>\n        <\/div>\n        <\/div><\/div><\/div>\n        <\/fieldset><\/form><div id='fluentform_6_errors' class='ff-errors-in-stack ff_form_instance_6_2 ff-form-loading_errors ff_form_instance_6_2_errors'><\/div><\/div>        <script type=\"text\/javascript\">\n            window.fluent_form_ff_form_instance_6_2 = {\"id\":\"6\",\"settings\":{\"layout\":{\"labelPlacement\":\"top\",\"helpMessagePlacement\":\"with_label\",\"errorMessagePlacement\":\"inline\",\"cssClassName\":\"\",\"asteriskPlacement\":\"asterisk-right\"},\"restrictions\":{\"denyEmptySubmission\":{\"enabled\":false}}},\"form_instance\":\"ff_form_instance_6_2\",\"form_id_selector\":\"fluentform_6\",\"rules\":{\"input_text_1\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"input_text\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"names[first_name]\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"names[middle_name]\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"names[last_name]\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"ssn\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"numeric-field\":{\"required\":{\"value\":false,\"message\":\"This field is required\"},\"numeric\":{\"value\":true,\"message\":\"This field must contain numeric value\"},\"min\":{\"value\":\"\",\"message\":\"Minimum value is \"},\"max\":{\"value\":\"\",\"message\":\"Maximum value is \"},\"digits\":{\"value\":\"\",\"message\":\"The number of digits has to be \"}},\"datetime\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"input_text_22\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"address_1[address_line_1]\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"address_1[address_line_2]\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"address_1[city]\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"address_1[state]\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"address_1[zip]\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"address_1[country]\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"patient_a_resident_of_Georgia\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"patient_have_medical_insurance\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"patient_an_active_Medicaid_recipient\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"file-upload\":{\"required\":{\"value\":false,\"message\":\"This field is required\"},\"max_file_size\":{\"value\":10485760,\"_valueFrom\":\"MB\",\"message\":\"Maximum file size limit is 10MB\"},\"max_file_count\":{\"value\":1,\"message\":\"You can upload maximum 1 file\"},\"allowed_file_types\":{\"value\":[\"pdf\",\"doc|ppt|pps|xls|mdb|docx|xlsx|pptx|odt|odp|ods|odg|odc|odb|odf|rtf|txt\"],\"message\":\"Invalid file type\"}},\"Family_Member_s_Name1\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"Age1\":{\"required\":{\"value\":false,\"message\":\"This field is required\"},\"numeric\":{\"value\":true,\"message\":\"This field must contain numeric value\"},\"min\":{\"value\":\"\",\"message\":\"Minimum value is \"},\"max\":{\"value\":\"\",\"message\":\"Maximum value is \"},\"digits\":{\"value\":\"\",\"message\":\"The number of digits has to be \"}},\"Date_of_Birth1\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"Relationship_to_Parent1\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"Source_of_Income_or_Employer_Name1\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"Income_for_3_months_prior_to_date_of_service1\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"Income_for_12_months_prior_to_date_of_service1\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"add_more1\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"Family_Member_s_Name2\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"Age2\":{\"required\":{\"value\":false,\"message\":\"This field is required\"},\"numeric\":{\"value\":true,\"message\":\"This field must contain numeric value\"},\"min\":{\"value\":\"\",\"message\":\"Minimum value is \"},\"max\":{\"value\":\"\",\"message\":\"Maximum value is \"},\"digits\":{\"value\":\"\",\"message\":\"The number of digits has to be \"}},\"Date_of_Birth2\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"Relationship_to_Parent2\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"Source_of_Income_or_Employer_Name2\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"Income_for_13_months_prior_to_date_of_service2\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"Income_for_14_months_prior_to_date_of_service2\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"add_more2\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"Family_Member_s_Name3\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"Age3\":{\"required\":{\"value\":false,\"message\":\"This field is required\"},\"numeric\":{\"value\":true,\"message\":\"This field must contain numeric value\"},\"min\":{\"value\":\"\",\"message\":\"Minimum value is \"},\"max\":{\"value\":\"\",\"message\":\"Maximum value is \"},\"digits\":{\"value\":\"\",\"message\":\"The number of digits has to be \"}},\"Date_of_Birth3\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"Relationship_to_Parent3\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"Source_of_Income_or_Employer_Name3\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"Income_for_15_months_prior_to_date_of_service3\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"Income_for_16_months_prior_to_date_of_service3\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"add_more3\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"Family_Member_s_Name4\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"Age4\":{\"required\":{\"value\":false,\"message\":\"This field is required\"},\"numeric\":{\"value\":true,\"message\":\"This field must contain numeric value\"},\"min\":{\"value\":\"\",\"message\":\"Minimum value is \"},\"max\":{\"value\":\"\",\"message\":\"Maximum value is \"},\"digits\":{\"value\":\"\",\"message\":\"The number of digits has 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file\"},\"allowed_file_types\":{\"value\":[\"pdf\",\"doc|ppt|pps|xls|mdb|docx|xlsx|pptx|odt|odp|ods|odg|odc|odb|odf|rtf|txt\"],\"message\":\"Invalid file type\"}},\"report__0_income\":{\"required\":{\"value\":false,\"message\":\"This field is required\"},\"max_file_size\":{\"value\":1048576,\"_valueFrom\":\"MB\",\"message\":\"Maximum file size limit is 1MB\"},\"max_file_count\":{\"value\":1,\"message\":\"You can upload maximum 1 file\"},\"allowed_file_types\":{\"value\":[\"pdf\",\"doc|ppt|pps|xls|mdb|docx|xlsx|pptx|odt|odp|ods|odg|odc|odb|odf|rtf|txt\"],\"message\":\"Invalid file type\"}},\"Monthly_Rent_Mortgage\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"Car_Payment\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"Insurance_premiums_\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"Clothing__Grocieries__Household_Goods\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"Utilities\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"Medical_Expenses\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"input_text_21\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"Checking_Account_\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"Business_Ownership\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"SSI_Disability_\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"Child_Support\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"Savings_Account_\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"Stocks_and_Bonds\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"Real_Estate__Excluding_Primary_Residence_\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"Applicant_s_Signature\":{\"required\":{\"value\":true,\"message\":\"This field is required\"}},\"Applicant_date\":{\"required\":{\"value\":true,\"message\":\"This field is required\"}},\"Spouse_s_Signature\":{\"required\":{\"value\":true,\"message\":\"This field is required\"}},\"Spouse_date\":{\"required\":{\"value\":true,\"message\":\"This field is required\"}},\"g-recaptcha-response\":[]},\"conditionals\":{\"file-upload\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"patient_have_medical_insurance\",\"value\":\"yes\",\"operator\":\"=\"},{\"field\":\"patient_an_active_Medicaid_recipient\",\"value\":\"yes\",\"operator\":\"=\"}]},\"ff_cn_id_8\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"add_more1\",\"value\":\"Add More\",\"operator\":\"=\"}]},\"Family_Member_s_Name2\":{\"conditions\":[],\"status\":false,\"type\":\"any\",\"container_condition\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"add_more1\",\"value\":\"Add 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