{"id":335,"date":"2018-02-07T14:38:36","date_gmt":"2018-02-07T19:38:36","guid":{"rendered":"https:\/\/sandbox0.foxtrotdev.com\/?page_id=335"},"modified":"2025-11-12T09:05:51","modified_gmt":"2025-11-12T14:05:51","slug":"prepare","status":"publish","type":"page","link":"https:\/\/sandbox0.foxtrotdev.com\/?page_id=335","title":{"rendered":"Prepare to Enroll"},"content":{"rendered":"<div class=\"wpb-content-wrapper\"><p>[vc_row disable_element=&#8221;yes&#8221;][vc_column][vc_column_text]<\/p>\n<h4>Learn about:<\/h4>\n<ul>\n<li><a href=\"https:\/\/sandbox0.foxtrotdev.com\/openseasonfaq\/\">Open Season<\/a><\/li>\n<li><a href=\"https:\/\/sandbox0.foxtrotdev.com\/prepare\/#eligibility\">Eligibility<\/a><\/li>\n<li><a href=\"https:\/\/sandbox0.foxtrotdev.com\/prepare\/#resources\">Resources<\/a><\/li>\n<li><a href=\"https:\/\/sandbox0.foxtrotdev.com\/prepare\/#enrollment\">Enrollment<\/a><\/li>\n<\/ul>\n<p>[\/vc_column_text][\/vc_column][\/vc_row][vc_row][vc_column width=&#8221;2\/3&#8243; css=&#8221;.vc_custom_1519074712913{padding-right: 40px !important;}&#8221;][vc_column_text css=&#8221;&#8221;]<\/p>\n<h3 id=\"eligibility\">First, Make Sure You\u2019re Eligible<\/h3>\n<p><strong>You are eligible to enroll in USFHP if you are 64 years of age or younger and:<\/strong><\/p>\n<ul>\n<li>It is <a href=\"https:\/\/sandbox0.foxtrotdev.com\/openseasonfaq\/\">Open Season<\/a><\/li>\n<li>You may be eligible to<strong> enroll outside of Open Season<\/strong> if you are currently enrolled in TRICARE Prime<sup>\u00ae <\/sup>or you have a Qualifying Life Event<\/li>\n<li>Live in an eligible zip code: As mandated by the Department of Defense, each of the six US Family Health Plans serves its own area of the country, defined by zip codes. To see if you live in an eligible zip code where we can provide you service as a member of the Johns Hopkins US Family Health Plan, use the zip code search tool.<\/li>\n<\/ul>\n<p>[\/vc_column_text]<div id=\"\" class=\"wpb_content_element wpfox_zipsearch format-default\"><div class=\"wpb_wrapper\"><form class=\"zipsearch-form\"><input type=\"text\" placeholder=\"Enter Zip Code\" name=\"zipcode\" \/><input type=\"hidden\" name=\"eligible_zips\" 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\/><input type=\"submit\" value=\"Submit\" \/><\/form><div class=\"message message-success\"><h4>Success! You reside within our service area!<\/h4>\n<p>Ready to enroll? <a target=\"_blank\" href=\"https:\/\/enroll.hopkinsusfhp.com\/online-enrollment-form\">Get started now<\/a>.<\/p><\/div><div class=\"message message-fail\"><h4>Sorry, your location is not eligible.<\/h4>\n<p>The ZIP code you entered is outside the Johns Hopkins US Family Health Plan service area. Planning a move or just exploring? <a href=\"\/request-a-call\/\">Request a Call<\/a> from a Field Service Representative to learn more.<\/p><\/div><\/div><\/div>[vc_column_text]<strong>And one of the following:<\/strong><\/p>\n<ul>\n<li>An active-duty family member<\/li>\n<li>A retired service member or family member*<\/li>\n<li>A family member of an Activated National Guard\/Reserve member<\/li>\n<li>A non-activated National Guard\/Reserve member or family member who qualifies for care under the Transitional Assistance Management Program<\/li>\n<li>A retired National Guard\/Reserve member (age 60 and receiving retired pay) or family member*<\/li>\n<li>A survivor<\/li>\n<li>A Medal of Honor recipient or family member<\/li>\n<li>A qualified former spouse<\/li>\n<\/ul>\n<p>[\/vc_column_text]<div id=\"\" class=\"wpb_content_element wpfox_footnote\"><div class=\"wpb_wrapper\"><div class=\"row\"><div class=\"columns col-text\"><small>*Retirees who were enrolled as of Sept. 30, 2012, and have remained enrolled, may continue to receive care through the US Family Health Plans beyond the age of 64. Beneficiaries who enrolled after Sept. 30, 2012 must transition to Tricare For Life when they reach age 65.<\/small><\/div><\/div><\/div><\/div>[\/vc_column][vc_column width=&#8221;1\/3&#8243; offset=&#8221;vc_hidden-xs&#8221;][vc_single_image image=&#8221;1359&#8243; img_size=&#8221;large&#8221;][\/vc_column][\/vc_row][vc_row][vc_column][vc_column_text el_id=&#8221;resources&#8221;]<\/p>\n<h3 id=\"resources\">Next, Review the Resources<\/h3>\n<p>[\/vc_column_text]<div id=\"\" class=\"wpb_content_element wpfox_reference_block\"><div class=\"wpb_wrapper\"><div class=\"elements\" style=\"\">[vc_column_text]<\/p>\n<h4>Benefits Overview<\/h4>\n<p>The US Family Health Plan offers all the TRICARE Prime benefits plus extras only available through Johns Hopkins. Active-duty family members pay no enrollment fees or out-of-pocket costs for any type of care received through the Johns Hopkins provider network.[\/vc_column_text]<div id=\"\" class=\"wpb_content_element wpfox_button_section\"><div class=\"wpb_wrapper\"><div class=\"buttons\" style=\"\"><div id=\"\" class=\"wpb_content_element wpfox_button_link\"><div class=\"wpb_wrapper\"><a class=\"button\" style=\"\" href=\"https:\/\/sandbox0.foxtrotdev.com\/plan\/benefits-costs\" target=\"\" rel=\"\">See Benefits<\/a><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div id=\"\" class=\"wpb_content_element wpfox_reference_block\"><div class=\"wpb_wrapper\"><div class=\"elements\" style=\"\">[vc_column_text]<\/p>\n<h4>Frequently Asked Questions<\/h4>\n<p>Still have questions about our plan? Here are the answers to some of the most frequently asked questions.[\/vc_column_text]<div id=\"\" class=\"wpb_content_element wpfox_button_section\"><div class=\"wpb_wrapper\"><div class=\"buttons\" style=\"\"><div id=\"\" class=\"wpb_content_element wpfox_button_link\"><div class=\"wpb_wrapper\"><a class=\"button\" style=\"\" href=\"https:\/\/sandbox0.foxtrotdev.com\/prepare\/faqs\/\" target=\"\" rel=\"\">Check the FAQs<\/a><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div id=\"\" class=\"wpb_content_element wpfox_reference_block\"><div class=\"wpb_wrapper\"><div class=\"elements\" style=\"\">[vc_column_text css=&#8221;&#8221;]<\/p>\n<h4>In-person and virtual Q&amp;A Sessions<\/h4>\n<p>Attend an information briefing, a 30-minute presentation offering a detailed plan review, enrollment instructions and a personal Q&amp;A session from a field service representative.[\/vc_column_text]<div id=\"\" class=\"wpb_content_element wpfox_button_section\"><div class=\"wpb_wrapper\"><div class=\"buttons\" style=\"\"><div id=\"\" class=\"wpb_content_element wpfox_button_link\"><div class=\"wpb_wrapper\"><a class=\"button\" style=\"\" href=\"https:\/\/sandbox0.foxtrotdev.com\/prepare\/attend-a-qa\/\" target=\"\" rel=\"\">Attend a Q&amp;A<\/a><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div id=\"\" class=\"wpb_content_element wpfox_reference_block\"><div class=\"wpb_wrapper\"><div class=\"elements\" style=\"\">[vc_column_text]<\/p>\n<h4>Find a Doctor<\/h4>\n<p>Use our provider search tool to find a doctor or facility near you.[\/vc_column_text]<div id=\"\" class=\"wpb_content_element wpfox_button_section\"><div class=\"wpb_wrapper\"><div class=\"buttons\" style=\"\"><div id=\"\" class=\"wpb_content_element wpfox_button_link\"><div class=\"wpb_wrapper\"><a class=\"button\" style=\"\" href=\"https:\/\/usfhp.healthtrioconnect.com\/public-app\/consumer\/provdir\/entry.page\" target=\"_blank\" rel=\"\">Find a Doctor or Facility<\/a><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div id=\"\" class=\"wpb_content_element wpfox_reference_block\"><div class=\"wpb_wrapper\"><div class=\"elements\" style=\"\">[vc_column_text]<\/p>\n<h4>Prescription Drug Benefits<\/h4>\n<p>We provide our members with full TRICARE Prime prescription drug benefits as mandated by the Department of Defense. Get the details about the prescription drug coverage and pharmacy benefits we offer.[\/vc_column_text]<div id=\"\" class=\"wpb_content_element wpfox_button_section\"><div class=\"wpb_wrapper\"><div class=\"buttons\" style=\"\"><div id=\"\" class=\"wpb_content_element wpfox_button_link\"><div class=\"wpb_wrapper\"><a class=\"button\" style=\"\" href=\"https:\/\/sandbox0.foxtrotdev.com\/plan\/benefits-costs\/pharmacies-medications\/\" target=\"\" rel=\"\">See the Rx Benefits<\/a><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div id=\"\" class=\"wpb_content_element wpfox_reference_block\"><div class=\"wpb_wrapper\"><div class=\"elements\" style=\"\">[vc_column_text]<\/p>\n<h4>Points to Consider<\/h4>\n<p>Why should you choose Johns Hopkins US Family Health Plan?[\/vc_column_text]<div id=\"\" class=\"wpb_content_element wpfox_button_section\"><div class=\"wpb_wrapper\"><div class=\"buttons\" style=\"\"><div id=\"\" class=\"wpb_content_element wpfox_button_link\"><div class=\"wpb_wrapper\"><a class=\"button\" style=\"\" href=\"\" target=\"_blank\" rel=\"\">Why Choose Johns Hopkins<\/a><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div id=\"\" class=\"wpb_content_element wpfox_reference_block\"><div class=\"wpb_wrapper\"><div class=\"elements\" style=\"\">[vc_column_text]<\/p>\n<h4>Open Season Frequently Asked Questions<\/h4>\n<p>Each fall, TRICARE will have an annual enrollment period called Open Season. This will be the time when eligible members select their TRICARE option\u2014including the US Family Health Plan\u2014for the following year.[\/vc_column_text]<div id=\"\" class=\"wpb_content_element wpfox_button_section\"><div class=\"wpb_wrapper\"><div class=\"buttons\" style=\"\"><div id=\"\" class=\"wpb_content_element wpfox_button_link\"><div class=\"wpb_wrapper\"><a class=\"button\" style=\"\" href=\"https:\/\/sandbox0.foxtrotdev.com\/openseasonfaq\/\" target=\"\" rel=\"\">Open Season FAQ<\/a><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div id=\"\" class=\"wpb_content_element wpfox_reference_block\"><div class=\"wpb_wrapper\"><div class=\"elements\" style=\"\">[vc_column_text]<\/p>\n<h4>Respecting\u00a0Your Privacy<\/h4>\n<p>Johns Hopkins US Family Health Plan follows a strict policy to protect the privacy and security rights of our members.[\/vc_column_text]<div id=\"\" class=\"wpb_content_element wpfox_button_section\"><div class=\"wpb_wrapper\"><div class=\"buttons\" style=\"\"><div id=\"\" class=\"wpb_content_element wpfox_button_link\"><div class=\"wpb_wrapper\"><a class=\"button\" style=\"\" href=\"https:\/\/sandbox0.foxtrotdev.com\/wp-content\/uploads\/2018\/03\/respecting-your-privacy.pdf\" target=\"_blank\" rel=\"\">Respecting Your Privacy<\/a><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div id=\"\" class=\"wpb_content_element wpfox_reference_block\"><div class=\"wpb_wrapper\"><div class=\"elements\" style=\"\">[vc_column_text]<\/p>\n<h4>Automatic Payment Form \u2013 Retirees &amp; Family<\/h4>\n<p>You can pay the enrollment fee\u00a0for Johns Hopkins USFHP by direct debit (automatic checking account withdrawal) or with a\u00a0credit card. Please indicate your desired method of payment and\u00a0submit the automatic payment\u00a0form with your enrollment application.[\/vc_column_text]<div id=\"\" class=\"wpb_content_element wpfox_button_section\"><div class=\"wpb_wrapper\"><div class=\"buttons\" style=\"\"><div id=\"\" class=\"wpb_content_element wpfox_button_link\"><div class=\"wpb_wrapper\"><a class=\"button\" style=\"\" href=\"https:\/\/sandbox0.foxtrotdev.com\/wp-content\/uploads\/2018\/02\/usfhp-automatic-payment-form.pdf\" target=\"_blank\" rel=\"\">Set Up Autopay<\/a><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div>[vc_row_inner][vc_column_inner][vc_column_text css=&#8221;&#8221;]<\/p>\n<h3 id=\"enrollment\">When You&#8217;re Ready:<\/h3>\n<p><a class=\"button blue\" href=\"https:\/\/enroll.hopkinsusfhp.com\/online-enrollment-form\"><strong>Enroll Online Now<\/strong><\/a><strong> \u00a0 \u00a0<\/strong><strong><a class=\"button blue\" href=\"\/enroll-now\/\">More Ways to Enroll<\/a><\/strong>[\/vc_column_text][\/vc_column_inner][\/vc_row_inner][\/vc_column][\/vc_row][vc_row gap=&#8221;35&#8243;][vc_column][vc_row_inner disable_element=&#8221;yes&#8221;][vc_column_inner][vc_column_text css=&#8221;&#8221;]<\/p>\n<h4 class=\"h-icon h-icon-arrow\">Online<\/h4>\n<p>You can also enroll using the <a href=\"https:\/\/milconnect.dmdc.osd.mil\/milconnect\/\" target=\"_blank\" rel=\"noopener noreferrer\">TRICARE Beneficiary Web Enrollment portal<\/a>.<\/p>\n<p>Sign into milConnect and choose <em>Beneficiary Web Enrollment (BWE)<\/em> from the Benefits menu.<\/p>\n<p>BWE auto-assigns a Primary Care Manager (PCM).\u00a0Update to your chosen PCM through <a href=\"\/members\/healthlink-faqs\/\">HealthLINK@Hopkins<\/a> or contacting the USFHP Enrollment Department.<\/p>\n<p><a class=\"button\" href=\"https:\/\/milconnect.dmdc.osd.mil\/milconnect\/\" target=\"_blank\" rel=\"noopener noreferrer\">Enroll Online<\/a>[\/vc_column_text][\/vc_column_inner][\/vc_row_inner][vc_row_inner disable_element=&#8221;yes&#8221; el_class=&#8221;gutters-80&#8243;][vc_column_inner width=&#8221;1\/2&#8243;][vc_column_text css=&#8221;&#8221;]<\/p>\n<h4 class=\"h-icon h-icon-phone\">Call<\/h4>\n<h4><a href=\"tel:8002315265\">800-231-5265<\/a><\/h4>\n<p><span style=\"color: #0073cf;\">Monday through Friday, 8:30 a.m. &#8211; 4:30 p.m.<\/span><\/p>\n<p>You will need:<\/p>\n<ul>\n<li>The sponsor\u2019s social security number<\/li>\n<li>The primary care manager (selected from our <a href=\"https:\/\/usfhp.healthtrioconnect.com\/public-app\/consumer\/provdir\/entry.page\" target=\"_blank\" rel=\"noopener noreferrer\">provider network<\/a>) of each person enrolling<\/li>\n<li>The payment method for the enrollment fee (military retirees and family members only)<\/li>\n<\/ul>\n<p>[\/vc_column_text][\/vc_column_inner][vc_column_inner width=&#8221;1\/2&#8243;][vc_column_text]<\/p>\n<h4 class=\"h-icon h-icon-email\">Mail or fax<\/h4>\n<p>Complete and print the following forms:<\/p>\n<ul>\n<li><a href=\"\/wp-content\/uploads\/2018\/02\/usfhp-enrollment-application.pdf\" target=\"_blank\" rel=\"noopener noreferrer\" download=\"\">Enrollment Application<\/a><\/li>\n<li><a href=\"https:\/\/sandbox0.foxtrotdev.com\/wp-content\/uploads\/2018\/02\/tricare-young-adult-application.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">TRICARE Young Adult Application<\/a><\/li>\n<li><a href=\"\/wp-content\/uploads\/2018\/02\/usfhp-automatic-payment-form.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Automatic Payment Form<\/a> (You only need to use this form if you are applying for coverage as a retiree or family member and choose monthly premium payment from a savings, checking, or credit card account.)<\/li>\n<\/ul>\n<p>And mail to:<\/p>\n<p style=\"color: #0073cf;\">Johns Hopkins US Family Health Plan<br \/>\nEnrollment Department<br \/>\nPO Box 8689<br \/>\nElkridge, MD 21075<\/p>\n<p>Or fax to: <span style=\"color: #0073cf;\"><a href=\"tel:4104244770\">410-424-4770<\/a><\/span><\/p>\n<p>To check the status of your application, please call Customer Service at <span style=\"color: #0073cf;\"><a href=\"tel:8008887347\">800-808-7347<\/a><\/span>.[\/vc_column_text][\/vc_column_inner][\/vc_row_inner][vc_row_inner][vc_column_inner][vc_separator css=&#8221;&#8221;][\/vc_column_inner][\/vc_row_inner][\/vc_column][\/vc_row][vc_row][vc_column width=&#8221;1\/3&#8243;][vc_single_image image=&#8221;11365&#8243; img_size=&#8221;large&#8221; alignment=&#8221;center&#8221; css=&#8221;&#8221;][vc_column_text css=&#8221;&#8221;]<span style=\"font-size: 9pt; color: #999999;\"><strong>Personally Provided Information<\/strong><br \/>\nBy filling out a form and providing Johns Hopkins USFHP with your information, you agree to allow us to use that information to provide you with material that you request. If you opt in to receive future communications from us, you may be contacted by phone, text or email using the details you provide. You can opt out at any time.<br \/>\n<\/span>[\/vc_column_text][\/vc_column][vc_column width=&#8221;2\/3&#8243;][vc_column_text css=&#8221;&#8221;]<\/p>\n<h4>Learn more about Johns Hopkins US Family Health Plan<\/h4>\n<p>Complete the form below to receive your Information Kit.[\/vc_column_text][vc_column_text css=&#8221;&#8221;]<script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_18' style='display:none'><form method='post' enctype='multipart\/form-data'  id='gform_18'  action='\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F335' data-formid='18' novalidate><input name=\"geolocation_submitter_location\" id=\"geolocation_submitter_location\" type=\"hidden\" data-js=\"geolocation_submitter_location\" value=\"\" \/>\n                        <div class='gform-body gform_body'><ul id='gform_fields_18' class='gform_fields top_label form_sublabel_above description_below validation_below'><li id=\"field_18_33\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_above gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_18_33'><span class='gform-field-label__text'>Comments<\/span><\/label><div class='ginput_container'><input name='input_33' id='input_18_33' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_18_33'>This field is for validation purposes and should be left unchanged.<\/div><\/li><li id=\"field_18_30\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full input-type-select input-paramname- field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_18_30'><span class='gform-field-label__text'>How would you like to receive your information packet?<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_30' id='input_18_30' class='large gfield_select'     aria-invalid=\"false\" ><option value='AD' >Mail<\/option><option value='ED' selected='selected'>Email<\/option><\/select><\/div><\/li><li id=\"field_18_1\" class=\"gfield gfield--type-text gfield--input-type-text col-6 input-type-text input-paramname- gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_18_1'><span class='gform-field-label__text'>First Name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_1' id='input_18_1' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_18_18\" class=\"gfield gfield--type-text gfield--input-type-text col-6 input-type-text input-paramname- gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_18_18'><span class='gform-field-label__text'>Last Name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_18' id='input_18_18' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_18_4\" class=\"gfield gfield--type-email gfield--input-type-email input-type-email input-paramname- gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_18_4'><span class='gform-field-label__text'>Email Address<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_4' id='input_18_4' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_18_22\" class=\"gfield gfield--type-text gfield--input-type-text input-type-text input-paramname- gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_18_22'><span class='gform-field-label__text'>Phone<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_18_22' type='text' value='' class='medium'    placeholder='(999) 999-9999' aria-required=\"true\" aria-invalid=\"false\"   data-mask=\"(999) 999-9999\"\/><\/div><\/li><li id=\"field_18_32\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full input-type-address input-paramname- gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"   data-js=\"geolocation-enabled\"><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Address<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_18_32' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_18_32_1_container' >\n                                        <label for='input_18_32_1' id='input_18_32_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                        <input type='text' name='input_32.1' id='input_18_32_1' value=''    aria-required='true'    \/>\n                                   <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_18_32_3_container' >\n                                    <label for='input_18_32_3' id='input_18_32_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                    <input type='text' name='input_32.3' id='input_18_32_3' value=''    aria-required='true'    \/>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_18_32_4_container' >\n                                        <label for='input_18_32_4' id='input_18_32_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                        <select name='input_32.4' id='input_18_32_4'     aria-required='true'    ><option value='' ><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' selected='selected'>Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_18_32_5_container' >\n                                    <label for='input_18_32_5' id='input_18_32_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label>\n                                    <input type='text' name='input_32.5' id='input_18_32_5' value=''    aria-required='true'    \/>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_32.6' id='input_18_32_6' value='US' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <input type='hidden' class='gform_hidden' name='input_32.geolocation_latitude' id='input_18_32_geolocation_latitude' value=''\/><input type='hidden' class='gform_hidden' name='input_32.geolocation_longitude' id='input_18_32_geolocation_longitude' value=''\/><\/div><\/li><li id=\"field_18_17\" class=\"gfield gfield--type-text gfield--input-type-text col-6 autocomplete-address input-type-text input-paramname- gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_18_17'><span class='gform-field-label__text'>Street Address<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_18_17' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_18_6\" class=\"gfield gfield--type-text gfield--input-type-text col-6 input-type-text input-paramname- gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_18_6'><span class='gform-field-label__text'>City<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_18_6' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_18_8\" class=\"gfield gfield--type-select gfield--input-type-select col-4 input-type-select input-paramname- gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_18_8'><span class='gform-field-label__text'>State<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_8' id='input_18_8' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select<\/option><option value='AL' >Alabama<\/option><option value='AK' >Alaska<\/option><option value='AZ' >Arizona<\/option><option value='AR' >Arkansas<\/option><option value='CA' >California<\/option><option value='CO' >Colorado<\/option><option value='CT' >Connecticut<\/option><option value='DC' >District of Columbia<\/option><option value='DE' >Delaware<\/option><option value='FL' >Florida<\/option><option value='GA' >Georgia<\/option><option value='HI' >Hawaii<\/option><option value='ID' >Idaho<\/option><option value='IL' >Illinois<\/option><option value='IN' >Indiana<\/option><option value='IA' >Iowa<\/option><option value='KS' >Kansas<\/option><option value='KY' >Kentucky<\/option><option value='LA' >Louisiana<\/option><option value='ME' >Maine<\/option><option value='MD' selected='selected'>Maryland<\/option><option value='MA' >Massachusetts<\/option><option value='MI' >Michigan<\/option><option value='MN' >Minnesota<\/option><option value='MS' >Mississippi<\/option><option value='MO' >Missouri<\/option><option value='MT' >Montana<\/option><option value='NE' >Nebraska<\/option><option value='NV' >Nevada<\/option><option value='NH' >New Hampshire<\/option><option value='NJ' >New Jersey<\/option><option value='NM' >New Mexico<\/option><option value='NY' >New York<\/option><option value='NC' >North Carolina<\/option><option value='ND' >North Dakota<\/option><option value='OH' >Ohio<\/option><option value='OK' >Oklahoma<\/option><option value='OR' >Oregon<\/option><option value='PA' >Pennsylvania<\/option><option value='RI' >Rhode Island<\/option><option value='SC' >South Carolina<\/option><option value='SD' >South Dakota<\/option><option value='TN' >Tennessee<\/option><option value='TX' >Texas<\/option><option value='UT' >Utah<\/option><option value='VT' >Vermont<\/option><option value='VA' >Virginia<\/option><option value='WA' >Washington<\/option><option value='WV' >West Virginia<\/option><option value='WI' >Wisconsin<\/option><option value='WY' >Wyoming<\/option><\/select><\/div><\/li><li id=\"field_18_7\" class=\"gfield gfield--type-text gfield--input-type-text col-3 input-type-text input-paramname- gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label 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