{"id":6664,"date":"2020-09-28T23:18:56","date_gmt":"2020-09-28T23:18:56","guid":{"rendered":"\/\/vcaaa.venturacounty.gov\/?page_id=6664"},"modified":"2024-12-04T12:51:56","modified_gmt":"2024-12-04T20:51:56","slug":"hicap-part-d-ma-comparison-form","status":"publish","type":"page","link":"https:\/\/vcaaa.venturacounty.gov\/es\/our-services\/medicare-help\/hicap-part-d-ma-comparison-form\/","title":{"rendered":"Formulario de comparaci\u00f3n de HICAP Parte D\/Medicare Advantage"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"6664\" class=\"elementor elementor-6664\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-65dc3ab3 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"65dc3ab3\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;jet_parallax_layout_list&quot;:[]}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-6b1eff7b\" data-id=\"6b1eff7b\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-6a2fc157 elementor-widget elementor-widget-shortcode\" data-id=\"6a2fc157\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\"><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 gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_9' style='display:none'><div id='gf_9' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_9' id='gform_9'  action='\/es\/wp-json\/wp\/v2\/pages\/6664#gf_9' data-formid='9' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_9' class='gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_9_1\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_9_1'>\n                            \n                            <span id='input_9_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_9_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_9_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            <span id='input_9_1_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.4' id='input_9_1_4' value=''   aria-required='false'     \/>\n                                                    <label for='input_9_1_4' class='gform-field-label gform-field-label--type-sub '>M.I.<\/label>\n                                                <\/span>\n                            <span id='input_9_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_9_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_9_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_9_2\" class=\"gfield gfield--type-address gfield--input-type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_9_2' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_9_2_1_container' >\n                                        <input type='text' name='input_2.1' id='input_9_2_1' value=''    aria-required='true'    \/>\n                                        <label for='input_9_2_1' id='input_9_2_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_9_2_2_container' >\n                                        <input type='text' name='input_2.2' id='input_9_2_2' value=''     aria-required='false'   \/>\n                                        <label for='input_9_2_2' id='input_9_2_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_9_2_3_container' >\n                                    <input type='text' name='input_2.3' id='input_9_2_3' value=''    aria-required='true'    \/>\n                                    <label for='input_9_2_3' id='input_9_2_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_9_2_4_container' >\n                                        <select name='input_2.4' id='input_9_2_4'     aria-required='true'    ><option value='' selected='selected'><\/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' >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                                        <label for='input_9_2_4' id='input_9_2_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_9_2_5_container' >\n                                    <input type='text' name='input_2.5' id='input_9_2_5' value=''    aria-required='true'    \/>\n                                    <label for='input_9_2_5' id='input_9_2_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_2.6' id='input_9_2_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><fieldset id=\"field_9_15\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Mailing address different from above?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_15'>\n\t\t\t<div class='gchoice gchoice_9_15_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='No'  id='choice_9_15_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_15_0' id='label_9_15_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_15_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='Yes'  id='choice_9_15_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_15_1' id='label_9_15_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_4\" class=\"gfield gfield--type-address gfield--input-type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Mailing Address<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_9_4' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_9_4_1_container' >\n                                        <input type='text' name='input_4.1' id='input_9_4_1' value=''    aria-required='false'    \/>\n                                        <label for='input_9_4_1' id='input_9_4_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_9_4_2_container' >\n                                        <input type='text' name='input_4.2' id='input_9_4_2' value=''     aria-required='false'   \/>\n                                        <label for='input_9_4_2' id='input_9_4_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_9_4_3_container' >\n                                    <input type='text' name='input_4.3' id='input_9_4_3' value=''    aria-required='false'    \/>\n                                    <label for='input_9_4_3' id='input_9_4_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_9_4_4_container' >\n                                        <select name='input_4.4' id='input_9_4_4'     aria-required='false'    ><option value='' selected='selected'><\/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' >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                                        <label for='input_9_4_4' id='input_9_4_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_9_4_5_container' >\n                                    <input type='text' name='input_4.5' id='input_9_4_5' value=''    aria-required='false'    \/>\n                                    <label for='input_9_4_5' id='input_9_4_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_4.6' id='input_9_4_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_9_5\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gf_left_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_5'>Birthdate<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_5' id='input_9_5' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_9_5_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_9_5_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_9_5' class='gform_hidden' value='https:\/\/vcaaa.venturacounty.gov\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_9_6\" class=\"gfield gfield--type-phone gfield--input-type-phone gf_middle_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_6'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_6' id='input_9_6' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_9_7\" class=\"gfield gfield--type-email gfield--input-type-email gf_right_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_7'>Email<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_7' id='input_9_7' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_9_8\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Preferred method of contact for appointment:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_8'>\n\t\t\t<div class='gchoice gchoice_9_8_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='Email'  id='choice_9_8_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_8_0' id='label_9_8_0' class='gform-field-label gform-field-label--type-inline'>Email<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_8_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='Telephone'  id='choice_9_8_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_8_1' id='label_9_8_1' class='gform-field-label gform-field-label--type-inline'>Telephone<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_8_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='Online zoom'  id='choice_9_8_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_8_2' id='label_9_8_2' class='gform-field-label gform-field-label--type-inline'>Online zoom<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_8_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='In person'  id='choice_9_8_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_8_3' id='label_9_8_3' class='gform-field-label gform-field-label--type-inline'>In person<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_54\" class=\"gfield gfield--type-time gfield--input-type-time gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >What is the best time to reach you?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class=\"ginput_container ginput_complex gform-grid-row\">\n                        <div class='gfield_time_hour ginput_container ginput_container_time gform-grid-col' id='input_9_54'>\n                            <input type='number' name='input_54[]' id='input_9_54_1' value=''  min='0' max='12' step='1'  placeholder='HH' aria-required='true'   \/> \n                            <label class='gform-field-label gform-field-label--type-sub hour_label screen-reader-text' for='input_9_54_1'>Hours<\/label>\n                        <\/div>\n                        <div class=\"below hour_minute_colon gform-grid-col\">:<\/div>\n                        <div class='gfield_time_minute ginput_container ginput_container_time gform-grid-col'>\n                            <input type='number' name='input_54[]' id='input_9_54_2' value=''  min='0' max='59' step='1'  placeholder='MM' aria-required='true'  \/>\n                            <label class='gform-field-label gform-field-label--type-sub minute_label screen-reader-text' for='input_9_54_2'>Minutes<\/label>\n                        <\/div>\n                        <div class='gfield_time_ampm ginput_container ginput_container_time below gform-grid-col' >\n                                \n                                <select name='input_54[]' id='input_9_54_3'  >\n                                    <option value='am' >AM<\/option>\n                                    <option value='pm' >PM<\/option>\n                                <\/select> \n                                <label class='gform-field-label gform-field-label--type-sub am_pm_label screen-reader-text' for='input_9_54_3'>AM\/PM<\/label>                                \n                           <\/div>\n                    <\/div><\/fieldset><fieldset id=\"field_9_10\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_3col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Preferred language?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_10'>\n\t\t\t<div class='gchoice gchoice_9_10_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='English'  id='choice_9_10_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_10_0' id='label_9_10_0' class='gform-field-label gform-field-label--type-inline'>English<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_10_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='Spanish'  id='choice_9_10_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_10_1' id='label_9_10_1' class='gform-field-label gform-field-label--type-inline'>Spanish<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_10_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='Other'  id='choice_9_10_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_10_2' id='label_9_10_2' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_9_55\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_55'>Please specify<\/label><div class='ginput_container ginput_container_text'><input name='input_55' id='input_9_55' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_9_13\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">SOCIAL HISTORY<\/h3><\/div><fieldset id=\"field_9_14\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_3col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Marital Status:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_14'>\n\t\t\t<div class='gchoice gchoice_9_14_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='Married'  id='choice_9_14_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_14_0' id='label_9_14_0' class='gform-field-label gform-field-label--type-inline'>Married<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_14_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='Separated'  id='choice_9_14_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_14_1' id='label_9_14_1' class='gform-field-label gform-field-label--type-inline'>Separated<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_14_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='Domestic Partner'  id='choice_9_14_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_14_2' id='label_9_14_2' class='gform-field-label gform-field-label--type-inline'>Domestic Partner<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_14_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='Never Married'  id='choice_9_14_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_14_3' id='label_9_14_3' class='gform-field-label gform-field-label--type-inline'>Never Married<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_14_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='Divorced'  id='choice_9_14_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_14_4' id='label_9_14_4' class='gform-field-label gform-field-label--type-inline'>Divorced<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_14_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='Widowed'  id='choice_9_14_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_14_5' id='label_9_14_5' class='gform-field-label gform-field-label--type-inline'>Widowed<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_14_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='Decline to state'  id='choice_9_14_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_14_6' id='label_9_14_6' class='gform-field-label gform-field-label--type-inline'>Decline to state<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_17\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Race<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_17'>\n\t\t\t<div class='gchoice gchoice_9_17_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='African American \/ Black'  id='choice_9_17_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_17_0' id='label_9_17_0' class='gform-field-label gform-field-label--type-inline'>African American \/ Black<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_17_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='American Indian \/ Alaskan Indian'  id='choice_9_17_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_17_1' id='label_9_17_1' class='gform-field-label gform-field-label--type-inline'>American Indian \/ Alaskan Indian<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_17_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='Caucasian \/ White (Not Hispanic)'  id='choice_9_17_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_17_2' id='label_9_17_2' class='gform-field-label gform-field-label--type-inline'>Caucasian \/ White (Not Hispanic)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_17_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='Asian Indian'  id='choice_9_17_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_17_3' id='label_9_17_3' class='gform-field-label gform-field-label--type-inline'>Asian Indian<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_17_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='Cambodian'  id='choice_9_17_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_17_4' id='label_9_17_4' class='gform-field-label gform-field-label--type-inline'>Cambodian<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_17_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='Chinese'  id='choice_9_17_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_17_5' id='label_9_17_5' class='gform-field-label gform-field-label--type-inline'>Chinese<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_17_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='Filipino'  id='choice_9_17_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_17_6' id='label_9_17_6' class='gform-field-label gform-field-label--type-inline'>Filipino<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_17_7'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='Guamanian'  id='choice_9_17_7' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_17_7' id='label_9_17_7' class='gform-field-label gform-field-label--type-inline'>Guamanian<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_17_8'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='Hawaiian'  id='choice_9_17_8' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_17_8' id='label_9_17_8' class='gform-field-label gform-field-label--type-inline'>Hawaiian<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_17_9'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='Japanese'  id='choice_9_17_9' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_17_9' id='label_9_17_9' class='gform-field-label gform-field-label--type-inline'>Japanese<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_17_10'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='Laotian'  id='choice_9_17_10' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_17_10' id='label_9_17_10' class='gform-field-label gform-field-label--type-inline'>Laotian<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_17_11'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='Samoan'  id='choice_9_17_11' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_17_11' id='label_9_17_11' class='gform-field-label gform-field-label--type-inline'>Samoan<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_17_12'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='Vietnamese'  id='choice_9_17_12' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_17_12' id='label_9_17_12' class='gform-field-label gform-field-label--type-inline'>Vietnamese<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_17_13'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='Not Collected'  id='choice_9_17_13' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_17_13' id='label_9_17_13' class='gform-field-label gform-field-label--type-inline'>Not Collected<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_17_14'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='Decline to state'  id='choice_9_17_14' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_17_14' id='label_9_17_14' class='gform-field-label gform-field-label--type-inline'>Decline to state<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_17_15'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='Two or More Races'  id='choice_9_17_15' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_17_15' id='label_9_17_15' class='gform-field-label gform-field-label--type-inline'>Two or More Races<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_17_16'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='Other'  id='choice_9_17_16' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_17_16' id='label_9_17_16' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_17_17'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='gf_other_choice'  id='choice_9_17_17' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_17_17' id='label_9_17_17' class='gform-field-label gform-field-label--type-inline'>Other<\/label><br \/><input id='input_9_17_other' class='gchoice_other_control' name='input_17_other' type='text' value='Other' aria-label='Other Choice, please specify'  disabled='disabled' \/>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_18\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_3col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Ethnicity<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_18'>\n\t\t\t<div class='gchoice gchoice_9_18_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='Hispanic \/ Latino'  id='choice_9_18_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_18_0' id='label_9_18_0' class='gform-field-label gform-field-label--type-inline'>Hispanic \/ Latino<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_18_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='Not Hispanic \/ Latino'  id='choice_9_18_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_18_1' id='label_9_18_1' class='gform-field-label gform-field-label--type-inline'>Not Hispanic \/ Latino<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_18_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='Not Collected'  id='choice_9_18_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_18_2' id='label_9_18_2' class='gform-field-label gform-field-label--type-inline'>Not Collected<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_18_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='Decline to state'  id='choice_9_18_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_18_3' id='label_9_18_3' class='gform-field-label gform-field-label--type-inline'>Decline to state<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_9_19\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">THE GAY BISEXUAL AND TRANSGENDER DISPARITIES REDUCTION ACT OF 2016 (AB 959)<\/h3><\/div><fieldset id=\"field_9_20\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >What is your gender?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_20'>\n\t\t\t<div class='gchoice gchoice_9_20_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='Male'  id='choice_9_20_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_20_0' id='label_9_20_0' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_20_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='Female'  id='choice_9_20_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_20_1' id='label_9_20_1' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_20_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='Transgender Female to Male'  id='choice_9_20_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_20_2' id='label_9_20_2' class='gform-field-label gform-field-label--type-inline'>Transgender Female to Male<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_20_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='Transgender Male to Female'  id='choice_9_20_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_20_3' id='label_9_20_3' class='gform-field-label gform-field-label--type-inline'>Transgender Male to Female<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_20_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='Genderqueer \/ Non-binary'  id='choice_9_20_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_20_4' id='label_9_20_4' class='gform-field-label gform-field-label--type-inline'>Genderqueer \/ Non-binary<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_20_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='Decline to state'  id='choice_9_20_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_20_5' id='label_9_20_5' class='gform-field-label gform-field-label--type-inline'>Decline to state<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_20_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='Missing \/ Not Collected'  id='choice_9_20_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_20_6' id='label_9_20_6' class='gform-field-label gform-field-label--type-inline'>Missing \/ Not Collected<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_20_7'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='Not listed, please specify'  id='choice_9_20_7' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_20_7' id='label_9_20_7' class='gform-field-label gform-field-label--type-inline'>Not listed, please specify<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_9_21\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_21'>Specify<\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_9_21' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_9_22\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >What was your sex at birth?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_22'>\n\t\t\t<div class='gchoice gchoice_9_22_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='Male'  id='choice_9_22_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_22_0' id='label_9_22_0' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_22_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='Female'  id='choice_9_22_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_22_1' id='label_9_22_1' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_22_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='Decline to state'  id='choice_9_22_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_22_2' id='label_9_22_2' class='gform-field-label gform-field-label--type-inline'>Decline to state<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_22_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='Missing \/ Not Collected'  id='choice_9_22_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_22_3' id='label_9_22_3' class='gform-field-label gform-field-label--type-inline'>Missing \/ Not Collected<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_23\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >How do you describe your sexual orientation or sexual identity?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_23'>\n\t\t\t<div class='gchoice gchoice_9_23_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='Straight \/ Heterosexual'  id='choice_9_23_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_23_0' id='label_9_23_0' class='gform-field-label gform-field-label--type-inline'>Straight \/ Heterosexual<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_23_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='Bisexual'  id='choice_9_23_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_23_1' id='label_9_23_1' class='gform-field-label gform-field-label--type-inline'>Bisexual<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_23_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='Gay \/ Lesbian'  id='choice_9_23_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_23_2' id='label_9_23_2' class='gform-field-label gform-field-label--type-inline'>Gay \/ Lesbian<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_23_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='Questioning \/ Unsure'  id='choice_9_23_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_23_3' id='label_9_23_3' class='gform-field-label gform-field-label--type-inline'>Questioning \/ Unsure<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_23_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='Decline to state'  id='choice_9_23_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_23_4' id='label_9_23_4' class='gform-field-label gform-field-label--type-inline'>Decline to state<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_23_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='Missing \/ Not Collected'  id='choice_9_23_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_23_5' id='label_9_23_5' class='gform-field-label gform-field-label--type-inline'>Missing \/ Not Collected<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_23_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='Not listed, please specify'  id='choice_9_23_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_23_6' id='label_9_23_6' class='gform-field-label gform-field-label--type-inline'>Not listed, please specify<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_9_24\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_24'>Specify<\/label><div class='ginput_container ginput_container_text'><input name='input_24' id='input_9_24' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_9_67\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">MILITARY SERVICE<\/h3><\/div><fieldset id=\"field_9_31\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_2col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you ever served in the United States military?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_31'>\n\t\t\t<div class='gchoice gchoice_9_31_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='No'  id='choice_9_31_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_31_0' id='label_9_31_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_31_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='Yes'  id='choice_9_31_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_31_1' id='label_9_31_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_59\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_2col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are you the spouse, legal partner, parent, or child of a person who is serving, or who has served, in the United States military?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_59'>\n\t\t\t<div class='gchoice gchoice_9_59_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_59' type='radio' value='No'  id='choice_9_59_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_59_0' id='label_9_59_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_59_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_59' type='radio' value='Yes'  id='choice_9_59_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_59_1' id='label_9_59_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_60\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_2col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >If you answered yes to either of the last two questions, do you consent to this agency and the California Department of Aging transmitting your name, email address, mailing address, and telephone number(s) to the Department of Veterans Affairs only for the purpose of receiving additional information on veterans benefits for which you may be eligible? I understand that this consent is valid for 12 months from the date of signature.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_60'>\n\t\t\t<div class='gchoice gchoice_9_60_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='No'  id='choice_9_60_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_60_0' id='label_9_60_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_60_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='Yes'  id='choice_9_60_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_60_1' id='label_9_60_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_60_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='N\/A'  id='choice_9_60_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_60_2' id='label_9_60_2' class='gform-field-label gform-field-label--type-inline'>N\/A<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_9_66\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Contact the California Department of Veterans Affairs (CalVet) to determine eligibility for services and supports at www.calvet.ca.gov or (800) 952-5626. You can also contact the Ventura County Veteran Services office at (805) 477-5155 for more information.<\/div><div id=\"field_9_25\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">PLEASE LOOK AT YOUR PRESCRIPTION DRUG CARD \/ HEALTH PLAN CARD AND LOOK FOR PDP OR HMO<\/h3><\/div><fieldset id=\"field_9_26\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_2col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you have Medicare Part A?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_26'>\n\t\t\t<div class='gchoice gchoice_9_26_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='No'  id='choice_9_26_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_26_0' id='label_9_26_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_26_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='Yes'  id='choice_9_26_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_26_1' id='label_9_26_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_9_73\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_73'>If yes, enter effective date:<\/label><div class='ginput_container ginput_container_text'><input name='input_73' id='input_9_73' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_9_72\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_2col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you have Medicare Part B?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_72'>\n\t\t\t<div class='gchoice gchoice_9_72_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='No'  id='choice_9_72_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_72_0' id='label_9_72_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_72_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='Yes'  id='choice_9_72_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_72_1' id='label_9_72_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_9_74\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_74'>If yes, enter effective date:<\/label><div class='ginput_container ginput_container_text'><input name='input_74' id='input_9_74' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_9_71\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_2col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you have a Medicare Stand Alone Part D Plan (PDP)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_71'>\n\t\t\t<div class='gchoice gchoice_9_71_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_71' type='radio' value='No'  id='choice_9_71_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_71_0' id='label_9_71_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_71_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_71' type='radio' value='Yes'  id='choice_9_71_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_71_1' id='label_9_71_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_9_27\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_27'>Please specify name of plan<\/label><div class='ginput_container ginput_container_text'><input name='input_27' id='input_9_27' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_9_29\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you have an HMO Medicare Advantage (Plan C)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_29'>\n\t\t\t<div class='gchoice gchoice_9_29_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='No'  id='choice_9_29_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_29_0' id='label_9_29_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_29_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='Yes'  id='choice_9_29_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_29_1' id='label_9_29_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_9_28\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_28'>Please specify name of plan<\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_9_28' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_9_30\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_2col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you receive prescription drug coverage from a retiree, union or employer plan?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_30'>\n\t\t\t<div class='gchoice gchoice_9_30_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='No'  id='choice_9_30_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_30_0' id='label_9_30_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_30_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Yes'  id='choice_9_30_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_30_1' id='label_9_30_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_9_50\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_50'>Specify preferred pharmacy<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_50' id='input_9_50' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_9_32\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">YOU MAY BE ELIGIBLE TO SAVE ON PRESCRIPTION DRUG COSTS &amp; QUALIFY FOR OTHER PROGRAMS<\/h3><\/div><fieldset id=\"field_9_56\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_2col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are you on Medi-Cal?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_56'>\n\t\t\t<div class='gchoice gchoice_9_56_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_56' type='radio' value='No'  id='choice_9_56_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_56_0' id='label_9_56_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_56_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_56' type='radio' value='Yes'  id='choice_9_56_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_56_1' id='label_9_56_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_9_57\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_57'>What is your share-of-cost (SOC) amount?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_57' id='input_9_57' type='text' value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_9_58\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_2col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Interested in applying?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_58'>\n\t\t\t<div class='gchoice gchoice_9_58_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_58' type='radio' value='No'  id='choice_9_58_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_58_0' id='label_9_58_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_58_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_58' type='radio' value='Yes'  id='choice_9_58_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_58_1' id='label_9_58_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_33\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_2col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are your ASSETS (bank and IRA accounts) LESS than $130,000 if single or $195,000 if married?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_33'>\n\t\t\t<div class='gchoice gchoice_9_33_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='No'  id='choice_9_33_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_33_0' id='label_9_33_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_33_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='Yes'  id='choice_9_33_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_33_1' id='label_9_33_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_34\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_2col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Is your MONTHLY GROSS INCOME LESS than $1,762 if single or $2,381 if married?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_34'>\n\t\t\t<div class='gchoice gchoice_9_34_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='No'  id='choice_9_34_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_34_0' id='label_9_34_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_34_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='Yes'  id='choice_9_34_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_34_1' id='label_9_34_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_9_38\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">PRESCRIPTION DRUGS<\/h3><\/div><div id=\"field_9_44\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >The information you provide will inform our comparison. <strong>TIP:<\/strong> Pull out your medication bottles and transcribe the full name of the drug(s) into the field(s) below.<\/div><fieldset id=\"field_9_42\" class=\"gfield gfield--type-list gfield--input-type-list gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Please list the specifics for each of your prescription drugs. Click on the + sign at the end to add more fields if necessary.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Name of Drug<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Dosage (how many mg)<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">How Often (# per day\/week\/mo)<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Brand Name Required? (Y\/N)<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_42_cell1 gform-grid-col' data-label='Name of Drug'><input aria-invalid='false' aria-required=\"true\"  aria-label='Name of Drug, Row 1' data-aria-label-template='Name of Drug, Row {0}' type='text' name='input_42[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_42_cell2 gform-grid-col' data-label='Dosage (how many mg)'><input aria-invalid='false' aria-required=\"true\"  aria-label='Dosage (how many mg), Row 1' data-aria-label-template='Dosage (how many mg), Row {0}' type='text' name='input_42[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_42_cell3 gform-grid-col' data-label='How Often (# per day\/week\/mo)'><input aria-invalid='false' aria-required=\"true\"  aria-label='How Often (# per day\/week\/mo), Row 1' data-aria-label-template='How Often (# per day\/week\/mo), Row {0}' type='text' name='input_42[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_42_cell4 gform-grid-col' data-label='Brand Name Required? (Y\/N)'><input aria-invalid='false' aria-required=\"true\"  aria-label='Brand Name Required? (Y\/N), Row 1' data-aria-label-template='Brand Name Required? (Y\/N), Row {0}' type='text' name='input_42[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type='button'  class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 0)'>Add<\/button>   <button type='button'  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_75\" class=\"gfield gfield--type-list gfield--input-type-list gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Please list name of drug \/ Dosage (how many mg) \/ How often (#per day\/week\/mo\/yr)<\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Name of Drug<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Dosage (how many mg)<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">How Often (# per day\/week\/mo)<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Brand Name Required? (Y\/N)<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_75_cell1 gform-grid-col' data-label='Name of Drug'><input aria-invalid='false'   aria-label='Name of Drug, Row 1' data-aria-label-template='Name of Drug, Row {0}' type='text' name='input_75[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_75_cell2 gform-grid-col' data-label='Dosage (how many mg)'><input aria-invalid='false'   aria-label='Dosage (how many mg), Row 1' data-aria-label-template='Dosage (how many mg), Row {0}' type='text' name='input_75[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_75_cell3 gform-grid-col' data-label='How Often (# per day\/week\/mo)'><input aria-invalid='false'   aria-label='How Often (# per day\/week\/mo), Row 1' data-aria-label-template='How Often (# per day\/week\/mo), Row {0}' type='text' name='input_75[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_75_cell4 gform-grid-col' data-label='Brand Name Required? (Y\/N)'><input aria-invalid='false'   aria-label='Brand Name Required? (Y\/N), Row 1' data-aria-label-template='Brand Name Required? (Y\/N), Row {0}' type='text' name='input_75[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type='button'  class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 0)'>Add<\/button>   <button type='button'  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_78\" class=\"gfield gfield--type-list gfield--input-type-list gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Please list name of drug \/ Dosage (how many mg) \/ How often (#per day\/week\/mo\/yr)<\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Name of Drug<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Dosage (how many mg)<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">How Often (# per day\/week\/mo)<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Brand Name Required? (Y\/N)<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_78_cell1 gform-grid-col' data-label='Name of Drug'><input aria-invalid='false'   aria-label='Name of Drug, Row 1' data-aria-label-template='Name of Drug, Row {0}' type='text' name='input_78[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_78_cell2 gform-grid-col' data-label='Dosage (how many mg)'><input aria-invalid='false'   aria-label='Dosage (how many mg), Row 1' data-aria-label-template='Dosage (how many mg), Row {0}' type='text' name='input_78[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_78_cell3 gform-grid-col' data-label='How Often (# per day\/week\/mo)'><input aria-invalid='false'   aria-label='How Often (# per day\/week\/mo), Row 1' data-aria-label-template='How Often (# per day\/week\/mo), Row {0}' type='text' name='input_78[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_78_cell4 gform-grid-col' data-label='Brand Name Required? (Y\/N)'><input aria-invalid='false'   aria-label='Brand Name Required? (Y\/N), Row 1' data-aria-label-template='Brand Name Required? (Y\/N), Row {0}' type='text' name='input_78[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type='button'  class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 0)'>Add<\/button>   <button type='button'  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_77\" class=\"gfield gfield--type-list gfield--input-type-list gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Please list name of drug \/ Dosage (how many mg) \/ How often (#per day\/week\/mo\/yr)<\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Name of Drug<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Dosage (how many mg)<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">How Often (# per day\/week\/mo)<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Brand Name Required? (Y\/N)<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_77_cell1 gform-grid-col' data-label='Name of Drug'><input aria-invalid='false'   aria-label='Name of Drug, Row 1' data-aria-label-template='Name of Drug, Row {0}' type='text' name='input_77[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_77_cell2 gform-grid-col' data-label='Dosage (how many mg)'><input aria-invalid='false'   aria-label='Dosage (how many mg), Row 1' data-aria-label-template='Dosage (how many mg), Row {0}' type='text' name='input_77[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_77_cell3 gform-grid-col' data-label='How Often (# per day\/week\/mo)'><input aria-invalid='false'   aria-label='How Often (# per day\/week\/mo), Row 1' data-aria-label-template='How Often (# per day\/week\/mo), Row {0}' type='text' name='input_77[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_77_cell4 gform-grid-col' data-label='Brand Name Required? (Y\/N)'><input aria-invalid='false'   aria-label='Brand Name Required? (Y\/N), Row 1' data-aria-label-template='Brand Name Required? (Y\/N), Row {0}' type='text' name='input_77[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type='button'  class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 0)'>Add<\/button>   <button type='button'  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_76\" class=\"gfield gfield--type-list gfield--input-type-list gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Please list name of drug \/ Dosage (how many mg) \/ How often (#per day\/week\/mo\/yr)<\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Name of Drug<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Dosage (how many mg)<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">How Often (# per day\/week\/mo)<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Brand Name Required? (Y\/N)<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_76_cell1 gform-grid-col' data-label='Name of Drug'><input aria-invalid='false'   aria-label='Name of Drug, Row 1' data-aria-label-template='Name of Drug, Row {0}' type='text' name='input_76[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_76_cell2 gform-grid-col' data-label='Dosage (how many mg)'><input aria-invalid='false'   aria-label='Dosage (how many mg), Row 1' data-aria-label-template='Dosage (how many mg), Row {0}' type='text' name='input_76[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_76_cell3 gform-grid-col' data-label='How Often (# per day\/week\/mo)'><input aria-invalid='false'   aria-label='How Often (# per day\/week\/mo), Row 1' data-aria-label-template='How Often (# per day\/week\/mo), Row {0}' type='text' name='input_76[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_76_cell4 gform-grid-col' data-label='Brand Name Required? (Y\/N)'><input aria-invalid='false'   aria-label='Brand Name Required? (Y\/N), Row 1' data-aria-label-template='Brand Name Required? (Y\/N), Row {0}' type='text' name='input_76[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type='button'  class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 0)'>Add<\/button>   <button type='button'  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><div id=\"field_9_64\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">ADDITIONAL INFORMATION<\/h3><\/div><fieldset id=\"field_9_52\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gf_list_3col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >How did you hear about us?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_9_52'><div class='gchoice gchoice_9_52_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.1' type='checkbox'  value='Another Agency (SSA, Medi-Cal, etc.)'  id='choice_9_52_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_52_1' id='label_9_52_1' class='gform-field-label gform-field-label--type-inline'>Another Agency (SSA, Medi-Cal, etc.)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_52_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.2' type='checkbox'  value='Aging into Medicare Booklet'  id='choice_9_52_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_52_2' id='label_9_52_2' class='gform-field-label gform-field-label--type-inline'>Aging into Medicare Booklet<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_52_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.3' type='checkbox'  value='California Department on Aging'  id='choice_9_52_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_52_3' id='label_9_52_3' class='gform-field-label gform-field-label--type-inline'>California Department on Aging<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_52_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.4' type='checkbox'  value='California Health Advocates'  id='choice_9_52_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_52_4' id='label_9_52_4' class='gform-field-label gform-field-label--type-inline'>California Health Advocates<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_52_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.5' type='checkbox'  value='Centers for Medicaid and Medicare Services'  id='choice_9_52_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_52_5' id='label_9_52_5' class='gform-field-label gform-field-label--type-inline'>Centers for Medicaid and Medicare Services<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_52_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.6' type='checkbox'  value='Friend\/Relative'  id='choice_9_52_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_52_6' id='label_9_52_6' class='gform-field-label gform-field-label--type-inline'>Friend\/Relative<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_52_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.7' type='checkbox'  value='Info-Van'  id='choice_9_52_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_52_7' id='label_9_52_7' class='gform-field-label gform-field-label--type-inline'>Info-Van<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_52_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.8' type='checkbox'  value='Internet'  id='choice_9_52_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_52_8' id='label_9_52_8' class='gform-field-label gform-field-label--type-inline'>Internet<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_52_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.9' type='checkbox'  value='Mailing'  id='choice_9_52_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_52_9' id='label_9_52_9' class='gform-field-label gform-field-label--type-inline'>Mailing<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_52_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.11' type='checkbox'  value='Media'  id='choice_9_52_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_52_11' id='label_9_52_11' class='gform-field-label gform-field-label--type-inline'>Media<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_52_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.12' type='checkbox'  value='Outreach Event by HICAP'  id='choice_9_52_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_52_12' id='label_9_52_12' class='gform-field-label gform-field-label--type-inline'>Outreach Event by HICAP<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_52_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.13' type='checkbox'  value='Other'  id='choice_9_52_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_52_13' id='label_9_52_13' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_9_53\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_53'>Please specify:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_53' id='input_9_53' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_9_65\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_65'>Please indicate the reason why you are requesting an appointment with a HICAP counselor.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_65' id='input_9_65' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_9_45\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">DISCLOSURE STATEMENT<\/h3><\/div><div id=\"field_9_46\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >HICAP counseling services are provided by trained counselors, registered by the California Department of Aging, who are acting in good faith to provide independent, impartial information about health insurance policies and benefits to clients. Counselors do not sell any type of health care coverage. They do not endorse or recommend any specific plan or policy. Information presented by HICAP volunteers should not be construed to be legal advice, and volunteers are not liable for acts and omissions in providing counseling to recipients of service. <i> Welfare and Institutions Code, Section 9541 (1)(4)<\/div><div id=\"field_9_48\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_48'>By entering your name and date below, you acknowledge that you have read and understand this disclosure.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_48' id='input_9_48' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_9_49\" class=\"gfield 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id='gforms_calendar_icon_input_9_49' class='gform_hidden' value='https:\/\/vcaaa.venturacounty.gov\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_9' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Submit'  \/> <input type='hidden' name='gform_ajax' value='form_id=9&amp;title=&amp;description=&amp;tabindex=0&amp;theme=gravity-theme&amp;styles=[]&amp;hash=e1e3b43f7b0902f2481be9d5bdb4bc93' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_9' value='iframe' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_9' id='gform_theme_9' value='gravity-theme' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' 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