{"id":4698,"date":"2024-11-04T15:29:19","date_gmt":"2024-11-04T21:29:19","guid":{"rendered":"https:\/\/aw-innovations.matrixdev.net\/cahiim\/?page_id=4698"},"modified":"2024-11-04T16:31:40","modified_gmt":"2024-11-04T22:31:40","slug":"cahiim-fee-payment","status":"publish","type":"page","link":"https:\/\/aw-innovations.matrixdev.net\/cahiim\/resources\/cahiim-fee-payment\/","title":{"rendered":"CAHIIM Fee Payment"},"content":{"rendered":"\n<div style=\"height:var(--wp--preset--spacing--40)\" aria-hidden=\"true\" class=\"wp-block-spacer\"><\/div>\n\n\n\n<p class=\"wp-block-paragraph\">Please use the following form to submit payment to CAHIIM via credit card.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">NOTE: Only <strong>Visa<\/strong> and <strong>Mastercard<\/strong> are accepted.<\/p>\n\n\n<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 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var(--gf-ctrl-choice-size-md);--gf-ctrl-checkbox-check-size: var(--gf-ctrl-checkbox-check-size-md);--gf-ctrl-radio-check-size: var(--gf-ctrl-radio-check-size-md);--gf-ctrl-btn-font-size: var(--gf-ctrl-btn-font-size-md);--gf-ctrl-btn-padding-x: var(--gf-ctrl-btn-padding-x-md);--gf-ctrl-btn-size: var(--gf-ctrl-btn-size-md);--gf-ctrl-btn-border-color-secondary: #686e77;--gf-ctrl-btn-bg-color-hover-tertiary: #EBEBEB;--gf-field-img-choice-size: var(--gf-field-img-choice-size-md);--gf-field-img-choice-card-space: var(--gf-field-img-choice-card-space-md);--gf-field-img-choice-check-ind-size: var(--gf-field-img-choice-check-ind-size-md);--gf-field-img-choice-check-ind-icon-size: var(--gf-field-img-choice-check-ind-icon-size-md);--gf-field-pg-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style>\n                        <div class='gform_heading'>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_2'  action='\/cahiim\/wp-json\/wp\/v2\/pages\/4698' data-formid='2' novalidate><input id=\"gpnf_session_hash_2\" type=\"hidden\" name=\"gpnf_session_hash\" value=\"0adf457d229d\">\n                        <div class='gform-body gform_body'><div id='gform_fields_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_2_14\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_14'><span class='gform-field-label__text'>Facebook<\/span><\/label><div class='ginput_container'><input name='input_14' id='input_2_14' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_2_14'>This field is for validation purposes and should be left unchanged.<\/div><\/div><fieldset id=\"field_2_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' ><span class='gform-field-label__text'>Name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_2_1'>\n                            \n                            <span id='input_2_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_2_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_2_1_3' class='gform-field-label gform-field-label--type-sub '>First Name<\/label>\n                                                <\/span>\n                            \n                            <span id='input_2_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_2_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_2_1_6' class='gform-field-label gform-field-label--type-sub '>Last Name<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_2_3\" class=\"gfield gfield--type-address gfield--input-type-address 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' ><span class='gform-field-label__text'>Address<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/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_2_3' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_2_3_1_container' >\n                                        <input type='text' name='input_3.1' id='input_2_3_1' value=''    aria-required='true'    \/>\n                                        <label for='input_2_3_1' id='input_2_3_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_2_3_2_container' >\n                                        <input type='text' name='input_3.2' id='input_2_3_2' value=''     aria-required='false'   \/>\n                                        <label for='input_2_3_2' id='input_2_3_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_2_3_3_container' >\n                                    <input type='text' name='input_3.3' id='input_2_3_3' value=''    aria-required='true'    \/>\n                                    <label for='input_2_3_3' id='input_2_3_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_2_3_4_container' >\n                                        <input type='text' name='input_3.4' id='input_2_3_4' value=''      aria-required='true'    \/>\n                                        <label for='input_2_3_4' id='input_2_3_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_2_3_5_container' >\n                                    <input type='text' name='input_3.5' id='input_2_3_5' value=''    aria-required='true'    \/>\n                                    <label for='input_2_3_5' id='input_2_3_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_3.6' id='input_2_3_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_2_4\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half 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_2_4'><span class='gform-field-label__text'>Contact Email<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_4' id='input_2_4' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_2_8\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half 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_2_8'><span class='gform-field-label__text'>Phone Number<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_2_8' type='text' value='' class='large'    placeholder='(###) ###-####x#####' aria-required=\"true\" aria-invalid=\"false\"   data-mask=\"(999) 999-9999? x99999\"\/><\/div><\/div><div id=\"field_2_7\" 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_2_7'><span class='gform-field-label__text'>Institution Name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_2_7' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_9\" class=\"gfield gfield--type-form gfield--input-type-form gform-theme__no-reset--children 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_2_9'><span class='gform-field-label__text'>Payments<\/span><\/label><div class=\"gpnf-nested-entries-container ginput_container\">\n\n\t<table class=\"gpnf-nested-entries\">\n\n\t\t<thead>\n\t\t<tr>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-row_id\">\n\t\t\t\t\tRow ID\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-3\">\n\t\t\t\t\tInvoice Number\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-6\">\n\t\t\t\t\tPayment Amount\t\t\t\t<\/th>\n\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-row-actions\"><span class=\"screen-reader-text\">Actions<\/span><\/th>\n\t\t<\/tr>\n\t\t<\/thead>\n\n\t\t<tbody data-bind=\"visible: entries().length, foreach: entries\">\n\t\t<tr data-bind=\"attr: { 'data-entryid': id }\">\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: frow_id.label, attr: { 'data-value': frow_id.label }\"\n\t\t\t\t\tdata-heading=\"Row ID\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f3.label, attr: { 'data-value': f3.label }\"\n\t\t\t\t\tdata-heading=\"Invoice Number\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f6.label, attr: { 'data-value': f6.label }\"\n\t\t\t\t\tdata-heading=\"Payment Amount\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t<td class=\"gpnf-row-actions\" style=\"display: none;\" data-bind=\"visible: true\">\n\t\t\t\t<ul>\n\t\t\t\t\t<li class=\"edit\"><button type=\"button\" class=\"edit-button gform-theme-button--secondary\" data-bind=\"click: $parent.editEntry, attr: { 'aria-label': 'Edit Entry {0} where Row ID is {1}.'.gformFormat( $index() + 1, frow_id.label ) }\">Edit<\/button><\/li>\n\t\t\t\t\t\t\t\t\t\t<li class=\"delete\"><button type=\"button\" class=\"delete-button gform-theme-button--simple gform-theme-button--size-md\" data-bind=\"click: $parent.deleteEntry, attr: { 'aria-label': 'Delete Entry {0} where Row ID is {1}.'.gformFormat( $index() + 1, frow_id.label ) }\">Delete<\/button><\/li>\n\t\t\t\t<\/ul>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<\/tbody>\n\n\t\t<tbody data-bind=\"visible: entries().length <= 0\">\n\t\t<tr class=\"gpnf-no-entries\" data-bind=\"visible: entries().length <= 0\" style=\"display: none;\">\n\t\t\t<td colspan=\"4\">\n\t\t\t\tThere are no <span>Entries.<\/span>\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<\/tbody>\n\n\t<\/table>\n\n\t<button type=\"button\" class=\"gpnf-add-entry\"\n\t\t        data-formid=\"2\"\n\t\t        data-nestedformid=\"3\"\n\t\t\t\tdata-bind=\"attr: { disabled: isMaxed }, css: { 'gf-default-disabled': isMaxed }\"\n\t\t\t\t>\n\t\t\t\tAdd Entry\n\t\t\t<\/button>\t\n\t\t\t<p class=\"gpnf-add-entry-max\" data-bind=\"visible: isMaxed\" style=\"display: none;\">\n\t\t\t\tMaximum number of entries reached.\n\t\t\t<\/p>\n<\/div>\n<input type=\"hidden\"\n                name=\"input_9\"\n                id=\"input_2_9\"\n                data-bind=\"value: entryIds\"\n                value=\"\" \/><\/div><div id=\"field_2_13\" class=\"gfield gfield--type-product gfield--input-type-calculation gfield--width-full gfield_price gfield_price_2_13 gfield_product_2_13 gfield_calculation field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' for='input_2_13_1'><span class='gform-field-label__text'>CAHIIM Fee<\/span><\/label><div class='ginput_container ginput_container_product_calculation'>\n\t\t\t\t\t<input type='hidden' name='input_13.1' value='CAHIIM Fee' class='gform_hidden' \/>\n\t\t\t\t\t<div id='ginput_product_price_2_13' class='ginput_product_price_wrapper'>\n\t\t\t\t\t\t<span class='gform-field-label gform-field-label--type-sub-large ginput_product_price_label'>Price:<\/span>\n\t\t\t\t\t\t<span class='gform-field-label gform-field-label--type-sub-large ginput_product_price' id='input_2_13'>$0.00<\/span>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<input type='hidden' name='input_13.2' id='ginput_base_price_2_13' class='gform_hidden ginput_calculated_price' value='$0.00'\/>\n\t\t\t\t\t<input type='hidden' name='input_13.3' value='1' class='ginput_quantity_2_13 gform_hidden' \/>\n\t\t\t\t<\/div><\/div><div id=\"field_2_10\" class=\"gfield gfield--type-total gfield--input-type-total gfield--width-full gfield_price gfield_price_2_ gfield_total gfield_total_2_ field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  aria-atomic=\"true\" aria-live=\"polite\" ><label 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