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new.html
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new.html
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---
excerpt: none
---
{% include head.html %}
<link href="{{site.baseurl}}/stylesheets/form.css" type="text/css" rel="stylesheet" />
<body class="no-js layout-claims layout-claims-new">
<a class="a-skip-to-main" href="#main">Skip to main content</a>
{% include site-header.html %}
<main role="main" id="main" class="page">
<div class="wrapper">
<h1>File a claim</h1>
<form id="claim"></form>
<div id="form-errors"></div>
<aside>
<h1>How does this work?</h1>
<ol class="steps">
<li>You’ll fill out and submit this form. We’ll provide a code to give to your healthcare provider.</li>
<li>You’ll notify your healthcare provider, who will provide information relevant to your claim. </li>
<li>We’ll process your application. You’ll receive an email when we receive the package, and once it’s been processed. (The average claims-processing time is currently 18 days.)</li>
<li>You’ll receive your benefits.</li>
</ol>
<p>If you have any questions, don't hesistate to <a href="#">contact us</a>. You can also <a href="#">read eligibility information</a>, <a href="#">estimate the benefits for which you qualify</a>, and <a href="#">request a paper form</a>.</p>
</aside>
</div>
</main>
{% include site-footer.html %}
</body>
<script type="text/javascript" src="{{site.baseurl}}/javascripts/underscore.js"></script>
<script type="text/javascript" src="{{site.baseurl}}/javascripts/jsonform.js"></script>
<script>
// Get the JSON Schema and form definitions
var json_form = $.get("{{site.baseurl}}/javascripts/form.json");
var json_schema = $.get("{{site.baseurl}}/javascripts/schema.json");
// When the schema and form are available, render the form
$.when(json_schema, json_form).done(function() {
$('#claim').jsonForm({
"schema": json_schema.responseJSON,
"form": json_form.responseJSON,
onSubmit: function (errors, values) {
if (errors) {
$('.form-errors').html('<p>Please fix the below errors.</p>');
}
else {
// Set this to a valid endpoint to receive the JSON form contents.
$.post('https://example.gov/', values);
}
}
});
}).fail(function() {
console.log('Schema could not be retrieved');
});
</script>