https://pss.tfaforms.net/78?tfa_1=THE%20MEET%20GROUP,%20INC.&tfa_1679=001U000000g1oP5IAI&tfa_3=Katie&tfa_4=Massenzio&tfa_2=kmassenzio@themeetgroup.com
Last Checked: Apr 24, 2024, 01:49 EDT
| IP Address: | 107.20.37.186 |
| ASN #: | AS14618 AMAZON-AES, US |
| Location: | Unknown, Unknown, Unknown |
| URL Reputation: |
|
Domain Name: TFAFORMS.NET
Registry Domain ID: 1704361096_DOMAIN_NET-VRSN
Registrar WHOIS Server: whois.tucows.com
Registrar URL: http://tucowsdomains.com
Updated Date: 2022-06-16T17:44:50
Creation Date: 2012-02-27T20:05:07
Registrar Registration Expiration Date: 2027-02-27T20:05:07
Registrar: TUCOWS, INC.
Registrar IANA ID: 69
Reseller: Hover
Domain Status: clientTransferProhibited https://icann.org/epp#clientTransferProhibited
Domain Status: clientUpdateProhibited https://icann.org/epp#clientUpdateProhibited
Registry Registrant ID:
Registrant Name: Contact Privacy Inc. Customer 0130470495
Registrant Organization: Contact Privacy Inc. Customer 0130470495
Registrant Street: 96 Mowat Ave
Registrant City: Toronto
Registrant State/Province: ON
Registrant Postal Code: M6K 3M1
Registrant Country: CA
Registrant Phone: +1.4165385457
Registrant Phone Ext:
Registrant Fax:
Registrant Fax Ext:
Registrant Email: tfaforms.net@contactprivacy.com
Registry Admin ID:
Admin Name: Contact Privacy Inc. Customer 0130470495
Admin Organization: Contact Privacy Inc. Customer 0130470495
Admin Street: 96 Mowat Ave
Admin City: Toronto
Admin State/Province: ON
Admin Postal Code: M6K 3M1
Admin Country: CA
Admin Phone: +1.4165385457
Admin Phone Ext:
Admin Fax:
Admin Fax Ext:
Admin Email: tfaforms.net@contactprivacy.com
Registry Tech ID:
Tech Name: Contact Privacy Inc. Customer 0130470495
Tech Organization: Contact Privacy Inc. Customer 0130470495
Tech Street: 96 Mowat Ave
Tech City: Toronto
Tech State/Province: ON
Tech Postal Code: M6K 3M1
Tech Country: CA
Tech Phone: +1.4165385457
Tech Phone Ext:
Tech Fax:
Tech Fax Ext:
Tech Email: tfaforms.net@contactprivacy.com
Name Server: ns-761.awsdns-31.net
Name Server: ns-508.awsdns-63.com
Name Server: ns-1165.awsdns-17.org
Name Server: ns-1849.awsdns-39.co.uk
DNSSEC: signedDelegation
Registrar Abuse Contact Email: domainabuse@tucows.com
Registrar Abuse Contact Phone: +1.4165350123
URL of the ICANN WHOIS Data Problem Reporting System: https://icann.org/wicf
>>> Last update of WHOIS database: 2024-04-24T05:49:04Z <<<
"For more information on Whois status codes, please visit https://icann.org/epp"
Registration Service Provider:
Hover, help@hover.com
+1.8667316556
https://help.hover.com
The Data in the Tucows Registrar WHOIS database is provided to you by Tucows
for information purposes only, and may be used to assist you in obtaining
information about or related to a domain name's registration record.
Tucows makes this information available "as is," and does not guarantee its
accuracy.
By submitting a WHOIS query, you agree that you will use this data only for
lawful purposes and that, under no circumstances will you use this data to:
a) allow, enable, or otherwise support the transmission by e-mail,
telephone, or facsimile of mass, unsolicited, commercial advertising or
solicitations to entities other than the data recipient's own existing
customers; or (b) enable high volume, automated, electronic processes that
send queries or data to the systems of any Registry Operator or
ICANN-Accredited registrar, except as reasonably necessary to register
domain names or modify existing registrations.
The compilation, repackaging, dissemination or other use of this Data is
expressly prohibited without the prior written consent of Tucows.
Tucows reserves the right to terminate your access to the Tucows WHOIS
database in its sole discretion, including without limitation, for excessive
querying of the WHOIS database or for failure to otherwise abide by this
policy.
Tucows reserves the right to modify these terms at any time.
By submitting this query, you agree to abide by these terms.
NOTE: THE WHOIS DATABASE IS A CONTACT DATABASE ONLY. LACK OF A DOMAIN
RECORD DOES NOT SIGNIFY DOMAIN AVAILABILITY.
-
GET0 Timed out waiting for a response.
https://pss.tfaforms.net/favicon.ico
<html lang="en-US"><head>
<title>Aetna Prescription Drug Data Collection Reporting Submission</title>
<meta name="viewport" content="width=device-width, initial-scale=1.0">
<meta http-equiv="Content-Type" content="text/html; charset=utf-8">
<meta name="referrer" content="no-referrer-when-downgrade">
<!-- THIS SCRIPT NEEDS TO BE LOADED FIRST BEFORE wforms.js -->
<script type="text/javascript" data-for="FA__DOMContentLoadedEventDispatch" src="https://pss.tfaforms.net/js/FA__DOMContentLoadedEventDispatcher.js" defer=""></script>
<script type="text/javascript">
document.addEventListener("FA__DOMContentLoaded", function(){
const FORM_TIME_START = Math.floor((new Date).getTime()/1000);
let formElement = document.getElementById("tfa_0");
if (null === formElement) {
formElement = document.getElementById("0");
}
let appendJsTimerElement = function(){
let formTimeDiff = Math.floor((new Date).getTime()/1000) - FORM_TIME_START;
let cumulatedTimeElement = document.getElementById("tfa_dbCumulatedTime");
if (null !== cumulatedTimeElement) {
let cumulatedTime = parseInt(cumulatedTimeElement.value);
if (null !== cumulatedTime && cumulatedTime > 0) {
formTimeDiff += cumulatedTime;
}
}
let jsTimeInput = document.createElement("input");
jsTimeInput.setAttribute("type", "hidden");
jsTimeInput.setAttribute("value", formTimeDiff.toString());
jsTimeInput.setAttribute("name", "tfa_dbElapsedJsTime");
jsTimeInput.setAttribute("id", "tfa_dbElapsedJsTime");
jsTimeInput.setAttribute("autocomplete", "off");
if (null !== formElement) {
formElement.appendChild(jsTimeInput);
}
};
if (null !== formElement) {
if(formElement.addEventListener){
formElement.addEventListener('submit', appendJsTimerElement, false);
} else if(formElement.attachEvent){
formElement.attachEvent('onsubmit', appendJsTimerElement);
}
}
});
</script>
<link href="https://pss.tfaforms.net/dist/form-builder/5.0.0/wforms-layout.css?v=c3017809f354a19064c2f4bbf2056dd2470797bb" rel="stylesheet" type="text/css">
<link href="https://pss.tfaforms.net/uploads/themes/theme-25.css" rel="stylesheet" type="text/css">
<link href="https://pss.tfaforms.net/dist/form-builder/5.0.0/wforms-jsonly.css?v=c3017809f354a19064c2f4bbf2056dd2470797bb" rel="stylesheet" title="" type="text/css">
<script type="text/javascript" src="https://pss.tfaforms.net/wForms/3.11/js/wforms.js?v=c3017809f354a19064c2f4bbf2056dd2470797bb"></script>
<script type="text/javascript">
if(wFORMS.behaviors.prefill) wFORMS.behaviors.prefill.skip = true;
</script>
<script type="text/javascript" src="https://pss.tfaforms.net/wForms/3.11/js/localization-en_US.js?v=c3017809f354a19064c2f4bbf2056dd2470797bb"></script>
</head>
<body class="default wFormWebPage">
<div id="tfaContent">
<div class="wFormContainer">
<div class="wFormHeader"></div>
<style type="text/css">
#tfa_1,
*[id^="tfa_1["] {
width: 416px !important;
}
#tfa_1-D,
*[id^="tfa_1["][class~="field-container-D"] {
width: auto !important;
}
#tfa_1-L,
label[id^="tfa_1["] {
width: 183px !important;
min-width: 0px;
}
#tfa_1679,
*[id^="tfa_1679["] {
width: 416px !important;
}
#tfa_1679-D,
*[id^="tfa_1679["][class~="field-container-D"] {
width: auto !important;
}
#tfa_1679-L,
label[id^="tfa_1679["] {
width: 183px !important;
min-width: 0px;
}
#tfa_3,
*[id^="tfa_3["] {
width: 416px !important;
}
#tfa_3-D,
*[id^="tfa_3["][class~="field-container-D"] {
width: auto !important;
}
#tfa_3-L,
label[id^="tfa_3["] {
width: 183px !important;
min-width: 0px;
}
#tfa_4,
*[id^="tfa_4["] {
width: 416px !important;
}
#tfa_4-D,
*[id^="tfa_4["][class~="field-container-D"] {
width: auto !important;
}
#tfa_4-L,
label[id^="tfa_4["] {
width: 183px !important;
min-width: 0px;
}
#tfa_2,
*[id^="tfa_2["] {
width: 416px !important;
}
#tfa_2-D,
*[id^="tfa_2["][class~="field-container-D"] {
width: auto !important;
}
#tfa_2-L,
label[id^="tfa_2["] {
width: 183px !important;
min-width: 0px;
}
#tfa_73,
*[id^="tfa_73["] {
width: 416px !important;
}
#tfa_73-D,
*[id^="tfa_73["][class~="field-container-D"] {
width: auto !important;
}
#tfa_73-L,
label[id^="tfa_73["] {
width: 183px !important;
min-width: 0px;
}
#tfa_5,
*[id^="tfa_5["] {
width: 416px !important;
}
#tfa_5-D,
*[id^="tfa_5["][class~="field-container-D"] {
width: auto !important;
}
#tfa_5-L,
label[id^="tfa_5["] {
width: 183px !important;
min-width: 0px;
}
#tfa_146,
*[id^="tfa_146["] {
width: 196px !important;
}
#tfa_146-D,
*[id^="tfa_146["][class~="field-container-D"] {
width: auto !important;
}
#tfa_146-L,
label[id^="tfa_146["] {
width: 263px !important;
min-width: 0px;
}
#tfa_147,
*[id^="tfa_147["] {
width: 196px !important;
}
#tfa_147-D,
*[id^="tfa_147["][class~="field-container-D"] {
width: auto !important;
}
#tfa_147-L,
label[id^="tfa_147["] {
width: 263px !important;
min-width: 0px;
}
</style><div class=""><div class="wForm" id="78-WRPR" data-language="en_US" dir="ltr">
<div class="codesection" id="code-78"></div>
<h3 class="wFormTitle" data-testid="form-title" id="78-T">Aetna Prescription Drug Data Collection Reporting Submission</h3>
<form method="post" action="https://pss.tfaforms.net/api_v2/workflow/processor" class=" labelsLeftAligned" id="78" role="form">
<div class="oneField field-container-D wf-acl-hidden" id="tfa_1-D">
<label id="tfa_1-L" class="label preField reqMark" for="tfa_1">Plan Sponsor</label><div class="inputWrapper"><input aria-required="true" type="text" id="tfa_1" name="tfa_1" value="THE MEET GROUP, INC." title="Plan Sponsor" class="required"></div>
</div>
<div class="oneField field-container-D wf-acl-hidden" id="tfa_1679-D">
<label id="tfa_1679-L" class="label preField reqMark" for="tfa_1679">Plan Sponsor ID</label><div class="inputWrapper"><input aria-required="true" type="text" id="tfa_1679" name="tfa_1679" value="001U000000g1oP5IAI" title="Plan Sponsor ID" class="required"></div>
</div>
<div class="oneField field-container-D wf-acl-hidden" id="tfa_3-D">
<label id="tfa_3-L" class="label preField reqMark" for="tfa_3">Submitter First Name</label><div class="inputWrapper"><input aria-required="true" type="text" id="tfa_3" name="tfa_3" value="Katie" title="Submitter First Name" class="required"></div>
</div>
<div class="oneField field-container-D wf-acl-hidden" id="tfa_4-D">
<label id="tfa_4-L" class="label preField reqMark" for="tfa_4">Submitter Last Name</label><div class="inputWrapper"><input aria-required="true" type="text" id="tfa_4" name="tfa_4" value="Massenzio" title="Submitter Last Name" class="required"></div>
</div>
<div class="oneField field-container-D wf-acl-hidden" id="tfa_2-D">
<label id="tfa_2-L" class="label preField reqMark" for="tfa_2">Submitter Email</label><div class="inputWrapper"><input aria-required="true" type="text" id="tfa_2" name="tfa_2" value="kmassenzio@themeetgroup.com" title="Submitter Email" class="required"></div>
</div>
<div class="oneField field-container-D wf-acl-hidden" id="tfa_73-D">
<label id="tfa_73-L" class="label preField reqMark" for="tfa_73">Legal Entity Name</label><div class="inputWrapper"><select aria-required="true" id="tfa_73" name="tfa_73" title="Legal Entity Name" class="required"><option value="">Please select...</option>
<option value="tfa_1680" id="tfa_1680" class="">Aetna Health Inc. - PA</option>
<option value="tfa_1681" id="tfa_1681" class="">Aetna Health Inc. (a Louisiana corporation)</option>
<option value="tfa_1682" id="tfa_1682" class="">Aetna Health Inc. (CT)</option>
<option value="tfa_1683" id="tfa_1683" class="">Aetna Health Inc. (FL)</option>
<option value="tfa_1684" id="tfa_1684" class="">Aetna Health Inc. (GA)</option>
<option value="tfa_1685" id="tfa_1685" class="">Aetna Health Inc. (ME)</option>
<option value="tfa_1686" id="tfa_1686" class="">Aetna Health Inc. (NJ)</option>
<option value="tfa_1687" id="tfa_1687" class="">Aetna Health Inc. (TX)</option>
<option value="tfa_1688" id="tfa_1688" class="">Aetna Health Insurance Company of New York</option>
<option value="tfa_1689" id="tfa_1689" class="">Aetna Health of California Inc.</option>
<option value="tfa_1690" id="tfa_1690" class="">Aetna Health of Iowa, Inc.</option>
<option value="tfa_1691" id="tfa_1691" class="">Aetna Health of Utah Inc.</option>
<option value="tfa_1692" id="tfa_1692" class="">Aetna HealthAssurance Pennsylvania, Inc.</option>
<option value="tfa_1693" id="tfa_1693" class="">Aetna Life Insurance Company</option>
<option value="tfa_1694" id="tfa_1694" class="">Allina Health and Aetna Insurance Company</option>
<option value="tfa_1695" id="tfa_1695" class="">Banner Health and Aetna Health Insurance Company</option>
<option value="tfa_1696" id="tfa_1696" class="">Banner Health and Aetna Health Plan Inc.</option>
<option value="tfa_1697" id="tfa_1697" class="">Innovation Health Insurance Company</option>
<option value="tfa_1698" id="tfa_1698" class="">Innovation Health Plan, Inc.</option>
<option value="tfa_1699" id="tfa_1699" class="">Sutter Health and Aetna Administrative Services LLC</option>
<option value="tfa_1700" id="tfa_1700" class="">Sutter Health and Aetna Insurance Company</option>
<option value="tfa_1701" id="tfa_1701" class="">Texas Health + Aetna Health Insurance Company</option>
<option value="tfa_1702" id="tfa_1702" class="">Texas Health + Aetna Health Plan Inc.</option>
<option value="tfa_1703" id="tfa_1703" class="">Texas Health and Aetna Health Insurance Company</option></select></div>
</div>
<div class="oneField field-container-D wf-acl-hidden" id="tfa_5-D">
<label id="tfa_5-L" class="label preField reqMark" for="tfa_5">Funding Arrangement</label><div class="inputWrapper"><select aria-required="true" id="tfa_5" name="tfa_5" title="Funding Arrangement" class="required"><option value="">Please select...</option>
<option value="tfa_6" id="tfa_6" class="">Fully Insured</option>
<option value="tfa_7" id="tfa_7" class="">Self-Insured</option>
<option value="tfa_8" id="tfa_8" class="">Split Funded</option></select></div>
</div>
<div class="oneField field-container-D wf-acl-hidden" id="tfa_146-D">
<label id="tfa_146-L" class="label preField reqMark" for="tfa_146">Total Premium paid by Employer</label><div class="inputWrapper"><input aria-required="true" type="text" id="tfa_146" name="tfa_146" value="" data-conditionals="#submit_button" title="Total Premium paid by Employer" class="validate-float required"></div>
</div>
<div class="oneField field-container-D wf-acl-hidden" id="tfa_147-D">
<label id="tfa_147-L" class="label preField reqMark" for="tfa_147">Total Premium paid by Members</label><div class="inputWrapper"><input aria-required="true" type="text" id="tfa_147" name="tfa_147" value="" title="Total Premium paid by Members" class="validate-float required"></div>
</div>
<div class="htmlSection" id="tfa_1704"><div class="htmlContent" id="tfa_1704-HTML">The data collection period for RxDC is closed.<br><br>If you did not submit by the deadline, there are additional steps you will need to take to ensure your compliance with the regulation.<br><br>Please reach out to your Account Representative for more information.</div></div>
<div class="actions" id="78-A" data-contentid="submit_button"><input type="submit" data-label="Submit" class="primaryAction offstate" id="submit_button" value="Submit" data-condition="`#tfa_146,neq,""`" data-conditional-mode="hidden" disabled=""></div>
<div style="clear:both"></div>
<input type="hidden" value="277-bd65572ca5841960994066e1a7a87ae1" name="tfa_dbCounters" id="tfa_dbCounters" autocomplete="off"><input type="hidden" value="78" name="tfa_dbFormId" id="tfa_dbFormId"><input type="hidden" value="" name="tfa_dbResponseId" id="tfa_dbResponseId"><input type="hidden" value="cd96e376e251a0e82abd8026725aacce" name="tfa_dbControl" id="tfa_dbControl"><input type="hidden" value="" name="tfa_dbWorkflowSessionUuid" id="tfa_dbWorkflowSessionUuid"><input type="hidden" value="" name="tfa_noOverWriteFields" id="tfa_noOverWriteFields"><input type="hidden" value="1713937721" name="tfa_dbTimeStarted" id="tfa_dbTimeStarted" autocomplete="off"><input type="hidden" value="3" name="tfa_dbVersionId" id="tfa_dbVersionId"><input type="hidden" value="submit_button" name="tfa_switchedoff" id="tfa_switchedoff">
</form>
</div></div><div class="wFormFooter"><p class="supportInfo"><br></p></div>
<p class="supportInfo">
</p>
</div>
<script id="open-telemetry-script" type="text/javascript" src="https://pss.tfaforms.net/dist/open-telemetry/open-telemetry.e3e59835d0ec08f714f1.js" data-customer-id="91981" data-exporter-url="https://us-east-1-otel.formassembly.com/v1/traces" data-exporter-console="0"></script>
</div>
<script src="https://pss.tfaforms.net/js/iframe_message_helper_internal.js?v=2"></script>
</body></html>
