K
kevin
I am generating a report Using ActiveReports by Data
Dynamics. They allow exporting of the report to HTML.
Then HTML export works in all browsers but when i try to
open it in Word, Word Crashes.
The specific line that crashes word is:
"<div style="page-break-inside:avoid;">"
apparently it doesnt like the page break stuff.
After I take that line out, the file opens in Word but
doesnt render correctly. Here is the HTML, copy it to a
file, then open it in a browser, then try to open it in
Word.
Thanks,
Kevin
See HTML starting below line...
-----------------------------------------------------------
<HTML>
<HEAD>
<title>Unicare Reports</title>
<script language="javascript">
this.onBlur = this.focus();
</script>
</HEAD>
<body>
<form name="Form1" method="post"
action="Reports.aspx?job=51DF4012-9696-11D7-BC9C-
009027E32D00" id="Form1">
<input type="hidden" name="__VIEWSTATE"
value="dDwtNDEzNDY0MTc2O3Q8O2w8aTwwPjs+O2w8dDw7bDxpPDE+O2k8
NT47PjtsPHQ8cDxwPGw8TmF2aWdhdGVVcmw7VmlzaWJsZTs+O2w8L3dlYnJ
lcG9ydHMvZG9jLzUxZGY0MDEyLTk2OTYtMTFkNy1iYzljLTAwOTAyN2UzMm
QwMC5wZGY7bzx0Pjs+Pjs+Ozs+O3Q8cDxwPGw8VmlzaWJsZTs+O2w8bzx0P
js+Pjs+Ozs+Oz4+Oz4+Oz6gvm6lrkM0PoDzM4QYYxbxOuhFng==" />
<table width="100%">
<tr>
<td><a
id="pdfLink" href="/webreports/doc/51df4012-9696-11d7-bc9c-
009027e32d00.pdf" target="_new">PDF Version</a>
<span
id="Label1">|</span>
<a
id="printLink" href="javascript:window.print();">Print
Report</a></td>
<td
align="right"></td>
</tr>
</table>
</form>
<style>
@page{size: 8.5in 11in;margin-
top:0in;margin-left:0in;margin-right:0in;margin-
bottom:0in;}
</style><div style="page-break-
inside:avoid;">
<div
style="position:relative;width:8.5in;height:11in;">
<span
style="position:absolute;top:0.7638889in;left:0.2638889in;w
idth:1.611111in;height:0.1861111in;overflow:hidden;font-
family:Arial;font-size:10pt;color:#000000;vertical-
align:top;">Polk</span><span
style="position:absolute;top:0.7638889in;left:2.263889in;wi
dth:1.548611in;height:0.1861111in;overflow:hidden;font-
family:Arial;font-size:10pt;color:#000000;vertical-
align:top;">Jacquel</span><span
style="position:absolute;top:1.638889in;left:3.638889in;wid
th:1.548611in;height:0.1861111in;overflow:hidden;font-
family:Arial;font-size:10pt;color:#000000;vertical-
align:top;">3000213 </span><span
style="position:absolute;top:1.638889in;left:5.388889in;wid
th:1.611111in;height:0.1861111in;overflow:hidden;font-
family:Arial;font-size:10pt;color:#000000;vertical-
align:top;">12/29/2001 12:00:00 AM</span><span
style="position:absolute;top:4.576389in;left:0.2638889in;wi
dth:1.611111in;height:0.1735976in;overflow:hidden;font-
family:Arial;font-size:10pt;color:#000000;vertical-
align:top;">1/5/1981 12:00:00 AM</span><span
style="position:absolute;top:3.951389in;left:0.2638889in;wi
dth:3.298611in;height:0.1861111in;overflow:hidden;font-
family:Arial;font-size:10pt;color:#000000;vertical-
align:top;">Jacquel Polk</span><span
style="position:absolute;top:7.694445in;left:0.3819444in;wi
dth:6.5in;height:0.01in;overflow:hidden;background-
color:#000000;"></span><span
style="position:absolute;top:8.069445in;left:0.3819444in;wi
dth:6.5in;height:0.01in;overflow:hidden;background-
color:#000000;"></span><span
style="position:absolute;top:7.944445in;left:0.3819444in;wi
dth:6.5in;height:0.01in;overflow:hidden;background-
color:#000000;"></span><span
style="position:absolute;top:7.819445in;left:0.3819444in;wi
dth:6.5in;height:0.01in;overflow:hidden;background-
color:#000000;"></span><span
style="position:absolute;top:8.319445in;left:0.3819444in;wi
dth:6.5in;height:0.01in;overflow:hidden;background-
color:#000000;"></span><span
style="position:absolute;top:8.194445in;left:0.3819444in;wi
dth:6.5in;height:0.01in;overflow:hidden;background-
color:#000000;"></span><span
style="position:absolute;top:0.1388889in;left:2.076389in;wi
dth:3.111111in;height:0.1875in;overflow:hidden;font-
family:Arial;font-size:9.75pt;color:#000000;font-
weight:bold;text-align:center;vertical-align:top;">Ohio
Department of Job and Family Services</span><span
style="position:absolute;top:0.3263889in;left:2.076389in;wi
dth:3.111111in;height:0.1875in;overflow:hidden;font-
family:Arial;font-size:9.75pt;color:#000000;font-
weight:bold;text-align:center;vertical-
align:top;">INPATIENT HOSPITAL ADMISSION</span><span
style="position:absolute;top:8.451389in;left:0.6388889in;wi
dth:2.236111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:5.25pt;color:#000000;vertical-
align:top;">COUNTY DEPARTMENT OF JOB AND FAMILY
SERVICES</span><span
style="position:absolute;top:8.388889in;left:2.888889in;wid
th:1.611111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;text-
align:center;vertical-align:middle;">Signature and Title
of Agency Employee</span><span
style="position:absolute;top:8.388889in;left:5.951389in;wid
th:0.2361111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;text-
align:center;vertical-align:middle;">Date</span><span
style="position:absolute;top:5.513889in;left:2.513889in;wid
th:2.361111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;font-
weight:bold;text-align:center;vertical-align:top;">COUNTY
DEPARTMENT OF JOB AND FAMILY SERVICES</span><span
style="position:absolute;top:5.638889in;left:2.513889in;wid
th:2.361111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:8.25pt;color:#000000;font-
weight:bold;text-align:center;vertical-align:top;">NOTICE
OF ELIGIBILITY TO HOSPITAL</span><span
style="position:absolute;top:5.826389in;left:0.4513889in;wi
dth:1.986111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6.75pt;color:#000000;font-
weight:bold;text-align:center;vertical-align:top;">GENERAL
RELIEF</span><span
style="position:absolute;top:5.826389in;left:2.888889in;wid
th:1.861111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6.75pt;color:#000000;font-
weight:bold;text-align:center;vertical-
align:top;">MEDICAID</span><span
style="position:absolute;top:5.826389in;left:5.263889in;wid
th:1.861111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6.75pt;color:#000000;font-
weight:bold;text-align:center;vertical-
align:top;">CRIPPLED CHILDREN</span><span
style="position:absolute;top:6.888889in;left:0.6388889in;wi
dth:2.048611in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;">Suspended
case. Must be approved for payment by</span><span
style="position:absolute;top:7.006945in;left:2.506944in;wid
th:4.375in;height:0.01in;overflow:hidden;background-
color:#000000;"></span><span
style="position:absolute;top:7.013889in;left:3.576389in;wid
th:2.236111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:5.25pt;color:#000000;text-
align:center;">Signature of County Department of Job and
Family Services Director</span><span
style="position:absolute;top:7.201389in;left:0.6388889in;wi
dth:4.736111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;">Patient's below
listed resources in the amount of
$_________________________ must be applied to the hospital
charges.</span><span
style="position:absolute;top:7.388889in;left:0.6388889in;wi
dth:4.736111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;">Patient is not
eligible. See explanation below.</span><span
style="position:absolute;top:6.319445in;left:0.3819444in;wi
dth:2.118in;height:0.01in;overflow:hidden;background-
color:#000000;"></span><span
style="position:absolute;top:6.194445in;left:0.3819444in;wi
dth:2.118in;height:0.01in;overflow:hidden;background-
color:#000000;"></span><span
style="position:absolute;top:6.444445in;left:0.3819444in;wi
dth:2.118in;height:0.01in;overflow:hidden;background-
color:#000000;"></span><span
style="position:absolute;top:6.569445in;left:0.3819444in;wi
dth:2.118in;height:0.01in;overflow:hidden;background-
color:#000000;"></span><span
style="position:absolute;top:5.951389in;left:0.6388889in;wi
dth:1.673611in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;">Patient is
eligible under GR</span><span
style="position:absolute;top:6.076389in;left:0.6388889in;wi
dth:1.673611in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;">Mail Claim
To:</span><span
style="position:absolute;top:5.951389in;left:3.076389in;wid
th:1.673611in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;">Patient is
eligible under Title XIX</span><span
style="position:absolute;top:6.076389in;left:3.076389in;wid
th:1.673611in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;">Mail Claim
To:</span><span
style="position:absolute;top:6.263889in;left:3.076389in;wid
th:1.673611in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;">Ohio Department
of Job and Family Services</span><span
style="position:absolute;top:6.388889in;left:3.076389in;wid
th:1.673611in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;">P.O. Box
2654</span><span
style="position:absolute;top:6.513889in;left:3.076389in;wid
th:1.673611in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;">Columbus, Ohio
43216</span><span
style="position:absolute;top:5.951389in;left:5.451389in;wid
th:1.673611in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;">Patient is
eligible under Title V</span><span
style="position:absolute;top:6.076389in;left:5.451389in;wid
th:1.673611in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;">Mail Claim
To:</span><span
style="position:absolute;top:6.263889in;left:5.451389in;wid
th:1.673611in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;">Ohio Department
of Health</span><span
style="position:absolute;top:6.388889in;left:5.451389in;wid
th:1.673611in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;">Crippled
Children Services</span><span
style="position:absolute;top:6.513889in;left:5.451389in;wid
th:1.673611in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;">P.O. Box
1603</span><span
style="position:absolute;top:6.638889in;left:5.451389in;wid
th:1.673611in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;">Columbus, Ohio
43216</span><span
style="position:absolute;top:5.076389in;left:0.2638889in;wi
dth:3.423611in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;"> 15. Signature (Patient or authorized
representitive) (Signature by mark must be witnessed)
</span><span
style="position:absolute;top:5.076389in;left:3.701389in;wid
th:3.423611in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;"> 16. Name and address of person other than
patient who gave above information</span><span
style="position:absolute;top:4.763889in;left:0.3888889in;wi
dth:1.298611in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;"> Social Security Claim Number</span><span
style="position:absolute;top:4.451389in;left:0.3888889in;wi
dth:1.298611in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;"> Date of birth</span><span
style="position:absolute;top:4.138889in;left:0.3888889in;wi
dth:1.298611in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;"> Address</span><span
style="position:absolute;top:3.826389in;left:0.3888889in;wi
dth:1.298611in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;"> Name of applicant</span><span
style="position:absolute;top:3.638889in;left:0.2638889in;wi
dth:6.798611in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;font-
weight:bold;vertical-align:middle;"> 14. ELIGIBILITY
DETERMINATION - This MUST be completed if the patient is
not an eligible recipient under the Medical Assistance
Program.</span><span
style="position:absolute;top:3.826389in;left:3.701389in;wid
th:3.423611in;height:0.1565in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;text-
align:center;vertical-align:middle;"> INCOME AND RESOURCES
REPORTED FOR APPLICANT AND/OR SPOUSE</span><span
style="position:absolute;top:4.013889in;left:4.638889in;wid
th:1.236111in;height:0.09350014in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;text-
align:center;vertical-align:middle;">APPLICANT</span><span
style="position:absolute;top:4.013889in;left:5.888889in;wid
th:1.236111in;height:0.09350014in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;text-
align:center;vertical-align:middle;">SPOUSE</span><span
style="position:absolute;top:4.138889in;left:3.701389in;wid
th:0.9236111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;"> Weekly
earnings</span><span
style="position:absolute;top:4.326389in;left:3.701389in;wid
th:0.9236111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;"> Retirement</span><span
style="position:absolute;top:4.451389in;left:3.701389in;wid
th:0.9236111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;"> Cash on
hand</span><span
style="position:absolute;top:4.638889in;left:3.701389in;wid
th:0.9236111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;"> Savings or checking</span><span
style="position:absolute;top:4.763889in;left:3.701389in;wid
th:0.9236111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;"> Real estate</span><span
style="position:absolute;top:4.951389in;left:3.701389in;wid
th:0.9236111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;"> Life insurance</span><span
style="position:absolute;top:4.451389in;left:2.076389in;wid
th:1.298611in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;"> Place of birth</span><span
style="position:absolute;top:4.763889in;left:2.076389in;wid
th:1.298611in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;"> Beneficiary</span><span
style="position:absolute;top:3.138889in;left:6.263889in;wid
th:0.7361111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;"> CODE</span><span
style="position:absolute;top:2.763889in;left:6.263889in;wid
th:0.7361111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;"> ICDA CODE</span><span
style="position:absolute;top:1.888889in;left:6.263889in;wid
th:0.7361111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;"> CODE</span><span
style="position:absolute;top:2.326389in;left:6.263889in;wid
th:0.7361111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;"> ICDA CODE</span><span
style="position:absolute;top:1.888889in;left:3.638889in;wid
th:2.611111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;"> 10. ADMITTING PHYSICIAN</span><span
style="position:absolute;top:2.326389in;left:3.638889in;wid
th:2.611111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;"> 12. (a) ADMITTING DIAGNOSIS OR NATURE OF
INJURY</span><span
style="position:absolute;top:2.763889in;left:3.638889in;wid
th:2.611111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;"> (b) SECONDARY DIAGNOSIS OR CAUSE OF
INJURY</span><span
style="position:absolute;top:3.263889in;left:0.2638889in;wi
dth:2.423611in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:top;"> nursing home within the last 60
days?</span><span
style="position:absolute;top:3.138889in;left:0.2638889in;wi
dth:2.423611in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;"> 13. (a) Was the patient an inpatient of a
hospital, ECF, or</span><span
style="position:absolute;top:3.451389in;left:0.7638889in;wi
dth:0.2986111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;">Yes</span><span
style="position:absolute;top:3.451389in;left:1.388889in;wid
th:0.2986111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;">No</span><span
style="position:absolute;top:3.138889in;left:2.701389in;wid
th:2.423611in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;"> (b) If yes, enter:</span><span
style="position:absolute;top:3.263889in;left:2.826389in;wid
th:0.4236111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;">
Name</span><span
style="position:absolute;top:3.388889in;left:2.826389in;wid
th:0.4861111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;">
Location</span><span
style="position:absolute;top:3.5in;left:3.3125in;width:2.81
25in;height:0.01in;overflow:hidden;background-
color:#000000;"></span><span
style="position:absolute;top:3.375in;left:3.25in;width:2.87
5in;height:0.01in;overflow:hidden;background-
color:#000000;"></span><span
style="position:absolute;top:1.451389in;left:5.388889in;wid
th:1.736111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;"> 9. ADMISSION DATE</span><span
style="position:absolute;top:1.451389in;left:3.638889in;wid
th:1.736111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;"> PROVIDER NUMBER</span><span
style="position:absolute;top:1.451389in;left:0.2638889in;wi
dth:1.736111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;"> PROVIDER NAME AND ADDRESS</span><span
style="position:absolute;top:1.013889in;left:0.2638889in;wi
dth:1.736111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;"> 3. CASE NUMBER (10 DIGITS)</span><span
style="position:absolute;top:1.013889in;left:2.513889in;wid
th:0.6736111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;"> 4. ADC NO.</span><span
style="position:absolute;top:1.013889in;left:3.263889in;wid
th:1.361111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;"> 5. MEDICAL RECORD NO.</span><span
style="position:absolute;top:1.013889in;left:4.701389in;wid
th:2.361111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;"> 6. IF THIS CLAIM REQUIRED PRIOR
AUTHORIZATION</span><span
style="position:absolute;top:1.138889in;left:4.701389in;wid
th:2.361111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:top;"> ENTER PRIOR AUTHORIZATION CONTROL
NUMBER</span><span
style="position:absolute;top:0.5138889in;left:4.326389in;wi
dth:2.798611in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;"> 2. CASE LAST NAME IF DIFFERENT FROM
PATIENT'S LAST NAME</span><span
style="position:absolute;top:0.5138889in;left:4.076389in;wi
dth:0.1736111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;"> MI</span><span
style="position:absolute;top:0.5138889in;left:2.263889in;wi
dth:1.736111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;"> FIRST</span><span
style="position:absolute;top:0.5138889in;left:0.2638889in;w
idth:2.798611in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;"> 1. PATIENT'S LAST NAME</span><span
style="position:absolute;top:8.701389in;left:0.2638889in;wi
dth:6.861111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;"> It is understood that the Department of
Job and Family Services can make no payment on behalf of
your patient if it is determined that he has sufficient
resources to meet his obligation</span><span
style="position:absolute;top:8.826389in;left:0.2638889in;wi
dth:6.861111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;"> to the hospital or is otherwise
ineligible according to agency policies and
standards.</span><span
style="position:absolute;top:1.013889in;left:2.138889in;wid
th:0.3611111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;text-
align:center;vertical-align:middle;">FOR</span><span
style="position:absolute;top:1.138889in;left:2.138889in;wid
th:0.3611111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;text-
align:center;vertical-align:top;">ADC</span><span
style="position:absolute;top:1.201389in;left:2.138889in;wid
th:0.3611111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;text-
align:center;vertical-align:middle;">CASE</span><span
style="position:absolute;top:1.326389in;left:2.138889in;wid
th:0.3611111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;text-
align:center;vertical-align:middle;">ONLY</span><span
style="position:absolute;top:1.888889in;left:0.2638889in;wi
dth:3.361111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;"> 11. (A) CHECK THE APPROPRIATE BOX TO
INDICATE PAYMENT SOURCES OTHER</span><span
style="position:absolute;top:2.013889in;left:0.2638889in;wi
dth:3.361111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:top;"> THAN MEDICAID</span><span
style="position:absolute;top:2.763889in;left:0.3263889in;wi
dth:3.361111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;"> (B) If any box is checked, give third
party name and address</span><span
style="position:absolute;top:2.888889in;left:0.5138889in;wi
dth:0.4236111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;">
Name</span><span
style="position:absolute;top:3.013889in;left:0.5138889in;wi
dth:0.4861111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;">
Address</span><span
style="position:absolute;top:3.095in;left:0.9444444in;width
:2.555556in;height:0.01in;overflow:hidden;background-
color:#000000;"></span><span
style="position:absolute;top:2.98in;left:0.9in;width:2.6in;
height:0.01in;overflow:hidden;background-
color:#000000;"></span><span
style="position:absolute;top:2.638889in;left:0.7013889in;wi
dth:0.1111111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;text-
align:center;vertical-align:middle;">a.</span><span
style="position:absolute;top:2.638889in;left:1.513889in;wid
th:0.1111111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;text-
align:center;vertical-align:middle;">b.</span><span
style="position:absolute;top:2.638889in;left:2.263889in;wid
th:0.1111111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;text-
align:center;vertical-align:middle;">c.</span><span
style="position:absolute;top:2.638889in;left:1.013889in;wid
th:0.4236111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;">Group</span><span
style="position:absolute;top:2.638889in;left:1.826389in;wid
th:0.4236111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;">Individual</span><span
style="position:absolute;top:2.638889in;left:2.576389in;wid
th:0.9236111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;">Major Medical</span><span
style="position:absolute;top:2.513889in;left:0.5763889in;wi
dth:2.986111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:top;">If (2) or (3) is checked, indicate type of
policy</span><span
style="position:absolute;top:2.138889in;left:0.2638889in;wi
dth:0.4236111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:top;"> (1)</span><span
style="position:absolute;top:2.388889in;left:0.2638889in;wi
dth:0.4236111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:top;"> (3)</span><span
style="position:absolute;top:2.263889in;left:0.2638889in;wi
dth:0.4236111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:top;"> (2)</span><span
style="position:absolute;top:2.138889in;left:0.8263889in;wi
dth:1.111111in;height:0.105in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:top;">Self or Family</span><span
style="position:absolute;top:2.263889in;left:0.8263889in;wi
dth:1.111111in;height:0.105in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:top;">Blue Cross-Blue Shield</span><span
style="position:absolute;top:2.388889in;left:0.8263889in;wi
dth:1.111111in;height:0.105in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:top;">Private Carrier</span><span
style="position:absolute;top:2.138889in;left:1.951389in;wid
th:0.1736111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;text-
align:center;vertical-align:top;">(4)</span><span
style="position:absolute;top:2.263889in;left:1.951389in;wid
th:0.1736111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;text-
align:center;vertical-align:top;">(5)</span><span
style="position:absolute;top:2.388889in;left:1.951389in;wid
th:0.1736111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;text-
align:center;vertical-align:top;">(6)</span><span
style="position:absolute;top:2.138889in;left:2.263889in;wid
th:1.111111in;height:0.105in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:top;">Employer or Union</span><span
style="position:absolute;top:2.263889in;left:2.263889in;wid
th:1.111111in;height:0.105in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:top;">Public Agency</span><span
style="position:absolute;top:2.388889in;left:2.263889in;wid
th:1.298611in;height:0.105in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:top;">Other_______________________</span><span
style="position:absolute;top:0.0625in;left:0.25in;width:0.0
1in;height:8.9375in;overflow:hidden;background-
color:#000000;"></span><span
style="position:absolute;top:0.0625in;left:0.25in;width:6.8
75in;height:0.01in;overflow:hidden;background-
color:#000000;"></span><span
style="position:absolute;top:0.0625in;left:7.125in;width:0.
01in;height:8.9375in;overflow:hidden;background-
color:#000000;"></span><span
style="position:absolute;top:9in;left:0.25in;width:6.875in;
height:0.01in;overflow:hidden;background-
color:#000000;"></span><span
style="position:absolute;top:8.6875in;left:0.25in;width:6.8
75in;height:0.01in;overflow:hidden;background-
color:#000000;"></span><span
style="position:absolute;top:8.375in;left:2.875in;width:0.0
1in;height:0.3125in;overflow:hidden;background-
color:#000000;"></span><span
style="position:absolute;top:8.375in;left:2.875in;width:3.9
375in;height:0.01in;overflow:hidden;background-
color:#000000;"></span><span
style="position:absolute;top:8.375in;left:6.8125in;width:0.
01in;height:0.3125in;overflow:hidden;background-
color:#000000;"></span><span
style="position:absolute;top:8.375in;left:5.9375in;width:0.
01in;height:0.3125in;overflow:hidden;background-
color:#000000;"></span><span
style="position:absolute;top:5.4375in;left:0.25in;width:6.8
75in;height:0.01in;overflow:hidden;background-
color:#000000;"></span><span
style="position:absolute;top:5.0625in;left:0.25in;width:6.8
75in;height:0.01in;overflow:hidden;background-
color:#000000;"></span><span
style="position:absolute;top:4.75in;left:0.25in;width:6.875
in;height:0.01in;overflow:hidden;background-
color:#000000;"></span><span
style="position:absolute;top:4.4375in;left:0.25in;width:6.8
75in;height:0.01in;overflow:hidden;background-
color:#000000;"></span><span
style="position:absolute;top:4.125in;left:0.25in;width:6.87
5in;height:0.01in;overflow:hidden;background-
color:#000000;"></span><span
style="position:absolute;top:3.8125in;left:0.25in;width:6.8
75in;height:0.01in;overflow:hidden;background-
color:#000000;"></span><span
style="position:absolute;top:3.8125in;left:3.6875in;width:0
..01in;height:1.625in;overflow:hidden;background-
color:#000000;"></span><span
style="position:absolute;top:4.281in;left:3.694444in;width:
3.4375in;height:0.01in;overflow:hidden;background-
color:#000000;"></span><span
style="position:absolute;top:4.594in;left:3.6875in;width:3.
4375in;height:0.01in;overflow:hidden;background-
color:#000000;"></span><span
style="position:absolute;top:4.906in;left:3.6875in;width:3.
4375in;height:0.01in;overflow:hidden;background-
color:#000000;"></span><span
style="position:absolute;top:4in;left:3.6875in;width:3.4375
in;height:0.01in;overflow:hidden;background-
color:#000000;"></span><span
style="position:absolute;top:4in;left:5.875in;width:0.01in;
height:1.0625in;overflow:hidden;background-
color:#000000;"></span><span
style="position:absolute;top:4in;left:4.625in;width:0.01in;
height:1.0625in;overflow:hidden;background-
color:#000000;"></span><span
style="position:absolute;top:3.5625in;left:0.25in;width:6.8
75in;height:0.01in;overflow:hidden;background-
color:#000000;"></span><span
style="position:absolute;top:3.125in;left:0.25in;width:6.87
5in;height:0.01in;overflow:hidden;background-
color:#000000;"></span><span
style="position:absolute;top:3.125in;left:2.6875in;width:0.
01in;height:0.4375in;overflow:hidden;background-
color:#000000;"></span><span
style="position:absolute;top:3.125in;left:6.25in;width:0.01
in;height:0.4375in;overflow:hidden;background-
color:#000000;"></span><span
style="position:absolute;top:1.4375in;left:0.25in;width:6.8
75in;height:0.01in;overflow:hidden;background-
color:#000000;"></span><span
style="position:absolute;top:1.4375in;left:3.625in;width:0.
01in;height:1.6875in;overflow:hidden;background-
color:#000000;"></span><span
style="position:absolute;top:1.875in;left:0.25in;width:6.87
5in;height:0.01in;overflow:hidden;background-
color:#000000;"></span><span
style="position:absolute;top:2.3125in;left:3.625in;width:3.
5in;height:0.01in;overflow:hidden;background-
color:#000000;"></span><span
style="position:absolute;top:1.875in;left:6.25in;width:0.01
in;height:1.25in;overflow:hidden;background-
color:#000000;"></span><span
style="position:absolute;top:2.75in;left:3.625in;width:3.5i
n;height:0.01in;overflow:hidden;background-
color:#000000;"></span><span
style="position:absolute;top:1.4375in;left:5.375in;width:0.
01in;height:0.4375in;overflow:hidden;background-
color:#000000;"></span><span
style="position:absolute;top:1in;left:0.25in;width:6.875in;
height:0.01in;overflow:hidden;background-
color:#000000;"></span><span
style="position:absolute;top:0.5in;left:0.25in;width:6.875i
n;height:0.01in;overflow:hidden;background-
color:#000000;"></span><span
style="position:absolute;top:0.5in;left:2.25in;width:0.01in
;height:0.5in;overflow:hidden;background-
color:#000000;"></span><span
style="position:absolute;top:0.5in;left:4.0625in;width:0.01
in;height:0.5in;overflow:hidden;background-
color:#000000;"></span><span
style="position:absolute;top:0.5in;left:4.3125in;width:0.01
in;height:0.5in;overflow:hidden;background-
color:#000000;"></span><span
style="position:absolute;top:1in;left:2.5in;width:0.01in;he
ight:0.4375in;overflow:hidden;background-
color:#000000;"></span><span
style="position:absolute;top:1in;left:2.125in;width:0.01in;
height:0.4375in;overflow:hidden;background-
color:#000000;"></span><span
style="position:absolute;top:1in;left:3.25in;width:0.01in;h
eight:0.4375in;overflow:hidden;background-
color:#000000;"></span><span
style="position:absolute;top:1in;left:4.6875in;width:0.01in
;height:0.4375in;overflow:hidden;background-
color:#000000;"></span>
</div>
</div>
</body>
</HTML>
Dynamics. They allow exporting of the report to HTML.
Then HTML export works in all browsers but when i try to
open it in Word, Word Crashes.
The specific line that crashes word is:
"<div style="page-break-inside:avoid;">"
apparently it doesnt like the page break stuff.
After I take that line out, the file opens in Word but
doesnt render correctly. Here is the HTML, copy it to a
file, then open it in a browser, then try to open it in
Word.
Thanks,
Kevin
See HTML starting below line...
-----------------------------------------------------------
<HTML>
<HEAD>
<title>Unicare Reports</title>
<script language="javascript">
this.onBlur = this.focus();
</script>
</HEAD>
<body>
<form name="Form1" method="post"
action="Reports.aspx?job=51DF4012-9696-11D7-BC9C-
009027E32D00" id="Form1">
<input type="hidden" name="__VIEWSTATE"
value="dDwtNDEzNDY0MTc2O3Q8O2w8aTwwPjs+O2w8dDw7bDxpPDE+O2k8
NT47PjtsPHQ8cDxwPGw8TmF2aWdhdGVVcmw7VmlzaWJsZTs+O2w8L3dlYnJ
lcG9ydHMvZG9jLzUxZGY0MDEyLTk2OTYtMTFkNy1iYzljLTAwOTAyN2UzMm
QwMC5wZGY7bzx0Pjs+Pjs+Ozs+O3Q8cDxwPGw8VmlzaWJsZTs+O2w8bzx0P
js+Pjs+Ozs+Oz4+Oz4+Oz6gvm6lrkM0PoDzM4QYYxbxOuhFng==" />
<table width="100%">
<tr>
<td><a
id="pdfLink" href="/webreports/doc/51df4012-9696-11d7-bc9c-
009027e32d00.pdf" target="_new">PDF Version</a>
<span
id="Label1">|</span>
<a
id="printLink" href="javascript:window.print();">Print
Report</a></td>
<td
align="right"></td>
</tr>
</table>
</form>
<style>
@page{size: 8.5in 11in;margin-
top:0in;margin-left:0in;margin-right:0in;margin-
bottom:0in;}
</style><div style="page-break-
inside:avoid;">
<div
style="position:relative;width:8.5in;height:11in;">
<span
style="position:absolute;top:0.7638889in;left:0.2638889in;w
idth:1.611111in;height:0.1861111in;overflow:hidden;font-
family:Arial;font-size:10pt;color:#000000;vertical-
align:top;">Polk</span><span
style="position:absolute;top:0.7638889in;left:2.263889in;wi
dth:1.548611in;height:0.1861111in;overflow:hidden;font-
family:Arial;font-size:10pt;color:#000000;vertical-
align:top;">Jacquel</span><span
style="position:absolute;top:1.638889in;left:3.638889in;wid
th:1.548611in;height:0.1861111in;overflow:hidden;font-
family:Arial;font-size:10pt;color:#000000;vertical-
align:top;">3000213 </span><span
style="position:absolute;top:1.638889in;left:5.388889in;wid
th:1.611111in;height:0.1861111in;overflow:hidden;font-
family:Arial;font-size:10pt;color:#000000;vertical-
align:top;">12/29/2001 12:00:00 AM</span><span
style="position:absolute;top:4.576389in;left:0.2638889in;wi
dth:1.611111in;height:0.1735976in;overflow:hidden;font-
family:Arial;font-size:10pt;color:#000000;vertical-
align:top;">1/5/1981 12:00:00 AM</span><span
style="position:absolute;top:3.951389in;left:0.2638889in;wi
dth:3.298611in;height:0.1861111in;overflow:hidden;font-
family:Arial;font-size:10pt;color:#000000;vertical-
align:top;">Jacquel Polk</span><span
style="position:absolute;top:7.694445in;left:0.3819444in;wi
dth:6.5in;height:0.01in;overflow:hidden;background-
color:#000000;"></span><span
style="position:absolute;top:8.069445in;left:0.3819444in;wi
dth:6.5in;height:0.01in;overflow:hidden;background-
color:#000000;"></span><span
style="position:absolute;top:7.944445in;left:0.3819444in;wi
dth:6.5in;height:0.01in;overflow:hidden;background-
color:#000000;"></span><span
style="position:absolute;top:7.819445in;left:0.3819444in;wi
dth:6.5in;height:0.01in;overflow:hidden;background-
color:#000000;"></span><span
style="position:absolute;top:8.319445in;left:0.3819444in;wi
dth:6.5in;height:0.01in;overflow:hidden;background-
color:#000000;"></span><span
style="position:absolute;top:8.194445in;left:0.3819444in;wi
dth:6.5in;height:0.01in;overflow:hidden;background-
color:#000000;"></span><span
style="position:absolute;top:0.1388889in;left:2.076389in;wi
dth:3.111111in;height:0.1875in;overflow:hidden;font-
family:Arial;font-size:9.75pt;color:#000000;font-
weight:bold;text-align:center;vertical-align:top;">Ohio
Department of Job and Family Services</span><span
style="position:absolute;top:0.3263889in;left:2.076389in;wi
dth:3.111111in;height:0.1875in;overflow:hidden;font-
family:Arial;font-size:9.75pt;color:#000000;font-
weight:bold;text-align:center;vertical-
align:top;">INPATIENT HOSPITAL ADMISSION</span><span
style="position:absolute;top:8.451389in;left:0.6388889in;wi
dth:2.236111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:5.25pt;color:#000000;vertical-
align:top;">COUNTY DEPARTMENT OF JOB AND FAMILY
SERVICES</span><span
style="position:absolute;top:8.388889in;left:2.888889in;wid
th:1.611111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;text-
align:center;vertical-align:middle;">Signature and Title
of Agency Employee</span><span
style="position:absolute;top:8.388889in;left:5.951389in;wid
th:0.2361111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;text-
align:center;vertical-align:middle;">Date</span><span
style="position:absolute;top:5.513889in;left:2.513889in;wid
th:2.361111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;font-
weight:bold;text-align:center;vertical-align:top;">COUNTY
DEPARTMENT OF JOB AND FAMILY SERVICES</span><span
style="position:absolute;top:5.638889in;left:2.513889in;wid
th:2.361111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:8.25pt;color:#000000;font-
weight:bold;text-align:center;vertical-align:top;">NOTICE
OF ELIGIBILITY TO HOSPITAL</span><span
style="position:absolute;top:5.826389in;left:0.4513889in;wi
dth:1.986111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6.75pt;color:#000000;font-
weight:bold;text-align:center;vertical-align:top;">GENERAL
RELIEF</span><span
style="position:absolute;top:5.826389in;left:2.888889in;wid
th:1.861111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6.75pt;color:#000000;font-
weight:bold;text-align:center;vertical-
align:top;">MEDICAID</span><span
style="position:absolute;top:5.826389in;left:5.263889in;wid
th:1.861111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6.75pt;color:#000000;font-
weight:bold;text-align:center;vertical-
align:top;">CRIPPLED CHILDREN</span><span
style="position:absolute;top:6.888889in;left:0.6388889in;wi
dth:2.048611in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;">Suspended
case. Must be approved for payment by</span><span
style="position:absolute;top:7.006945in;left:2.506944in;wid
th:4.375in;height:0.01in;overflow:hidden;background-
color:#000000;"></span><span
style="position:absolute;top:7.013889in;left:3.576389in;wid
th:2.236111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:5.25pt;color:#000000;text-
align:center;">Signature of County Department of Job and
Family Services Director</span><span
style="position:absolute;top:7.201389in;left:0.6388889in;wi
dth:4.736111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;">Patient's below
listed resources in the amount of
$_________________________ must be applied to the hospital
charges.</span><span
style="position:absolute;top:7.388889in;left:0.6388889in;wi
dth:4.736111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;">Patient is not
eligible. See explanation below.</span><span
style="position:absolute;top:6.319445in;left:0.3819444in;wi
dth:2.118in;height:0.01in;overflow:hidden;background-
color:#000000;"></span><span
style="position:absolute;top:6.194445in;left:0.3819444in;wi
dth:2.118in;height:0.01in;overflow:hidden;background-
color:#000000;"></span><span
style="position:absolute;top:6.444445in;left:0.3819444in;wi
dth:2.118in;height:0.01in;overflow:hidden;background-
color:#000000;"></span><span
style="position:absolute;top:6.569445in;left:0.3819444in;wi
dth:2.118in;height:0.01in;overflow:hidden;background-
color:#000000;"></span><span
style="position:absolute;top:5.951389in;left:0.6388889in;wi
dth:1.673611in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;">Patient is
eligible under GR</span><span
style="position:absolute;top:6.076389in;left:0.6388889in;wi
dth:1.673611in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;">Mail Claim
To:</span><span
style="position:absolute;top:5.951389in;left:3.076389in;wid
th:1.673611in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;">Patient is
eligible under Title XIX</span><span
style="position:absolute;top:6.076389in;left:3.076389in;wid
th:1.673611in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;">Mail Claim
To:</span><span
style="position:absolute;top:6.263889in;left:3.076389in;wid
th:1.673611in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;">Ohio Department
of Job and Family Services</span><span
style="position:absolute;top:6.388889in;left:3.076389in;wid
th:1.673611in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;">P.O. Box
2654</span><span
style="position:absolute;top:6.513889in;left:3.076389in;wid
th:1.673611in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;">Columbus, Ohio
43216</span><span
style="position:absolute;top:5.951389in;left:5.451389in;wid
th:1.673611in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;">Patient is
eligible under Title V</span><span
style="position:absolute;top:6.076389in;left:5.451389in;wid
th:1.673611in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;">Mail Claim
To:</span><span
style="position:absolute;top:6.263889in;left:5.451389in;wid
th:1.673611in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;">Ohio Department
of Health</span><span
style="position:absolute;top:6.388889in;left:5.451389in;wid
th:1.673611in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;">Crippled
Children Services</span><span
style="position:absolute;top:6.513889in;left:5.451389in;wid
th:1.673611in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;">P.O. Box
1603</span><span
style="position:absolute;top:6.638889in;left:5.451389in;wid
th:1.673611in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;">Columbus, Ohio
43216</span><span
style="position:absolute;top:5.076389in;left:0.2638889in;wi
dth:3.423611in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;"> 15. Signature (Patient or authorized
representitive) (Signature by mark must be witnessed)
</span><span
style="position:absolute;top:5.076389in;left:3.701389in;wid
th:3.423611in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;"> 16. Name and address of person other than
patient who gave above information</span><span
style="position:absolute;top:4.763889in;left:0.3888889in;wi
dth:1.298611in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;"> Social Security Claim Number</span><span
style="position:absolute;top:4.451389in;left:0.3888889in;wi
dth:1.298611in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;"> Date of birth</span><span
style="position:absolute;top:4.138889in;left:0.3888889in;wi
dth:1.298611in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;"> Address</span><span
style="position:absolute;top:3.826389in;left:0.3888889in;wi
dth:1.298611in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;"> Name of applicant</span><span
style="position:absolute;top:3.638889in;left:0.2638889in;wi
dth:6.798611in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;font-
weight:bold;vertical-align:middle;"> 14. ELIGIBILITY
DETERMINATION - This MUST be completed if the patient is
not an eligible recipient under the Medical Assistance
Program.</span><span
style="position:absolute;top:3.826389in;left:3.701389in;wid
th:3.423611in;height:0.1565in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;text-
align:center;vertical-align:middle;"> INCOME AND RESOURCES
REPORTED FOR APPLICANT AND/OR SPOUSE</span><span
style="position:absolute;top:4.013889in;left:4.638889in;wid
th:1.236111in;height:0.09350014in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;text-
align:center;vertical-align:middle;">APPLICANT</span><span
style="position:absolute;top:4.013889in;left:5.888889in;wid
th:1.236111in;height:0.09350014in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;text-
align:center;vertical-align:middle;">SPOUSE</span><span
style="position:absolute;top:4.138889in;left:3.701389in;wid
th:0.9236111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;"> Weekly
earnings</span><span
style="position:absolute;top:4.326389in;left:3.701389in;wid
th:0.9236111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;"> Retirement</span><span
style="position:absolute;top:4.451389in;left:3.701389in;wid
th:0.9236111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;"> Cash on
hand</span><span
style="position:absolute;top:4.638889in;left:3.701389in;wid
th:0.9236111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;"> Savings or checking</span><span
style="position:absolute;top:4.763889in;left:3.701389in;wid
th:0.9236111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;"> Real estate</span><span
style="position:absolute;top:4.951389in;left:3.701389in;wid
th:0.9236111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;"> Life insurance</span><span
style="position:absolute;top:4.451389in;left:2.076389in;wid
th:1.298611in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;"> Place of birth</span><span
style="position:absolute;top:4.763889in;left:2.076389in;wid
th:1.298611in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;"> Beneficiary</span><span
style="position:absolute;top:3.138889in;left:6.263889in;wid
th:0.7361111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;"> CODE</span><span
style="position:absolute;top:2.763889in;left:6.263889in;wid
th:0.7361111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;"> ICDA CODE</span><span
style="position:absolute;top:1.888889in;left:6.263889in;wid
th:0.7361111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;"> CODE</span><span
style="position:absolute;top:2.326389in;left:6.263889in;wid
th:0.7361111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;"> ICDA CODE</span><span
style="position:absolute;top:1.888889in;left:3.638889in;wid
th:2.611111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;"> 10. ADMITTING PHYSICIAN</span><span
style="position:absolute;top:2.326389in;left:3.638889in;wid
th:2.611111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;"> 12. (a) ADMITTING DIAGNOSIS OR NATURE OF
INJURY</span><span
style="position:absolute;top:2.763889in;left:3.638889in;wid
th:2.611111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;"> (b) SECONDARY DIAGNOSIS OR CAUSE OF
INJURY</span><span
style="position:absolute;top:3.263889in;left:0.2638889in;wi
dth:2.423611in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:top;"> nursing home within the last 60
days?</span><span
style="position:absolute;top:3.138889in;left:0.2638889in;wi
dth:2.423611in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;"> 13. (a) Was the patient an inpatient of a
hospital, ECF, or</span><span
style="position:absolute;top:3.451389in;left:0.7638889in;wi
dth:0.2986111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;">Yes</span><span
style="position:absolute;top:3.451389in;left:1.388889in;wid
th:0.2986111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;">No</span><span
style="position:absolute;top:3.138889in;left:2.701389in;wid
th:2.423611in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;"> (b) If yes, enter:</span><span
style="position:absolute;top:3.263889in;left:2.826389in;wid
th:0.4236111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;">
Name</span><span
style="position:absolute;top:3.388889in;left:2.826389in;wid
th:0.4861111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;">
Location</span><span
style="position:absolute;top:3.5in;left:3.3125in;width:2.81
25in;height:0.01in;overflow:hidden;background-
color:#000000;"></span><span
style="position:absolute;top:3.375in;left:3.25in;width:2.87
5in;height:0.01in;overflow:hidden;background-
color:#000000;"></span><span
style="position:absolute;top:1.451389in;left:5.388889in;wid
th:1.736111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;"> 9. ADMISSION DATE</span><span
style="position:absolute;top:1.451389in;left:3.638889in;wid
th:1.736111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;"> PROVIDER NUMBER</span><span
style="position:absolute;top:1.451389in;left:0.2638889in;wi
dth:1.736111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;"> PROVIDER NAME AND ADDRESS</span><span
style="position:absolute;top:1.013889in;left:0.2638889in;wi
dth:1.736111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;"> 3. CASE NUMBER (10 DIGITS)</span><span
style="position:absolute;top:1.013889in;left:2.513889in;wid
th:0.6736111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;"> 4. ADC NO.</span><span
style="position:absolute;top:1.013889in;left:3.263889in;wid
th:1.361111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;"> 5. MEDICAL RECORD NO.</span><span
style="position:absolute;top:1.013889in;left:4.701389in;wid
th:2.361111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;"> 6. IF THIS CLAIM REQUIRED PRIOR
AUTHORIZATION</span><span
style="position:absolute;top:1.138889in;left:4.701389in;wid
th:2.361111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:top;"> ENTER PRIOR AUTHORIZATION CONTROL
NUMBER</span><span
style="position:absolute;top:0.5138889in;left:4.326389in;wi
dth:2.798611in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;"> 2. CASE LAST NAME IF DIFFERENT FROM
PATIENT'S LAST NAME</span><span
style="position:absolute;top:0.5138889in;left:4.076389in;wi
dth:0.1736111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;"> MI</span><span
style="position:absolute;top:0.5138889in;left:2.263889in;wi
dth:1.736111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;"> FIRST</span><span
style="position:absolute;top:0.5138889in;left:0.2638889in;w
idth:2.798611in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;"> 1. PATIENT'S LAST NAME</span><span
style="position:absolute;top:8.701389in;left:0.2638889in;wi
dth:6.861111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;"> It is understood that the Department of
Job and Family Services can make no payment on behalf of
your patient if it is determined that he has sufficient
resources to meet his obligation</span><span
style="position:absolute;top:8.826389in;left:0.2638889in;wi
dth:6.861111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;"> to the hospital or is otherwise
ineligible according to agency policies and
standards.</span><span
style="position:absolute;top:1.013889in;left:2.138889in;wid
th:0.3611111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;text-
align:center;vertical-align:middle;">FOR</span><span
style="position:absolute;top:1.138889in;left:2.138889in;wid
th:0.3611111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;text-
align:center;vertical-align:top;">ADC</span><span
style="position:absolute;top:1.201389in;left:2.138889in;wid
th:0.3611111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;text-
align:center;vertical-align:middle;">CASE</span><span
style="position:absolute;top:1.326389in;left:2.138889in;wid
th:0.3611111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;text-
align:center;vertical-align:middle;">ONLY</span><span
style="position:absolute;top:1.888889in;left:0.2638889in;wi
dth:3.361111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;"> 11. (A) CHECK THE APPROPRIATE BOX TO
INDICATE PAYMENT SOURCES OTHER</span><span
style="position:absolute;top:2.013889in;left:0.2638889in;wi
dth:3.361111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:top;"> THAN MEDICAID</span><span
style="position:absolute;top:2.763889in;left:0.3263889in;wi
dth:3.361111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;"> (B) If any box is checked, give third
party name and address</span><span
style="position:absolute;top:2.888889in;left:0.5138889in;wi
dth:0.4236111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;">
Name</span><span
style="position:absolute;top:3.013889in;left:0.5138889in;wi
dth:0.4861111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;">
Address</span><span
style="position:absolute;top:3.095in;left:0.9444444in;width
:2.555556in;height:0.01in;overflow:hidden;background-
color:#000000;"></span><span
style="position:absolute;top:2.98in;left:0.9in;width:2.6in;
height:0.01in;overflow:hidden;background-
color:#000000;"></span><span
style="position:absolute;top:2.638889in;left:0.7013889in;wi
dth:0.1111111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;text-
align:center;vertical-align:middle;">a.</span><span
style="position:absolute;top:2.638889in;left:1.513889in;wid
th:0.1111111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;text-
align:center;vertical-align:middle;">b.</span><span
style="position:absolute;top:2.638889in;left:2.263889in;wid
th:0.1111111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;text-
align:center;vertical-align:middle;">c.</span><span
style="position:absolute;top:2.638889in;left:1.013889in;wid
th:0.4236111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;">Group</span><span
style="position:absolute;top:2.638889in;left:1.826389in;wid
th:0.4236111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;">Individual</span><span
style="position:absolute;top:2.638889in;left:2.576389in;wid
th:0.9236111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:middle;">Major Medical</span><span
style="position:absolute;top:2.513889in;left:0.5763889in;wi
dth:2.986111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:top;">If (2) or (3) is checked, indicate type of
policy</span><span
style="position:absolute;top:2.138889in;left:0.2638889in;wi
dth:0.4236111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:top;"> (1)</span><span
style="position:absolute;top:2.388889in;left:0.2638889in;wi
dth:0.4236111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:top;"> (3)</span><span
style="position:absolute;top:2.263889in;left:0.2638889in;wi
dth:0.4236111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:top;"> (2)</span><span
style="position:absolute;top:2.138889in;left:0.8263889in;wi
dth:1.111111in;height:0.105in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:top;">Self or Family</span><span
style="position:absolute;top:2.263889in;left:0.8263889in;wi
dth:1.111111in;height:0.105in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:top;">Blue Cross-Blue Shield</span><span
style="position:absolute;top:2.388889in;left:0.8263889in;wi
dth:1.111111in;height:0.105in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:top;">Private Carrier</span><span
style="position:absolute;top:2.138889in;left:1.951389in;wid
th:0.1736111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;text-
align:center;vertical-align:top;">(4)</span><span
style="position:absolute;top:2.263889in;left:1.951389in;wid
th:0.1736111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;text-
align:center;vertical-align:top;">(5)</span><span
style="position:absolute;top:2.388889in;left:1.951389in;wid
th:0.1736111in;height:0.125in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;text-
align:center;vertical-align:top;">(6)</span><span
style="position:absolute;top:2.138889in;left:2.263889in;wid
th:1.111111in;height:0.105in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:top;">Employer or Union</span><span
style="position:absolute;top:2.263889in;left:2.263889in;wid
th:1.111111in;height:0.105in;overflow:hidden;font-
family:Arial;font-size:6pt;color:#000000;vertical-
align:top;">Public Agency</span><span
style="position:absolute;top:2.388889in;left:2.263889in;wid
th:1.298611in;height:0.105in;overflow:hidden;font-
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