/* /Pages/SubmitClaims/ClaimManualEntryForm.razor.rz.scp.css */
.has-feedback[b-ydnojzho4h] { position: relative; }

.has-feedback .form-control[b-ydnojzho4h] { padding-right: 42.5px; }

.has-feedback label ~ .form-control-feedback[b-ydnojzho4h] { top: 25px; }

.has-feedback label.sr-only ~ .form-control-feedback[b-ydnojzho4h] { top: 0; }

.form-inline .has-feedback .form-control-feedback[b-ydnojzho4h] { top: 0; }

.form-horizontal .has-feedback .form-control-feedback[b-ydnojzho4h] { right: 15px; }

.navbar-form .has-feedback .form-control-feedback[b-ydnojzho4h] { top: 0; }

.has-error .help-block[b-ydnojzho4h],
.has-error .control-label[b-ydnojzho4h],
.has-error .radio[b-ydnojzho4h],
.has-error .checkbox[b-ydnojzho4h],
.has-error .radio-inline[b-ydnojzho4h],
.has-error .checkbox-inline[b-ydnojzho4h],
.has-error.radio label[b-ydnojzho4h],
.has-error.checkbox label[b-ydnojzho4h],
.has-error.radio-inline label[b-ydnojzho4h],
.has-error.checkbox-inline label[b-ydnojzho4h] { color: #a94442; }

.has-error .form-control[b-ydnojzho4h] {
    -webkit-box-shadow: inset 0 1px 1px rgba(0, 0, 0, 0.075);
    border-color: #a94442;
    box-shadow: inset 0 1px 1px rgba(0, 0, 0, 0.075);
}

.has-error .form-control:focus[b-ydnojzho4h] {
    -webkit-box-shadow: inset 0 1px 1px rgba(0, 0, 0, 0.075), 0 0 6px #ce8483;
    border-color: #843534;
    box-shadow: inset 0 1px 1px rgba(0, 0, 0, 0.075), 0 0 6px #ce8483;
}

.has-error .input-group-addon[b-ydnojzho4h] {
    background-color: #f2dede;
    border-color: #a94442;
    color: #a94442;
}

.has-error .form-control-feedback[b-ydnojzho4h] { color: #a94442; }

.has-feedback label ~ .form-control-feedback[b-ydnojzho4h] { top: 25px; }

.has-feedback label.sr-only ~ .form-control-feedback[b-ydnojzho4h] { top: 0; }

.lblvalue[b-ydnojzho4h] {
    margin-bottom: 5px;
    margin-top: 5px;
    text-align: center;
    width: 100%;
}


#snackbar[b-ydnojzho4h] {
    background-color: #67b56e;
    border-radius: 10px;
    bottom: 30px;
    color: #fff;
    font-size: 17px;
    left: 50%;
    margin-left: -125px;
    min-width: 250px;
    padding: 16px;
    position: fixed;
    text-align: center;
    visibility: hidden;
    z-index: 1;
}

#snackbar.show[b-ydnojzho4h] {
    -webkit-animation: fadein 0.5s, fadeout 0.5s 2.5s;
    animation: fadein-b-ydnojzho4h 0.5s, fadeout-b-ydnojzho4h 0.5s 2.5s;
    visibility: visible;
}

@-webkit-keyframes fadein {
    from {
        bottom: 0;
        opacity: 0;
    }

    to {
        bottom: 30px;
        opacity: 1;
    }
}

@keyframes fadein-b-ydnojzho4h {
    from {
        bottom: 0;
        opacity: 0;
    }

    to {
        bottom: 30px;
        opacity: 1;
    }
}

@-webkit-keyframes fadeout {
    from {
        bottom: 30px;
        opacity: 1;
    }

    to {
        bottom: 0;
        opacity: 0;
    }
}

@keyframes fadeout-b-ydnojzho4h {
    from {
        bottom: 30px;
        opacity: 1;
    }

    to {
        bottom: 0;
        opacity: 0;
    }
}


#divClaimEntriesPrint *[b-ydnojzho4h] {
    font-family: InterstateLight, Helvetica, sans-serif;
    font-weight: 300;
    letter-spacing: -0.3px;
}

#divClaimEntriesPrint input[type=text][b-ydnojzho4h] {
    margin-top: 7px;
    vertical-align: middle;
    height: 20px;
    padding: 0;
    border: 1px solid #ccc;
}

#divClaimEntriesPrint input[type=date][b-ydnojzho4h] {
    margin-top: 7px;
    vertical-align: middle;
    height: 20px;
    width: 140px;
    padding: 0;
    border: 1px solid #ccc;
}

#divClaimEntriesPrint input[type=number][b-ydnojzho4h] {
    height: 20px;
    background-color: #eadfdf;
    border: 1px solid #ccc;
    width: 200px;
}

#divClaimEntriesPrint input[type=radio][b-ydnojzho4h] {
    display: inline-block !important;
    height: 1em !important;
    padding: 0 !important;
    width: 1em !important;
    border-radius: 1em !important;
    vertical-align: middle !important;
    opacity: 1.0 !important;
    position: relative !important;
    font-family: inherit !important; /* 1 */
    font-size: 100% !important; /* 1 */
    line-height: 1.15 !important; /* 1 */
    margin: 0 2px 2px 0 !important; /* 2 */
    overflow: visible !important;
    box-sizing: border-box !important; /* 1 */
}

    #divClaimEntriesPrint input[type=radio]:checked[b-ydnojzho4h] {
        background-color: #0079c1;
    }

    input[type="radio"] + label[b-ydnojzho4h] {
        padding-bottom: 15px;
    }

    #divClaimEntriesPrint textarea[b-ydnojzho4h] {
    margin-top: 7px;
    font-size: 15px;
    height: 80px;
    line-height: 1.0;
    border: 1px solid #ccc;
}

#divClaimEntriesPrint text[b-ydnojzho4h] {
    font-size: 15px;
}

#divClaimEntriesPrint[b-ydnojzho4h] {
    align-content: center;
    flex-direction: column;
    font-family: InterstateLight, Helvetica, sans-serif;
    font-family: sans-serif;
    font-size: 14px;
    font-weight: 300;
    justify-content: center;
    letter-spacing: 0 !important;
    padding-top: 20px;
}

table#tblProcedures td[b-ydnojzho4h] {
    padding-bottom: 5px;
    padding-top: 5px;
}

table#tblProcedures input[type=text][b-ydnojzho4h] {
    margin-top: 0;
}

.healthformlabel[b-ydnojzho4h] {
    color: #333333;
    font-family: InterstateLight, Helvetica, sans-serif;
    font-size: 11px;
    font-weight: 300;
}

.patientFormContainer[b-ydnojzho4h] {
    font-size: 11px;
    font-family: arial;
}

.patientFormContainer[b-ydnojzho4h] {
    display: grid;
    grid-template-columns: 1fr 1fr 1fr;
    grid-template-rows: 68px 58px 75px 75px 75px 75px 75px 75px 75px 75px 75px 75px 75px 75px 75px;
    gap: 0 0;
    grid-auto-flow: row;
    grid-template-areas:
        "Health_Insurance_Claim_Form Health_Insurance_Claim_Form Health_Insurance_Claim_Form"
        "Patient_and_insured_information Patient_and_insured_information Patient_and_insured_information"
        "_1_Name_of_insurance_company _1_Name_of_insurance_company _1a_Insureds_certificate_number"
        "_2_Patients_name _3_Patients_birthdate_sex _4_Insureds_name"
        "_5_Patients_address _6_Patient_relationship_to_insured _7_Insureds_address"
        "_5_Patients_address _6_Patient_relationship_to_insured _7_Insureds_address"
        "_5_Parish _8_Patient_status _7_Parish"
        "_5_Postal_code_telephone _8_Patient_status _7_Postal_code_telephone"
        "_9_Other_insureds_name _10_Is_patients_condition_related_to _11_Insureds_policy_group_number"
        "_9a_Other_insureds_policy_or_group_number _10_Is_patients_condition_related_to _11a_Insureds_date_of_birth_sex"
        "_9b_Other_insureds_date_of_birth_sex _10_Is_patients_condition_related_to _11b_Employers_name_or_school_name"
        "_9c_Employers_name_or_school_name _10_Is_patients_condition_related_to _11c_Insurance_plan_name_or_program_name"
        "_9d_Insurance_plan_name_or_program_name _9d_Insurance_plan_name_or_program_name _11d_Is_there_another_health_benefit_plan"
        "_12_Patients_or_authorized_persons_signature _12_Patients_or_authorized_persons_signature _13_Insureds_or_authorized_persons_signature"
        "_12_Patients_or_authorized_persons_signature _12_Patients_or_authorized_persons_signature _13_Insureds_or_authorized_persons_signature";
}

.Health_Insurance_Claim_Form[b-ydnojzho4h] {
    display: grid;
    grid-template-columns: 1fr;
    grid-template-rows: 1fr 1fr;
    gap: 0 0;
    grid-auto-flow: row;
    grid-template-areas:
        "Health_Insurance_Title"
        "Health_Insurance_Subtitle";
    grid-area: Health_Insurance_Claim_Form;
}

.Health_Insurance_Title[b-ydnojzho4h] {
    grid-area: Health_Insurance_Title;
}

.Health_Insurance_Subtitle[b-ydnojzho4h] {
    grid-area: Health_Insurance_Subtitle;
}

.Patient_and_insured_information[b-ydnojzho4h] {
    grid-area: Patient_and_insured_information;
    display: flex;
    align-items: center;
    justify-content: center;
}

._1_Name_of_insurance_company[b-ydnojzho4h] {
    padding: 5px;
    border-top: 4px solid brown;
    border-left: 1px solid brown;
    display: grid;
    grid-template-rows: 1fr 1fr;
    grid-auto-columns: 1fr;
    gap: 0 0;
    grid-auto-flow: row;
    grid-area: _1_Name_of_insurance_company;
}

._1_Top[b-ydnojzho4h] {
    justify-self: start;
    grid-area: 1 / 1 / 2 / 2;
}

._1_Bottom[b-ydnojzho4h] {
    justify-self: center;
    grid-area: 2 / 1 / 3 / 2;
}

._1a_Insureds_certificate_number[b-ydnojzho4h] {
    padding: 5px;
    border-top: 4px solid brown;
    border-left: 1px solid brown;
    border-right: 1px solid brown;
    display: grid;
    grid-template-columns: 1fr;
    grid-template-rows: 0.7fr 1fr 0.6fr;
    gap: 0 0;
    grid-auto-flow: row;
    grid-template-areas:
        "_1a_Top"
        "_1a_Bottom"
        "_1a_Error";
    grid-area: _1a_Insureds_certificate_number;
}

._1a_Top[b-ydnojzho4h] {
    grid-area: _1a_Top;
}

._1a_Bottom[b-ydnojzho4h] {
    grid-area: _1a_Bottom;
}

._1a_Error[b-ydnojzho4h] {
    grid-area: _1a_Error;
}

._2_Patients_name[b-ydnojzho4h] {
    padding: 5px;
    border-top: 1px solid brown;
    border-left: 1px solid brown;
    border-right: 1px solid brown;
    display: grid;
    grid-template-columns: 1fr;
    grid-template-rows: 0.7fr 1fr 0.6fr;
    gap: 0 0;
    grid-auto-flow: row;
    grid-template-areas:
        "_2_Top"
        "_2_Bottom"
        "_2_Error";
    grid-area: _2_Patients_name;
}

._2_Top[b-ydnojzho4h] {
    grid-area: _2_Top;
}

._2_Bottom[b-ydnojzho4h] {
    grid-area: _2_Bottom;
}

._2_Error[b-ydnojzho4h] {
    grid-area: _2_Error;
}

._3_Patients_birthdate_sex[b-ydnojzho4h] {
    padding: 5px;
    border-top: 1px solid brown;
    display: grid;
    grid-template-columns: 1fr 0.6fr;
    grid-template-rows: 0.7fr 1fr 0.6fr;
    gap: 0 0;
    grid-auto-flow: row;
    grid-template-areas:
        "_3_TopLeft _3_TopRight"
        "_3_BottomLeft _3_BottomRight"
        "_3_ErrorLeft _3_ErrorRight";
    grid-area: _3_Patients_birthdate_sex;
}

._3_TopLeft[b-ydnojzho4h] {
    grid-area: _3_TopLeft;
}

._3_TopRight[b-ydnojzho4h] {
    grid-area: _3_TopRight;
}

._3_BottomLeft[b-ydnojzho4h] {
    grid-area: _3_BottomLeft;
}

._3_BottomRight[b-ydnojzho4h] {
    grid-area: _3_BottomRight;
    display: flex;
    margin-top: 9px;
    justify-content: center;
}

._3_ErrorLeft[b-ydnojzho4h] {
    grid-area: _3_ErrorLeft;
    margin-top: -12px;
}

._3_ErrorRight[b-ydnojzho4h] {
    grid-area: _3_ErrorRight;
    margin-top: -12px;
}

._4_Insureds_name[b-ydnojzho4h] {
    padding: 5px;
    border-top: 1px solid brown;
    border-left: 1px solid brown;
    border-right: 1px solid brown;
    display: grid;
    grid-template-columns: 1fr;
    grid-template-rows: 0.7fr 1fr 0.6fr;
    gap: 0 0;
    grid-auto-flow: row;
    grid-template-areas:
        "_4_Top"
        "_4_Bottom"
        "_4_Error";
    grid-area: _4_Insureds_name;
}

._4_Top[b-ydnojzho4h] {
    grid-area: _4_Top;
}

._4_Bottom[b-ydnojzho4h] {
    grid-area: _4_Bottom;
}

._4_Error[b-ydnojzho4h] {
    grid-area: _4_Error;
}

._5_Patients_address[b-ydnojzho4h] {
    padding: 5px;
    border-top: 1px solid brown;
    border-left: 1px solid brown;
    border-right: 1px solid brown;
    display: grid;
    grid-template-columns: 1fr;
    grid-template-rows: 0.3fr 1.2fr 0.3fr;
    gap: 0 0;
    grid-auto-flow: row;
    grid-template-areas:
        "_5_AddressTop"
        "_5_AddressBottom"
        "_5_AddressError";
    grid-area: _5_Patients_address;
}

._5_AddressTop[b-ydnojzho4h] {
    grid-area: _5_AddressTop;
}

._5_AddressBottom[b-ydnojzho4h] {
    grid-area: _5_AddressBottom;
}

._5_AddressError[b-ydnojzho4h] {
    grid-area: _5_AddressError;
}

._6_Patient_relationship_to_insured[b-ydnojzho4h] {
    padding: 5px;
    border-top: 1px solid brown;
    display: grid;
    grid-template-columns: 1fr 1fr 1fr 1fr;
    grid-template-rows: 0.6fr 1fr 0.6fr 1.8fr;
    gap: 0 0;
    grid-auto-flow: row;
    grid-template-areas:
        "_6_Top _6_Top _6_Top _6_Top"
        "_6_Self _6_Spouse _6_Child _6_Other"
        "_6_Error _6_Error _6_Error _6_Error"
        ". . . .";
    grid-area: _6_Patient_relationship_to_insured;
}

._6_Top[b-ydnojzho4h] {
    grid-area: _6_Top;
    margin-bottom: 12px;
}

._6_Self[b-ydnojzho4h] {
    grid-area: _6_Self;
    margin-left: 25px;
}

._6_Spouse[b-ydnojzho4h] {
    grid-area: _6_Spouse;
}

._6_Child[b-ydnojzho4h] {
    grid-area: _6_Child;
}

._6_Other[b-ydnojzho4h] {
    grid-area: _6_Other;
}

._6_Error[b-ydnojzho4h] {
    grid-area: _6_Error;
}

._7_Insureds_address[b-ydnojzho4h] {
    padding: 5px;
    border-top: 1px solid brown;
    border-left: 1px solid brown;
    border-right: 1px solid brown;
    display: grid;
    grid-template-columns: 1fr;
    grid-template-rows: 0.3fr 1.2fr 0.3fr;
    gap: 0 0;
    grid-auto-flow: row;
    grid-template-areas:
        "_7_AddressTop"
        "_7_AddressBottom"
        "_7_AddressError";
    grid-area: _7_Insureds_address;
}

._7_AddressTop[b-ydnojzho4h] {
    grid-area: _7_AddressTop;
}

._7_AddressBottom[b-ydnojzho4h] {
    grid-area: _7_AddressBottom;
}

._7_AddressError[b-ydnojzho4h] {
    grid-area: _7_AddressError;
}

._5_Parish[b-ydnojzho4h] {
    padding: 5px;
    border-top: 1px solid brown;
    border-left: 1px solid brown;
    border-right: 1px solid brown;
    display: grid;
    grid-template-columns: 1fr;
    grid-template-rows: 0.7fr 1fr 0.6fr;
    gap: 0 0;
    grid-auto-flow: row;
    grid-template-areas:
        "_5_ParishTop"
        "_5_ParishBottom"
        "_5_ParishError";
    grid-area: _5_Parish;
}

._5_ParishTop[b-ydnojzho4h] {
    grid-area: _5_ParishTop;
}

._5_ParishBottom[b-ydnojzho4h] {
    grid-area: _5_ParishBottom;
}

._5_ParishError[b-ydnojzho4h] {
    grid-area: _5_ParishError;
}

._5_Postal_code_telephone[b-ydnojzho4h] {
    padding: 5px;
    border-top: 1px solid brown;
    border-left: 1px solid brown;
    border-right: 1px solid brown;
    display: grid;
    grid-template-columns: 1fr 1fr;
    grid-template-rows: 0.7fr 1fr 0.6fr;
    gap: 0 0;
    grid-auto-flow: row;
    grid-template-areas:
        "_5_PostalCodeTop _5_TelephoneTop"
        "_5_PostalCodeBottom _5_TelephoneBottom"
        "_5_PostalCodeError _5_TelephoneError";
    grid-area: _5_Postal_code_telephone;
}

._5_PostalCodeTop[b-ydnojzho4h] {
    grid-area: _5_PostalCodeTop;
}

._5_TelephoneTop[b-ydnojzho4h] {
    grid-area: _5_TelephoneTop;
}

._5_PostalCodeBottom[b-ydnojzho4h] {
    grid-area: _5_PostalCodeBottom;
}

._5_TelephoneBottom[b-ydnojzho4h] {
    grid-area: _5_TelephoneBottom;
}

._5_PostalCodeError[b-ydnojzho4h] {
    grid-area: _5_PostalCodeError;
}

._5_TelephoneError[b-ydnojzho4h] {
    grid-area: _5_TelephoneError;
}

._8_Patient_status[b-ydnojzho4h] {
    padding: 5px;
    border-top: 1px solid brown;
    display: grid;
    grid-template-columns: 1fr 1fr 1fr;
    grid-template-rows: 0.6fr 1.4fr 1.4fr 0.5fr;
    gap: 0 0;
    grid-auto-flow: row;
    grid-template-areas:
        "_8_Top _8_Top _8_Top"
        "_8_Single _8_Married _8_Other"
        "_8_Full _8_Part _8_Employed"
        "_8_Error _8_Error _8_Error";
    grid-area: _8_Patient_status;
}

._8_Top[b-ydnojzho4h] {
    grid-area: _8_Top;
    margin-bottom: 12px;
}

._8_Single[b-ydnojzho4h] {
    grid-area: _8_Single;
    margin-left: 44px;
}

._8_Married[b-ydnojzho4h] {
    grid-area: _8_Married;
    margin-left: 28px;
}

._8_Other[b-ydnojzho4h] {
    grid-area: _8_Other;
    margin-left: 12px;
}

._8_Full[b-ydnojzho4h] {
    grid-area: _8_Full;
    margin-left: 10px;
}

._8_Part[b-ydnojzho4h] {
    grid-area: _8_Part;
    margin-left: 20px;
}

._8_Employed[b-ydnojzho4h] {
    grid-area: _8_Employed;
    margin-left: 30px;
}

._8_Error[b-ydnojzho4h] {
    grid-area: _8_Error;
}

._7_Parish[b-ydnojzho4h] {
    padding: 5px;
    border-top: 1px solid brown;
    border-left: 1px solid brown;
    border-right: 1px solid brown;
    display: grid;
    grid-template-columns: 1fr;
    grid-template-rows: 0.7fr 1fr 0.6fr;
    gap: 0 0;
    grid-auto-flow: row;
    grid-template-areas:
        "_7_ParishTop"
        "_7_ParishBottom"
        "_7_ParishError";
    grid-area: _7_Parish;
}

._7_ParishTop[b-ydnojzho4h] {
    grid-area: _7_ParishTop;
}

._7_ParishBottom[b-ydnojzho4h] {
    grid-area: _7_ParishBottom;
}

._7_ParishError[b-ydnojzho4h] {
    grid-area: _7_ParishError;
}

._7_Postal_code_telephone[b-ydnojzho4h] {
    padding: 5px;
    border-top: 1px solid brown;
    border-left: 1px solid brown;
    border-right: 1px solid brown;
    display: grid;
    grid-template-columns: 1fr 1fr;
    grid-template-rows: 0.7fr 1fr 0.6fr;
    gap: 0 0;
    grid-auto-flow: row;
    grid-template-areas:
        "_7_PostalCodeTop _7_TelephoneTop"
        "_7_PostalCodeBottom _7_TelephoneBottom"
        "_7_PostalCodeError _7_TelephoneError";
    grid-area: _7_Postal_code_telephone;
}

._7_PostalCodeTop[b-ydnojzho4h] {
    grid-area: _7_PostalCodeTop;
}

._7_TelephoneTop[b-ydnojzho4h] {
    grid-area: _7_TelephoneTop;
}

._7_PostalCodeBottom[b-ydnojzho4h] {
    grid-area: _7_PostalCodeBottom;
}

._7_TelephoneBottom[b-ydnojzho4h] {
    grid-area: _7_TelephoneBottom;
}

._7_PostalCodeError[b-ydnojzho4h] {
    grid-area: _7_PostalCodeError;
}

._7_TelephoneError[b-ydnojzho4h] {
    grid-area: _7_TelephoneError;
}

._10_Is_patients_condition_related_to[b-ydnojzho4h] {
    padding: 5px;
    border-top: 1px solid brown;
    display: grid;
    grid-template-columns: 1fr;
    grid-template-rows: 0.8fr 0.7fr 0.7fr 1fr 0.6fr 0.5fr 0.7fr 1fr 0.6fr 0.5fr 0.7fr 1fr 0.6fr 0.5fr;
    gap: 0 0;
    grid-auto-flow: row;
    grid-template-areas:
        "_10_Title"
        "."
        "_10a_Top"
        "_10a_Bottom"
        "_10a_Error"
        "."
        "_10b_Top"
        "_10b_Bottom"
        "_10b_Error"
        "."
        "_10c_Top"
        "_10c_Bottom"
        "_10c_Error"
        ".";
    grid-area: _10_Is_patients_condition_related_to;
}

._10_Title[b-ydnojzho4h] {
    grid-area: _10_Title;
}

._10a_Top[b-ydnojzho4h] {
    grid-area: _10a_Top;
}

._10a_Bottom[b-ydnojzho4h] {
    grid-area: _10a_Bottom;
    margin-left: 140px;
}

._10a_Error[b-ydnojzho4h] {
    grid-area: _10a_Error;
}

._10b_Top[b-ydnojzho4h] {
    grid-area: _10b_Top;
}

._10b_Bottom[b-ydnojzho4h] {
    grid-area: _10b_Bottom;
    margin-left: 140px;
}

._10b_Error[b-ydnojzho4h] {
    grid-area: _10b_Error;
}

._10c_Top[b-ydnojzho4h] {
    grid-area: _10c_Top;
}

._10c_Bottom[b-ydnojzho4h] {
    grid-area: _10c_Bottom;
    margin-left: 140px;
}

._10c_Error[b-ydnojzho4h] {
    grid-area: _10c_Error;
}

._9_Other_insureds_name[b-ydnojzho4h] {
    padding: 5px;
    border-top: 1px solid brown;
    border-left: 1px solid brown;
    border-right: 1px solid brown;
    display: grid;
    grid-template-columns: 1fr;
    grid-template-rows: 0.7fr 1fr 0.6fr;
    gap: 0 0;
    grid-auto-flow: row;
    grid-template-areas:
        "_9_Top"
        "_9_Bottom"
        "_9_Error";
    grid-area: _9_Other_insureds_name;
}

._9_Top[b-ydnojzho4h] {
    grid-area: _9_Top;
}

._9_Bottom[b-ydnojzho4h] {
    grid-area: _9_Bottom;
}

._9_Error[b-ydnojzho4h] {
    grid-area: _9_Error;
}

._9a_Other_insureds_policy_or_group_number[b-ydnojzho4h] {
    padding: 5px;
    border-top: 1px solid brown;
    border-left: 1px solid brown;
    border-right: 1px solid brown;
    display: grid;
    grid-template-columns: 1fr;
    grid-template-rows: .7fr 1fr 0.6fr;
    gap: 0 0;
    grid-auto-flow: row;
    grid-template-areas:
        "_9a_Top"
        "_9a_Bottom"
        "_9a_Error";
    grid-area: _9a_Other_insureds_policy_or_group_number;
}

._9a_Top[b-ydnojzho4h] {
    grid-area: _9a_Top;
}

._9a_Bottom[b-ydnojzho4h] {
    grid-area: _9a_Bottom;
}

._9a_Error[b-ydnojzho4h] {
    grid-area: _9a_Error;
}

._9b_Other_insureds_date_of_birth_sex[b-ydnojzho4h] {
    padding: 5px;
    border-top: 1px solid brown;
    border-left: 1px solid brown;
    border-right: 1px solid brown;
    display: grid;
    grid-template-columns: 1fr 0.6fr;
    grid-template-rows: 0.7fr 1fr 0.6fr;
    gap: 0 0;
    grid-auto-flow: row;
    grid-template-areas:
        "_9b_TopLeft _9b_TopRight"
        "_9b_BottomLeft _9b_BottomRight"
        "_9b_ErrorLeft _9b_ErrorRight";
    grid-area: _9b_Other_insureds_date_of_birth_sex;
}

._9b_TopLeft[b-ydnojzho4h] {
    grid-area: _9b_TopLeft;
}

._9b_TopRight[b-ydnojzho4h] {
    grid-area: _9b_TopRight;
}

._9b_BottomLeft[b-ydnojzho4h] {
    grid-area: _9b_BottomLeft;
}

._9b_BottomRight[b-ydnojzho4h] {
    grid-area: _9b_BottomRight;
    display: flex;
    margin-top: 9px;
    justify-content: center;
}

._9b_ErrorLeft[b-ydnojzho4h] {
    grid-area: _9b_ErrorLeft;
    margin-top: -12px;
}

._9b_ErrorRight[b-ydnojzho4h] {
    grid-area: _9b_ErrorRight;
    margin-top: -12px;
}

._9c_Employers_name_or_school_name[b-ydnojzho4h] {
    padding: 5px;
    border-top: 1px solid brown;
    border-left: 1px solid brown;
    border-right: 1px solid brown;
    display: grid;
    grid-template-columns: 1fr;
    grid-template-rows: 0.7fr 1fr 0.6fr;
    gap: 0 0;
    grid-auto-flow: row;
    grid-template-areas:
        "_9c_Top"
        "_9c_Bottom"
        "_9c_Error";
    grid-area: _9c_Employers_name_or_school_name;
}

._9c_Top[b-ydnojzho4h] {
    grid-area: _9c_Top;
}

._9c_Bottom[b-ydnojzho4h] {
    grid-area: _9c_Bottom;
}

._9c_Error[b-ydnojzho4h] {
    grid-area: _9c_Error;
}

._11_Insureds_policy_group_number[b-ydnojzho4h] {
    padding: 5px;
    border-top: 1px solid brown;
    border-left: 1px solid brown;
    border-right: 1px solid brown;
    display: grid;
    grid-template-columns: 1fr;
    grid-template-rows: 0.7fr 1fr 0.6fr;
    gap: 0 0;
    grid-auto-flow: row;
    grid-template-areas:
        "_11_Top"
        "_11_Bottom"
        "_11_Error";
    grid-area: _11_Insureds_policy_group_number;
}

._11_Top[b-ydnojzho4h] {
    grid-area: _11_Top;
}

._11_Bottom[b-ydnojzho4h] {
    grid-area: _11_Bottom;
}

._11_Error[b-ydnojzho4h] {
    grid-area: _11_Error;
}

._11a_Insureds_date_of_birth_sex[b-ydnojzho4h] {
    padding: 5px;
    border-top: 1px solid brown;
    border-left: 1px solid brown;
    border-right: 1px solid brown;
    display: grid;
    grid-template-columns: 1fr 0.6fr;
    grid-template-rows: 0.7fr 1fr 0.6fr;
    gap: 0 0;
    grid-auto-flow: row;
    grid-template-areas:
        "_11a_TopLeft _11a_TopRight"
        "_11a_BottomLeft _11a_BottomRight"
        "_11a_ErrorLeft _11a_ErrorRight";
    grid-area: _11a_Insureds_date_of_birth_sex;
}

._11a_ErrorLeft[b-ydnojzho4h] {
    grid-area: _11a_ErrorLeft;
    margin-top: -12px;
}

._11a_ErrorRight[b-ydnojzho4h] {
    grid-area: _11a_ErrorRight;
    margin-top: -12px;
}

._11a_BottomLeft[b-ydnojzho4h] {
    grid-area: _11a_BottomLeft;
}

._11a_BottomRight[b-ydnojzho4h] {
    grid-area: _11a_BottomRight;
    display: flex;
    margin-top: 9px;
    justify-content: center;
}

._11a_TopLeft[b-ydnojzho4h] {
    grid-area: _11a_TopLeft;
}

._11a_TopRight[b-ydnojzho4h] {
    grid-area: _11a_TopRight;
}

._11b_Employers_name_or_school_name[b-ydnojzho4h] {
    padding: 5px;
    border-top: 1px solid brown;
    border-left: 1px solid brown;
    border-right: 1px solid brown;
    display: grid;
    grid-template-columns: 1fr;
    grid-template-rows: 0.7fr 1fr 0.6fr;
    gap: 0 0;
    grid-auto-flow: row;
    grid-template-areas:
        "_11b_Top"
        "_11b_Bottom"
        "_11b_Error";
    grid-area: _11b_Employers_name_or_school_name;
}

._11b_Top[b-ydnojzho4h] {
    grid-area: _11b_Top;
}

._11b_Bottom[b-ydnojzho4h] {
    grid-area: _11b_Bottom;
}

._11b_Error[b-ydnojzho4h] {
    grid-area: _11b_Error;
}

._11c_Insurance_plan_name_or_program_name[b-ydnojzho4h] {
    padding: 5px;
    border-top: 1px solid brown;
    border-left: 1px solid brown;
    border-right: 1px solid brown;
    display: grid;
    grid-template-columns: 1fr;
    grid-template-rows: 0.7fr 1fr 0.6fr;
    gap: 0 0;
    grid-auto-flow: row;
    grid-template-areas:
        "_11c_Top"
        "_11c_Bottom"
        "_11c_Error";
    grid-area: _11c_Insurance_plan_name_or_program_name;
}

._11c_Top[b-ydnojzho4h] {
    grid-area: _11c_Top;
}

._11c_Bottom[b-ydnojzho4h] {
    grid-area: _11c_Bottom;
}

._11c_Error[b-ydnojzho4h] {
    grid-area: _11c_Error;
}

._9d_Insurance_plan_name_or_program_name[b-ydnojzho4h] {
    padding: 5px;
    border-top: 1px solid brown;
    border-left: 1px solid brown;
    display: grid;
    grid-template-columns: 1fr;
    grid-template-rows: 0.7fr 1fr 0.6fr;
    gap: 0 0;
    grid-auto-flow: row;
    grid-template-areas:
        "_9d_InsuranceTop"
        "_9d_InsuranceBottom"
        "_9d_InsuranceError";
    grid-area: _9d_Insurance_plan_name_or_program_name;
}

._9d_InsuranceTop[b-ydnojzho4h] {
    grid-area: _9d_InsuranceTop;
}

._9d_InsuranceBottom[b-ydnojzho4h] {
    grid-area: _9d_InsuranceBottom;
}

._9d_InsuranceError[b-ydnojzho4h] {
    grid-area: _9d_InsuranceError;
}

._11d_Is_there_another_health_benefit_plan[b-ydnojzho4h] {
    padding: 5px;
    border-top: 1px solid brown;
    border-left: 1px solid brown;
    border-right: 1px solid brown;
    display: grid;
    grid-template-columns: 1fr;
    grid-template-rows: 0.7fr 1fr 0.6fr;
    gap: 0 0;
    grid-auto-flow: row;
    grid-template-areas:
        "_11d_Top"
        "_11d_Bottom"
        "_11d_Error";
    grid-area: _11d_Is_there_another_health_benefit_plan;
}

._11d_Top[b-ydnojzho4h] {
    grid-area: _11d_Top;
}

._11d_Bottom[b-ydnojzho4h] {
    grid-area: _11d_Bottom;
}

._11d_Error[b-ydnojzho4h] {
    grid-area: _11d_Error;
}

._12_Patients_or_authorized_persons_signature[b-ydnojzho4h] {
    padding: 5px;
    border-top: 1px solid brown;
    border-left: 1px solid brown;
    border-bottom: 1px solid brown;
    display: grid;
    grid-template-columns: 1fr 1fr;
    grid-template-rows: 0.5fr 0.7fr 0.7fr 1fr 0.6fr;
    gap: 0 0;
    grid-auto-flow: row;
    grid-template-areas:
        "_12_Title _12_Title"
        ". ."
        "_12_SignedTop _12_DateTop"
        "_12_SignedBottom _12_DateBottom"
        "_12_SignedError _12_DateError";
    grid-area: _12_Patients_or_authorized_persons_signature;
}

._12_Title[b-ydnojzho4h] {
    grid-area: _12_Title;
}

._12_SignedTop[b-ydnojzho4h] {
    grid-area: _12_SignedTop;
}

._12_DateTop[b-ydnojzho4h] {
    grid-area: _12_DateTop;
}

._12_SignedBottom[b-ydnojzho4h] {
    grid-area: _12_SignedBottom;
}

._12_DateBottom[b-ydnojzho4h] {
    grid-area: _12_DateBottom;
}

._12_SignedError[b-ydnojzho4h] {
    grid-area: _12_SignedError;
}

._12_DateError[b-ydnojzho4h] {
    grid-area: _12_DateError;
}

._13_Insureds_or_authorized_persons_signature[b-ydnojzho4h] {
    padding: 5px;
    border: 1px solid brown;
    display: grid;
    grid-template-columns: 1fr;
    grid-template-rows: 0.5fr 0.7fr 0.7fr 1fr 0.6fr;
    gap: 0 0;
    grid-auto-flow: row;
    grid-template-areas:
        "_13_Title"
        "."
        "_13_Top"
        "_13_Bottom"
        "_13_Error";
    grid-area: _13_Insureds_or_authorized_persons_signature;
}

._13_Title[b-ydnojzho4h] {
    grid-area: _13_Title;
}

._13_Top[b-ydnojzho4h] {
    grid-area: _13_Top;
}

._13_Bottom[b-ydnojzho4h] {
    grid-area: _13_Bottom;
}

._13_Error[b-ydnojzho4h] {
    grid-area: _13_Error;
}

.physicianOrProviderContainer[b-ydnojzho4h] {
    font-size: 11px;
    font-family: arial;
}

.physicianOrProviderContainer[b-ydnojzho4h] {
    display: grid;
    grid-template-columns: 1fr 1fr 1fr;
    grid-template-rows: 75px 95px 125px 75px 150px 30px;
    gap: 0 0;
    grid-auto-flow: row;
    grid-template-areas:
        "_Physician_or_provider_information _Physician_or_provider_information _Physician_or_provider_information"
        "_14_Date_of_current _15_First_date_similar _16_Dates_unable_to_work"
        "_17_Name_of_referring_provider _17_Name_of_referring_provider _18_Hospitalization_dates"
        "_19_Address _19_Address _20_Hospital_lab_charges"
        "_21_Diagnosis_or_nature_of_illness _21_Diagnosis_or_nature_of_illness _22_Prior_authorization_number"
        "_Remove_procedures _Procedure_details _Add_procedures";
}

._Physician_or_provider_information[b-ydnojzho4h] {
    display: flex;
    justify-content: center;
    align-items: center;
    margin-top: 5px;
    margin-bottom: -5px;
    grid-area: _Physician_or_provider_information;
}

._14_Date_of_current[b-ydnojzho4h] {
    padding: 5px;
    border-top: 3px solid brown;
    border-left: 1px solid brown;
    display: grid;
    grid-template-columns: 1fr;
    grid-template-rows: 0.7fr 1fr 0.6fr;
    gap: 0 0;
    grid-auto-flow: row;
    grid-template-areas:
        "_14_Top"
        "_14_Bottom"
        "_14_Error";
    grid-area: _14_Date_of_current;
}

._14_Top[b-ydnojzho4h] {
    grid-area: _14_Top;
}

._14_Bottom[b-ydnojzho4h] {
    grid-area: _14_Bottom;
}

._14_Error[b-ydnojzho4h] {
    grid-area: _14_Error;
}

._15_First_date_similar[b-ydnojzho4h] {
    padding: 5px;
    border-top: 3px solid brown;
    display: grid;
    grid-template-columns: 1fr;
    grid-template-rows: 0.5fr 0.65fr 0;
    gap: 0 0;
    grid-auto-flow: row;
    grid-template-areas:
        "_15_Top"
        "_15_Bottom"
        "_15_Error";
    grid-area: _15_First_date_similar;
}

._15_Top[b-ydnojzho4h] {
    grid-area: _15_Top;
}

._15_Bottom[b-ydnojzho4h] {
    grid-area: _15_Bottom;
}

._15_Error[b-ydnojzho4h] {
    grid-area: _15_Error;
}

._16_Dates_unable_to_work[b-ydnojzho4h] {
    padding: 5px;
    border-top: 3px solid brown;
    border-right: 1px solid brown;
    border-left: 1px solid brown;
    display: grid;
    grid-template-columns: 1fr;
    grid-template-rows: 0.7fr 1fr 0.6fr;
    gap: 0 0;
    grid-auto-flow: row;
    grid-template-areas:
        "_16_Top"
        "_16_Bottom"
        "_16_Error";
    grid-area: _16_Dates_unable_to_work;
}

._16_Top[b-ydnojzho4h] {
    grid-area: _16_Top;
}

._16_Bottom[b-ydnojzho4h] {
    display: flex;
    flex-direction: row;
    grid-area: _16_Bottom;
}

._16_Error[b-ydnojzho4h] {
    grid-area: _16_Error;
}

._17_Name_of_referring_provider[b-ydnojzho4h] {
    padding: 5px;
    border-top: 1px solid brown;
    border-left: 1px solid brown;
    display: grid;
    grid-template-columns: 1fr;
    grid-template-rows: 0.7fr 1fr 0.6fr;
    gap: 0 0;
    grid-auto-flow: row;
    grid-template-areas:
        "_17_Top"
        "_17_Bottom"
        "_17_Error";
    grid-area: _17_Name_of_referring_provider;
}

._17_Top[b-ydnojzho4h] {
    grid-area: _17_Top;
}

._17_Bottom[b-ydnojzho4h] {
    grid-area: _17_Bottom;
}

._17_Error[b-ydnojzho4h] {
    grid-area: _17_Error;
}

._18_Hospitalization_dates[b-ydnojzho4h] {
    padding: 5px;
    border-top: 1px solid brown;
    border-right: 1px solid brown;
    border-left: 1px solid brown;
    display: grid;
    grid-template-columns: 1fr;
    grid-template-rows: 0.7fr 1fr 0.6fr;
    gap: 0 0;
    grid-auto-flow: row;
    grid-template-areas:
        "_18_Top"
        "_18_Bottom"
        "_18_Error";
    grid-area: _18_Hospitalization_dates;
}

._18_Top[b-ydnojzho4h] {
    grid-area: _18_Top;
}

._18_Bottom[b-ydnojzho4h] {
    display: flex;
    flex-direction: row;
    grid-area: _18_Bottom;
}

._18_Error[b-ydnojzho4h] {
    grid-area: _18_Error;
}

._19_Address[b-ydnojzho4h] {
    padding: 5px;
    border-top: 1px solid brown;
    border-left: 1px solid brown;
    display: grid;
    grid-template-columns: 1fr;
    grid-template-rows: 0.7fr 1fr 0.6fr;
    gap: 0 0;
    grid-auto-flow: row;
    grid-template-areas:
        "_19_Top"
        "_19_Bottom"
        "_19_Error";
    grid-area: _19_Address;
}

._19_Top[b-ydnojzho4h] {
    grid-area: _19_Top;
}

._19_Bottom[b-ydnojzho4h] {
    grid-area: _19_Bottom;
}

._19_Error[b-ydnojzho4h] {
    grid-area: _19_Error;
}

._20_Hospital_lab_charges[b-ydnojzho4h] {
    padding: 5px;
    border-top: 1px solid brown;
    border-left: 1px solid brown;
    border-right: 1px solid brown;
    display: grid;
    grid-template-columns: 0.4fr 0.6fr;
    grid-template-rows: 0.7fr 1fr 0.6fr;
    gap: 0 0;
    grid-template-areas:
        "_20_TopLeft _20_TopRight"
        "_20_BottomLeft _20_BottomRight"
        "_20_ErrorLeft _20_ErrorRight";
    grid-area: _20_Hospital_lab_charges;
}

._20_TopLeft[b-ydnojzho4h] {
    grid-area: _20_TopLeft;
}

._20_TopRight[b-ydnojzho4h] {
    grid-area: _20_TopRight;
}

._20_BottomLeft[b-ydnojzho4h] {
    margin-top: 10px;
    grid-area: _20_BottomLeft;
}

._20_BottomRight[b-ydnojzho4h] {
    margin-top: 10px;
    grid-area: _20_BottomRight;
}

._20_ErrorLeft[b-ydnojzho4h] {
    grid-area: _20_ErrorLeft;
}

._20_ErrorRight[b-ydnojzho4h] {
    grid-area: _20_ErrorRight;
}

._21_Diagnosis_or_nature_of_illness[b-ydnojzho4h] {
    padding: 5px;
    border-top: 1px solid brown;
    border-bottom: 1px solid brown;
    border-left: 1px solid brown;
    display: grid;
    grid-template-columns: 1fr;
    grid-template-rows: 0.7fr 1fr 0.6fr;
    gap: 0 0;
    grid-auto-flow: row;
    grid-template-areas:
        "_21_Top"
        "_21_Bottom"
        "_21_Error";
    grid-area: _21_Diagnosis_or_nature_of_illness;
}

._21_Top[b-ydnojzho4h] {
    grid-area: _21_Top;
}

._21_Bottom[b-ydnojzho4h] {
    grid-area: _21_Bottom;
}

._21_Error[b-ydnojzho4h] {
    grid-area: _21_Error;
}

._22_Prior_authorization_number[b-ydnojzho4h] {
    padding: 5px;
    border-top: 1px solid brown;
    border-bottom: 1px solid brown;
    border-left: 1px solid brown;
    border-right: 1px solid brown;
    display: grid;
    grid-template-columns: 1fr;
    grid-template-rows: 0.7fr 1fr 0.6fr;
    gap: 0 0;
    grid-auto-flow: row;
    grid-template-areas:
        "_22_Top"
        "_22_Bottom"
        "_22_Error";
    grid-area: _22_Prior_authorization_number;
}

._22_Top[b-ydnojzho4h] {
    grid-area: _22_Top;
}

._22_Bottom[b-ydnojzho4h] {
    grid-area: _22_Bottom;
}

._22_Error[b-ydnojzho4h] {
    grid-area: _22_Error;
}

._Remove_procedures[b-ydnojzho4h] {
    grid-area: _Remove_procedures;
}

._Procedure_details[b-ydnojzho4h] {
    text-align: center;
    grid-area: _Procedure_details;
}

._Add_procedures[b-ydnojzho4h] {
    text-align: right;
    grid-area: _Add_procedures;
}

.patientFormBottomContainer[b-ydnojzho4h] {
    font-size: 11px;
    font-family: arial;
}

.patientFormBottomContainer[b-ydnojzho4h] {
    display: grid;
    grid-template-columns: 1fr 1fr 1fr 1fr 1fr 1fr 1fr 1fr 1fr 1fr 1fr 1fr 1fr 1fr 1fr;
    grid-template-rows: 75px 150px;
    gap: 0 0;
    grid-auto-flow: row;
    grid-template-areas:
        "_24_Patients_Account_Number _24_Patients_Account_Number _24_Patients_Account_Number _25_Accept_Assignment _25_Accept_Assignment _25_Accept_Assignment _26_Total_Charge _26_Total_Charge _26_Total_Charge _27_Amount_Paid _27_Amount_Paid _27_Amount_Paid _28_Balance_Due _28_Balance_Due _28_Balance_Due"
        "_29_Signature_Of_Provider _29_Signature_Of_Provider _29_Signature_Of_Provider _29_Signature_Of_Provider _29_Signature_Of_Provider _30_Name_And_Address_Of_Office_Submitting_Claim _30_Name_And_Address_Of_Office_Submitting_Claim _30_Name_And_Address_Of_Office_Submitting_Claim _30_Name_And_Address_Of_Office_Submitting_Claim _30_Name_And_Address_Of_Office_Submitting_Claim _31_Provider_Type _31_Provider_Type _31_Provider_Type _31_Provider_Type _31_Provider_Type";
}

._24_Patients_Account_Number[b-ydnojzho4h] {
    padding: 5px;
    border-top: 1px solid brown;
    border-left: 1px solid brown;
    border-right: 1px solid brown;
    display: grid;
    grid-template-rows: 0.7fr 1fr 0.6fr;
    grid-auto-columns: 1fr;
    gap: 0 0;
    grid-auto-flow: row;
    grid-area: _24_Patients_Account_Number;
}

._24_Top[b-ydnojzho4h] {
    grid-area: 1 / 1 / 2 / 2;
}

._24_Bottom[b-ydnojzho4h] {
    grid-area: 2 / 1 / 3 / 2;
}

._24_Error[b-ydnojzho4h] {
    grid-area: 3 / 1 / 4 / 2;
}

._25_Accept_Assignment[b-ydnojzho4h] {
    padding: 5px;
    border-top: 1px solid brown;
    border-left: 1px solid brown;
    display: grid;
    grid-template-rows: 0.7fr 1fr 0.6fr;
    grid-auto-columns: 1fr;
    gap: 0 0;
    grid-auto-flow: row;
    grid-area: _25_Accept_Assignment;
}

._25_Top[b-ydnojzho4h] {
    grid-area: 1 / 1 / 2 / 2;
}

._25_Bottom[b-ydnojzho4h] {
    margin-left: 55px;
    margin-top: 10px;
    grid-area: 2 / 1 / 3 / 2;
}

._25_Error[b-ydnojzho4h] {
    grid-area: 3 / 1 / 4 / 2;
}

._26_Total_Charge[b-ydnojzho4h] {
    padding: 5px;
    border-top: 1px solid brown;
    border-left: 1px solid brown;
    display: grid;
    grid-template-columns: 1fr;
    grid-template-rows: 0.7fr 1fr 0.6fr;
    grid-auto-columns: 1fr;
    gap: 0 0;
    grid-auto-flow: row;
    grid-template-areas:
        "_26_Top"
        "_26_Bottom"
        "_26_Error";
    grid-area: _26_Total_Charge;
}

._26_Top[b-ydnojzho4h] {
    grid-area: _26_Top;
}

._26_Bottom[b-ydnojzho4h] {
    margin-top: 5px;
    grid-area: _26_Bottom;
}

._26_Error[b-ydnojzho4h] {
    grid-area: _26_Error;
}

._27_Amount_Paid[b-ydnojzho4h] {
    padding: 5px;
    border-top: 1px solid brown;
    border-left: 1px solid brown;
    display: grid;
    grid-template-columns: 1fr;
    grid-template-rows: 0.7fr 1fr 0.6fr;
    gap: 0 0;
    grid-auto-flow: row;
    grid-template-areas:
        "_27_Top"
        "_27_Bottom"
        "_27_Error";
    grid-area: _27_Amount_Paid;
}

._27_Top[b-ydnojzho4h] {
    grid-area: _27_Top;
}

._27_Bottom[b-ydnojzho4h] {
    margin-top: 5px;
    grid-area: _27_Bottom;
}

._27_Error[b-ydnojzho4h] {
    grid-area: _27_Error;
}

._28_Balance_Due[b-ydnojzho4h] {
    padding: 5px;
    border-top: 1px solid brown;
    border-left: 1px solid brown;
    border-right: 1px solid brown;
    display: grid;
    grid-template-columns: 1fr;
    grid-template-rows: 0.7fr 1fr 0.6fr;
    gap: 0 0;
    grid-auto-flow: row;
    grid-template-areas:
        "_28_Top"
        "_28_Bottom"
        "_28_Error";
    grid-area: _28_Balance_Due;
}

._28_Top[b-ydnojzho4h] {
    grid-area: _28_Top;
}

._28_Bottom[b-ydnojzho4h] {
    margin-top: 5px;
    grid-area: _28_Bottom;
}

._28_Error[b-ydnojzho4h] {
    grid-area: _28_Error;
}

._29_Signature_Of_Provider[b-ydnojzho4h] {
    padding: 5px;
    border-top: 1px solid brown;
    border-left: 1px solid brown;
    border-right: 1px solid brown;
    border-bottom: 1px solid brown;
    display: grid;
    grid-template-columns: 1fr 1fr;
    grid-template-rows: 1.8fr 0.2fr 1fr 1fr 1fr 1fr;
    gap: 0 0;
    grid-auto-flow: row;
    grid-template-areas:
        "_29_Top _29_Top"
        "_29_Space _29_Space"
        "_29_Signed_Left _29_Signed_Right"
        ". _29_Signed_Error"
        "_29_Date_Left _29_Date_Right"
        ". _29_Date_Error";
    grid-area: _29_Signature_Of_Provider;
}

._29_Top[b-ydnojzho4h] {
    grid-area: _29_Top;
}

._29_Space[b-ydnojzho4h] {
    grid-area: _29_Space;
}

._29_Signed_Left[b-ydnojzho4h] {
    margin-top: 8px;
    grid-area: _29_Signed_Left;
}

._29_Signed_Right[b-ydnojzho4h] {
    grid-area: _29_Signed_Right;
}

._29_Date_Left[b-ydnojzho4h] {
    margin-top: 9px;
    grid-area: _29_Date_Left;
}

._29_Date_Right[b-ydnojzho4h] {
    grid-area: _29_Date_Right;
}

._29_Signed_Error[b-ydnojzho4h] {
    grid-area: _29_Signed_Error;
}

._29_Date_Error[b-ydnojzho4h] {
    grid-area: _29_Date_Error;
}

._30_Name_And_Address_Of_Office_Submitting_Claim[b-ydnojzho4h] {
    padding: 5px;
    border-top: 1px solid brown;
    border-right: 1px solid brown;
    border-bottom: 1px solid brown;
    display: grid;
    grid-template-columns: 1fr;
    grid-template-rows: 0.7fr 1fr 0.6fr;
    gap: 0 0;
    grid-auto-flow: row;
    grid-template-areas:
        "_30_Top"
        "_30_Bottom"
        "_30_Error";
    grid-area: _30_Name_And_Address_Of_Office_Submitting_Claim;
}

._30_Top[b-ydnojzho4h] {
    grid-area: _30_Top;
}

._30_Bottom[b-ydnojzho4h] {
    grid-area: _30_Bottom;
}

._30_Error[b-ydnojzho4h] {
    grid-area: _30_Error;
}

._31_Provider_Type[b-ydnojzho4h] {
    padding: 5px;
    border-top: 1px solid brown;
    border-right: 1px solid brown;
    border-bottom: 1px solid brown;
    display: grid;
    grid-template-columns: 1fr 1fr 1fr;
    grid-template-rows: 1.5fr 0.9fr 0.9fr 0.9fr 0.8fr;
    gap: 0 0;
    grid-auto-flow: row;
    grid-template-areas:
        "_31_Top _31_Top _31_Top"
        "_31_Physician _31_Optometrist _31_Psychologist"
        "_31_Dentist _31_Allied_Health ."
        "_31_Other_Option _31_Other_Text _31_Other_Text"
        "_31_Error _31_Error _31_Error";
    grid-area: _31_Provider_Type;
}

._31_Top[b-ydnojzho4h] {
    grid-area: _31_Top;
}

._31_Error[b-ydnojzho4h] {
    grid-area: _31_Error;
}

._31_Physician[b-ydnojzho4h] {
    grid-area: _31_Physician;
}

._31_Optometrist[b-ydnojzho4h] {
    grid-area: _31_Optometrist;
}

._31_Psychologist[b-ydnojzho4h] {
    grid-area: _31_Psychologist;
}

._31_Dentist[b-ydnojzho4h] {
    grid-area: _31_Dentist;
}

._31_Allied_Health[b-ydnojzho4h] {
    grid-area: _31_Allied_Health;
}

._31_Other_Option[b-ydnojzho4h] {
    grid-area: _31_Other_Option;
}

._31_Other_Text[b-ydnojzho4h] {
    margin-top: -10px;
    grid-area: _31_Other_Text;
}

.modal-label[b-ydnojzho4h] {
    display: inline-block;
    line-height: 2.2em;
    padding: 0 0.62em;
    border: 1px solid #666;
    border-radius: 0.25em;
    background-image: linear-gradient( to bottom, #fff, #ccc );
    box-shadow: inset 0 0 0.1em #fff, 0.2em 0.2em 0.2em rgba( 0, 0, 0, 0.3 );
    font-family: arial, sans-serif;
    font-size: 0.8em;
}

    .modal-label:hover[b-ydnojzho4h] {
        border-color: #3c7fb1;
        background-image: linear-gradient( to bottom, #fff, #a9dbf6 );
    }

    .modal-label:focus[b-ydnojzho4h] {
        padding: 0 0.56em 0 0.68em;
    }