{"id":16461,"date":"2024-08-05T08:48:16","date_gmt":"2024-08-05T12:48:16","guid":{"rendered":"https:\/\/awpli.org\/?page_id=16461"},"modified":"2024-08-05T10:14:08","modified_gmt":"2024-08-05T14:14:08","slug":"health-insurance","status":"publish","type":"page","link":"https:\/\/awpli.org\/es\/health-insurance\/","title":{"rendered":"Health Insurance"},"content":{"rendered":"<div class=\"wp-block-file\"><a id=\"wp-block-file--media-3f290bc6-1a41-4e9d-ae53-02fef49a6339\" href=\"https:\/\/awpli.org\/wp-content\/uploads\/2024\/08\/Family-Insurance-SDOH-1.png\">Family-Insurance-SDOH-1<\/a><a href=\"https:\/\/awpli.org\/wp-content\/uploads\/2024\/08\/Family-Insurance-SDOH-1.png\" class=\"wp-block-file__button wp-element-button\" download aria-describedby=\"wp-block-file--media-3f290bc6-1a41-4e9d-ae53-02fef49a6339\">Download<\/a><\/div>\n\n\n<script type=\"text\/javascript\">var 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class='gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_1_3\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_3\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_1_3'>\n                            \n                            <span id='input_1_3_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_3.3' id='input_1_3_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_1_3_3' class='gform-field-label gform-field-label--type-sub'>First Initial<\/label>\n                                                <\/span>\n                            \n                            <span id='input_1_3_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_3.6' id='input_1_3_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_1_3_6' class='gform-field-label gform-field-label--type-sub'>Last Name<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_1_5\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_5\" ><label class='gfield_label gform-field-label' for='input_1_5'>Age:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_5' id='input_1_5' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='15-under' >15-under<\/option><option value='16-17' >16-17<\/option><option value='18-24' >18-24<\/option><option value='25-49' >25-49<\/option><option value='50-64' >50-64<\/option><option value='65+' >65+<\/option><option value='Decline to Respond' >Decline to Respond<\/option><\/select><\/div><\/div><div id=\"field_1_6\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_6\" ><label class='gfield_label gform-field-label' for='input_1_6'>Race:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_6' id='input_1_6' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='American Indian\/Alaska Native' >American Indian\/Alaska Native<\/option><option value='Asian' >Asian<\/option><option value='Black or African American' >Black or African American<\/option><option value='Native Hawaiian or other Pacific Islander' >Native Hawaiian or other Pacific Islander<\/option><option value='White' >White<\/option><option value='Decline to Respond' >Decline to Respond<\/option><\/select><\/div><\/div><div id=\"field_1_7\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_7\" ><label class='gfield_label gform-field-label' for='input_1_7'>Ethnicity:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_7' id='input_1_7' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Hispanic' >Hispanic<\/option><option value='Non-Hispanic' >Non-Hispanic<\/option><option value='Decline to Respond' >Decline to Respond<\/option><\/select><\/div><\/div><div id=\"field_1_18\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_18\" ><label class='gfield_label gform-field-label' for='input_1_18'>Phone:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_18' id='input_1_18' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_19\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_19\" ><label class='gfield_label gform-field-label' for='input_1_19'>Email:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_19' id='input_1_19' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_1_22\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_22\" ><label class='gfield_label gform-field-label' for='input_1_22'>Zip Code:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_22' id='input_1_22' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='20710' >20710<\/option><option value='20712' >20712<\/option><option value='20740' >20740<\/option><option value='20743' >20743<\/option><option value='20744' >20744<\/option><option value='20745' >20745<\/option><option value='20746' >20746<\/option><option value='20747' >20747<\/option><option value='20748' >20748<\/option><option value='20782' >20782<\/option><\/select><\/div><\/div><div id=\"field_1_8\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_8\" ><h3 class=\"gsection_title\"><\/h3><\/div><fieldset id=\"field_1_11\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_11\" ><legend class='gfield_label gform-field-label' >I received the following:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_11'>\n\t\t\t<div class='gchoice gchoice_1_11_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='1st Dose of COVID-19 Vaccine'  id='choice_1_11_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_11_0' id='label_1_11_0' class='gform-field-label gform-field-label--type-inline'>1st Dose of COVID-19 Vaccine<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_11_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='1st &amp; 2nd Dose of COVID-19 Vaccine'  id='choice_1_11_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_11_1' id='label_1_11_1' class='gform-field-label gform-field-label--type-inline'>1st &amp; 2nd Dose of COVID-19 Vaccine<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_11_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='1st, 2nd, and Booster Dose of COVID-19 Vaccine'  id='choice_1_11_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_11_2' id='label_1_11_2' class='gform-field-label gform-field-label--type-inline'>1st, 2nd, and Booster Dose of COVID-19 Vaccine<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_11_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='Decline to Respond'  id='choice_1_11_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_11_3' id='label_1_11_3' class='gform-field-label gform-field-label--type-inline'>Decline to Respond<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_23\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_23\" ><h3 class=\"gsection_title\"><\/h3><\/div><fieldset id=\"field_1_13\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_13\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >I need help with the following health concerns:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_1_13'><div class='gchoice gchoice_1_13_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.1' type='checkbox'  value='COVID-19 education, testing, vaccination and\/or boosters'  id='choice_1_13_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_13_1' id='label_1_13_1' class='gform-field-label gform-field-label--type-inline'>COVID-19 education, testing, vaccination and\/or boosters<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_13_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.2' type='checkbox'  value='Diabetes Prevention Programs (DPPs)'  id='choice_1_13_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_13_2' id='label_1_13_2' class='gform-field-label gform-field-label--type-inline'>Diabetes Prevention Programs (DPPs)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_13_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.3' type='checkbox'  value='Asthma'  id='choice_1_13_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_13_3' id='label_1_13_3' class='gform-field-label gform-field-label--type-inline'>Asthma<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_13_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.4' type='checkbox'  value='Hypertension'  id='choice_1_13_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_13_4' id='label_1_13_4' class='gform-field-label gform-field-label--type-inline'>Hypertension<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_13_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.5' type='checkbox'  value='Monkey Pox'  id='choice_1_13_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_13_5' id='label_1_13_5' class='gform-field-label gform-field-label--type-inline'>Monkey Pox<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_13_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.6' type='checkbox'  value='Obesity'  id='choice_1_13_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_13_6' id='label_1_13_6' class='gform-field-label gform-field-label--type-inline'>Obesity<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_13_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.7' type='checkbox'  value='Strokes'  id='choice_1_13_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_13_7' id='label_1_13_7' class='gform-field-label gform-field-label--type-inline'>Strokes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_13_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.8' type='checkbox'  value='Type 2 Diabetes'  id='choice_1_13_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_13_8' id='label_1_13_8' class='gform-field-label gform-field-label--type-inline'>Type 2 Diabetes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_13_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.9' type='checkbox'  value='Other health condition (please specify)'  id='choice_1_13_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_13_9' id='label_1_13_9' class='gform-field-label gform-field-label--type-inline'>Other health condition (please specify)<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_15\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_15\" ><label class='gfield_label gform-field-label' for='input_1_15'>List:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_1_15' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_24\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_24\" ><h3 class=\"gsection_title\"><\/h3><\/div><fieldset id=\"field_1_16\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_16\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >I need help with the following supports:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_1_16'><div class='gchoice gchoice_1_16_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.1' type='checkbox'  value='Behavioral health services'  id='choice_1_16_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_16_1' id='label_1_16_1' class='gform-field-label gform-field-label--type-inline'>Behavioral health services<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_16_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.2' type='checkbox'  value='Childcare'  id='choice_1_16_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_16_2' id='label_1_16_2' class='gform-field-label gform-field-label--type-inline'>Childcare<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_16_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.3' type='checkbox'  value='Community-based health support'  id='choice_1_16_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_16_3' id='label_1_16_3' class='gform-field-label gform-field-label--type-inline'>Community-based health support<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_16_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.4' type='checkbox'  value='Employment'  id='choice_1_16_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_16_4' id='label_1_16_4' class='gform-field-label gform-field-label--type-inline'>Employment<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_16_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.5' type='checkbox'  value='Finances'  id='choice_1_16_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_16_5' id='label_1_16_5' class='gform-field-label gform-field-label--type-inline'>Finances<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_16_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.6' type='checkbox'  value='Food Pantry Services'  id='choice_1_16_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_16_6' id='label_1_16_6' class='gform-field-label gform-field-label--type-inline'>Food Pantry Services<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_16_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.7' type='checkbox'  value='GED, vocational or other educational services'  id='choice_1_16_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_16_7' id='label_1_16_7' class='gform-field-label gform-field-label--type-inline'>GED, vocational or other educational services<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_16_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.8' type='checkbox'  value='Health insurance\/coverage of health expenses'  id='choice_1_16_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_16_8' id='label_1_16_8' class='gform-field-label gform-field-label--type-inline'>Health insurance\/coverage of health expenses<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_16_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.9' type='checkbox'  value='Housing Support\/Sssistance'  id='choice_1_16_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_16_9' id='label_1_16_9' class='gform-field-label gform-field-label--type-inline'>Housing Support\/Sssistance<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_16_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.11' type='checkbox'  value='Legal aid'  id='choice_1_16_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_16_11' id='label_1_16_11' class='gform-field-label gform-field-label--type-inline'>Legal aid<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_16_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.12' type='checkbox'  value='Personal safety'  id='choice_1_16_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_16_12' id='label_1_16_12' class='gform-field-label gform-field-label--type-inline'>Personal safety<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_16_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.13' type='checkbox'  value='Primary care medical home'  id='choice_1_16_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_16_13' id='label_1_16_13' class='gform-field-label gform-field-label--type-inline'>Primary care medical home<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_16_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.14' type='checkbox'  value='Social services'  id='choice_1_16_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_16_14' id='label_1_16_14' class='gform-field-label gform-field-label--type-inline'>Social services<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_16_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.15' type='checkbox'  value='Substance use'  id='choice_1_16_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_16_15' id='label_1_16_15' class='gform-field-label gform-field-label--type-inline'>Substance use<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_16_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.16' type='checkbox'  value='Utilities Support'  id='choice_1_16_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_16_16' id='label_1_16_16' class='gform-field-label gform-field-label--type-inline'>Utilities Support<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_16_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.17' type='checkbox'  value='Transportation Support'  id='choice_1_16_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_16_17' id='label_1_16_17' class='gform-field-label gform-field-label--type-inline'>Transportation Support<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_16_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.18' type='checkbox'  value='Other (please specify)'  id='choice_1_16_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_16_18' id='label_1_16_18' class='gform-field-label gform-field-label--type-inline'>Other (please specify)<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_17\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_17\" ><label class='gfield_label gform-field-label' for='input_1_17'>List:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_1_17' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><\/div><\/div>\n        <div class='gform_footer before'> <input type='submit' id='gform_submit_button_1' class='gform_button button' value='Enviar'  onclick='if(window[\"gf_submitting_1\"]){return false;}  if( !jQuery(\"#gform_1\")[0].checkValidity || jQuery(\"#gform_1\")[0].checkValidity()){window[\"gf_submitting_1\"]=true;}  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_1\"]){return false;} if( !jQuery(\"#gform_1\")[0].checkValidity || 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