{html:"<div class='formInstructions'>Chat agents on this page can only assist with eServices account / password issues. For Medicare inquiries or other questions please log into eServices first or chat on <a href='http://www.palmettogba.com' target='_new'>PalmettoGBA.com</a>. </div><div class='formInstructions'>Please answer the questions below. Fields with a red asterisk (<span style='color:#C00'>*</span>) are required. </div><div class='formgroup'><div class='formgroupHeader'>Your Information</div><label for='user-chat' required><span class='sr-only'>First</span> Name</label><div class='fieldgroup'><input type='text' id='user-chat' maxLength='50' placeholder='First' title='Max length 50 characters'><label class='sr-only' for='user-chat-last' required>Last Name</label><input type='text' id='user-chat-last' maxLength='50' placeholder='Last' title='Max length 50 characters'></div><label for='email-chat' required>E-mail</label><input type='email' id='email-chat' maxLength='255' placeholder='' oninput='chatLogon.checkEmailValidity(this)'><label for='phone-area-code-chat' required>Phone<span class='sr-only'> Area Code</span></label><div class='fieldgroup'><span class='stylingText'>1(</span><input type='text' id='phone-area-code-chat' maxLength='3' pattern='[0-9]{3,3}' title='Area code. Numbers only'> <span class='stylingText'>)</span> <label for='phone-exchange-chat' class='sr-only' required>Phone Exchange</label><input type='text' id='phone-exchange-chat' maxLength='3' pattern='[0-9]{3,3}' title='Phone number. Numbers only'> <span class='stylingText'>-</span><label for='phone-line-chat' class='sr-only' required>Phone Line</label><input type='text' id='phone-line-chat' maxLength='32' pattern='[0-9]{4}[A-Za-z0-9 _]{0,}' title='Phone number. Numbers only'></div></div><div class='formgroup'><div class='formgroupHeader'>Provider Information</div><div class='wide'><label for='avaya_attributeLOB' required>Medicare Jurisdiction</label><select id='avaya_attributeLOB' class='avaya_attributeSelect' attributeName='LOB' errorMessage='Please select a Jurisdiction.'><option selected disabled invalid>Select a Jurisdiction</option><option value='JJA'>Jurisdiction J Part A</option><option value='JJB'>Jurisdiction J Part B</option><option value='JMA'>Jurisdiction M Part A</option><option value='JMB'>Jurisdiction M Part B</option><option value='JMHHH'>Jurisdiction M Home Health & Hospice</option><option value='RR_Providers'>Railroad Medicare</option></select></div><label for='customFieldMI-PTAN' required>PTAN</label><input type='text' id='customFieldMI-PTAN' class='avaya_customField' customFieldName='providerId' value='' maxlength='10' pattern='[A-Za-z0-9]{4,10}' errormessage='Please provide a valid PTAN'><label for='customFieldMI-NPI' required>NPI</label><input type='text' id='customFieldMI-NPI' class='avaya_customField' customFieldName='npi' value='' maxlength='10' pattern='[0-9]{10,10}' errormessage='Please provide a valid NPI'><label for='customFieldMI-TIN' required>Last 5 of TIN</label><input type='text' id='customFieldMI-TIN' class='avaya_customField' customFieldName='taxId' value='' maxlength='5' pattern='[0-9]{5,5}' errormessage='Please provide the last five digits of your Tax ID Number (TIN)'></div><div class='formgroup' name='logon' style='display:block'><!--Login errors are printed here--><div id='loginErrorsDiv'></div><!--Button to Launch Chat--><a id='openbutton-chat' onclick='chatLogon.gatherDetails()'>Chat Now</a></div><!-- topic for the customer journey. This is different than the topic attribute, not sure what this does but removing it breaks everything so it's hidden for now.--><div class='formLabel hidden'>Topic</div><div class='formField hidden'><input type='text' id='topic' maxLength='255' title='Denotes a topic for the contact. Allows groups of uppercase/lowercase letters and numbers, separated by full stops(.), underscore(_), tilda(~) or hyphen(-), but not spaces' pattern='([a-zA-Z0-9])+([_~\-.][a-zA-Z0-9]+)*' placeholder=''></div><!-- end -->"}