{"id":62225,"date":"2025-08-10T11:37:02","date_gmt":"2025-08-10T15:37:02","guid":{"rendered":"https:\/\/gatransplant.blackbaudwp.com\/?page_id=62225"},"modified":"2025-08-10T11:53:19","modified_gmt":"2025-08-10T15:53:19","slug":"tfp-application","status":"publish","type":"page","link":"https:\/\/gatransplant.blackbaudwp.com\/vi\/our-programs\/transplant-fundraising-program\/tfp-application\/","title":{"rendered":"Transplant Fundraising Program Application"},"content":{"rendered":"<h1>\n\t\t\tTransplant Fundraising Program Application\n\t\t<\/h1>\n\t\t\t<p>B\u1ea1n ph\u1ea3i ho\u00e0n th\u00e0nh \u0111\u01a1n \u0111\u0103ng k\u00fd n\u00e0y trong kh\u1ea3 n\u0103ng c\u1ee7a m\u00ecnh v\u00e0 cung c\u1ea5p t\u1ea5t c\u1ea3 c\u00e1c t\u00e0i li\u1ec7u h\u1ed7 tr\u1ee3 \u0111\u1ec3 \u0111\u01b0\u1ee3c xem x\u00e9t h\u1ed7 tr\u1ee3.&nbsp;&nbsp;<em>Please note: you can click &#8220;Save and Continue Later&#8221; at the bottom of the page, which will provide you with a link to access your application for 30 days. If you misplace this link or take longer than 30 days, you will lose any information previously entered.<\/em><\/p>\t\t\n\t\t\t<h3>Transplant Fundraising Program Application<\/h3>\n\t\t\n                            \n\t\t\t\t\t\t\t&#8220;*&#8221; indicates required fields\n                        <form method=\"post\" enctype=\"multipart\/form-data\" target=\"gform_ajax_frame_9\" id=\"gform_9\" class=\"compact\" action=\"https:\/\/gatransplant.blackbaudwp.com\/vi\/our-programs\/transplant-fundraising-program\/tfp-application-2\/?fl_builder&#038;fl_builder_ui_iframe#gf_9\" data-formid=\"9\" novalidate=\"\" data-trp-original-action=\"https:\/\/gatransplant.blackbaudwp.com\/our-programs\/transplant-fundraising-program\/tfp-application-2\/?fl_builder&amp;fl_builder_ui_iframe#gf_9\">\n        \tStep 1 of 9 &#8211; General Information\n        \t\n                11%\n\t\t\t\t\t<fieldset id=\"field_9_1\"><legend class=\"gfield_label gform-field-label gfield_label_before_complex\">T\u00ean*<\/legend>\n                                                    <select name=\"input_1.2\" id=\"input_9_1_2\" aria-required=\"false\">\n                          <option value=\"\"><\/option><option value=\"Mr.\">\u00d4ng.<\/option><option value=\"Mrs.\">B\u00e0.<\/option><option value=\"Miss\">C\u00f4<\/option><option value=\"Ms.\">B\u1ec7nh \u0111a x\u01a1 c\u1ee9ng.<\/option><option value=\"Dr.\">Dr.<\/option><option value=\"Prof.\">GS.<\/option><option value=\"Rev.\">Rev.<\/option>\n                      <\/select>\n                                                    <label for=\"input_9_1_2\" class=\"gform-field-label gform-field-label--type-sub\">Ti\u00eau \u0111\u1ec1<\/label>\n                                                    <input type=\"text\" name=\"input_1.3\" id=\"input_9_1_3\" value=\"\" aria-required=\"true\">\n                                                    <label for=\"input_9_1_3\" class=\"gform-field-label gform-field-label--type-sub\">\u0110\u1ea7u ti\u00ean<\/label>\n                                                    <input type=\"text\" name=\"input_1.4\" id=\"input_9_1_4\" value=\"\" aria-required=\"false\">\n                                                    <label for=\"input_9_1_4\" class=\"gform-field-label gform-field-label--type-sub\">\u1ede gi\u1eefa<\/label>\n                                                    <input type=\"text\" name=\"input_1.6\" id=\"input_9_1_6\" value=\"\" aria-required=\"true\">\n                                                    <label for=\"input_9_1_6\" class=\"gform-field-label gform-field-label--type-sub\">Cu\u1ed1i c\u00f9ng<\/label>\n                        <\/fieldset><fieldset id=\"field_9_23\"><legend class=\"gfield_label gform-field-label gfield_label_before_complex\">\u0110\u1ecba ch\u1ec9 g\u1eedi th\u01b0 *<\/legend>    \n                                        <input type=\"text\" name=\"input_23.1\" id=\"input_9_23_1\" value=\"\" aria-required=\"true\">\n                                        <label for=\"input_9_23_1\" id=\"input_9_23_1_label\" class=\"gform-field-label gform-field-label--type-sub\">\u0110\u1ecba ch\u1ec9 \u0111\u01b0\u1eddng ph\u1ed1<\/label>\n                                        <input type=\"text\" name=\"input_23.2\" id=\"input_9_23_2\" value=\"\" aria-required=\"false\">\n                                        <label for=\"input_9_23_2\" id=\"input_9_23_2_label\" class=\"gform-field-label gform-field-label--type-sub\">H\u1ea1t<\/label>\n                                    <input type=\"text\" name=\"input_23.3\" id=\"input_9_23_3\" value=\"\" aria-required=\"true\">\n                                    <label for=\"input_9_23_3\" id=\"input_9_23_3_label\" class=\"gform-field-label gform-field-label--type-sub\">Tp.<\/label>\n                                        <select name=\"input_23.4\" id=\"input_9_23_4\" aria-required=\"true\"><option value=\"\"><\/option><option value=\"Alabama\">Alabama<\/option><option value=\"Alaska\">Alaska<\/option><option value=\"American Samoa\">American Samoa<\/option><option value=\"Arizona\">Arizona<\/option><option value=\"Arkansas\">Arkansas<\/option><option value=\"California\">California<\/option><option value=\"Colorado\">Colorado<\/option><option value=\"Connecticut\">Connecticut<\/option><option value=\"Delaware\">Delaware<\/option><option value=\"District of Columbia\">\u0110\u1eb7c khu Columbia<\/option><option value=\"Florida\">Florida<\/option><option value=\"Georgia\" selected=\"selected\">Georgia<\/option><option value=\"Guam\">Guam<\/option><option value=\"Hawaii\">Hawaii<\/option><option value=\"Idaho\">Idaho<\/option><option value=\"Illinois\">Illinois<\/option><option value=\"Indiana\">Indiana<\/option><option value=\"Iowa\">Iowa<\/option><option value=\"Kansas\">Kansas<\/option><option value=\"Kentucky\">Kentucky<\/option><option value=\"Louisiana\">Louisiana<\/option><option value=\"Maine\">Maine<\/option><option value=\"Maryland\">Maryland<\/option><option value=\"Massachusetts\">Massachusetts<\/option><option value=\"Michigan\">Michigan<\/option><option value=\"Minnesota\">Minnesota<\/option><option value=\"Mississippi\">Mississippi<\/option><option value=\"Missouri\">Missouri<\/option><option value=\"Montana\">Montana<\/option><option value=\"Nebraska\">Nebraska<\/option><option value=\"Nevada\">Nevada<\/option><option value=\"New Hampshire\">M\u1edbi Hampshire<\/option><option value=\"New Jersey\">\u00c1o m\u1edbi<\/option><option value=\"New Mexico\">New Mexico<\/option><option value=\"New York\">Newyork<\/option><option value=\"North Carolina\">b\u1eafc Carolina<\/option><option value=\"North Dakota\">B\u1eafc Dakota<\/option><option value=\"Northern Mariana Islands\">Qu\u1ea7n \u0111\u1ea3o B\u1eafc Mariana<\/option><option value=\"Ohio\">Ohio<\/option><option value=\"Oklahoma\">Oklahoma<\/option><option value=\"Oregon\">Oregon<\/option><option value=\"Pennsylvania\">Pennsylvania<\/option><option value=\"Puerto Rico\">Puerto Rico<\/option><option value=\"Rhode Island\">\u0111\u1ea3o Rhode<\/option><option value=\"South Carolina\">ph\u00eda Nam Carolina<\/option><option value=\"South Dakota\">Nam Dakota<\/option><option value=\"Tennessee\">Tennessee<\/option><option value=\"Texas\">Texas<\/option><option value=\"Utah\">Utah<\/option><option value=\"U.S. Virgin Islands\">U.S. Virgin Islands<\/option><option value=\"Vermont\">Vermont<\/option><option value=\"Virginia\">Virginia<\/option><option value=\"Washington\">Washington<\/option><option value=\"West Virginia\">phia T\u00e2y Virginia<\/option><option value=\"Wisconsin\">Wisconsin<\/option><option value=\"Wyoming\">Wyoming<\/option><option value=\"Armed Forces Americas\">Qu\u00e2n \u0111\u1ed9i M\u1ef9<\/option><option value=\"Armed Forces Europe\">L\u1ef1c l\u01b0\u1ee3ng v\u0169 trang Ch\u00e2u \u00c2u<\/option><option value=\"Armed Forces Pacific\">L\u1ef1c l\u01b0\u1ee3ng v\u0169 trang Th\u00e1i B\u00ecnh D\u01b0\u01a1ng<\/option><\/select>\n                                        <label for=\"input_9_23_4\" id=\"input_9_23_4_label\" class=\"gform-field-label gform-field-label--type-sub\">Ti\u1ec3u bang<\/label>\n                                    <input type=\"text\" name=\"input_23.5\" id=\"input_9_23_5\" value=\"\" aria-required=\"true\">\n                                    <label for=\"input_9_23_5\" id=\"input_9_23_5_label\" class=\"gform-field-label gform-field-label--type-sub\">M\u00e3 B\u01b0u Ch\u00ednh<\/label>\n                                <input type=\"hidden\" class=\"gform_hidden\" name=\"input_23.6\" id=\"input_9_23_6\" value=\"United States\">\n                <\/fieldset>This field is hidden when viewing the form<label class=\"gfield_label gform-field-label\" for=\"input_9_189\">H\u1ea1t<\/label><input name=\"input_189\" id=\"input_9_189\" type=\"text\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_25\">\u0110i\u00ea\u0323n thoa\u0323i di \u0111\u00f4\u0323ng<\/label><input name=\"input_25\" id=\"input_9_25\" type=\"tel\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_24\">\u0110i\u1ec7n tho\u1ea1i nh\u00e0<\/label><input name=\"input_24\" id=\"input_9_24\" type=\"tel\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_26\">E-mail*<\/label>\n                            <input name=\"input_26\" id=\"input_9_26\" type=\"email\" value=\"\" class=\"large\" aria-required=\"true\" aria-invalid=\"false\">\n                        <label class=\"gfield_label gform-field-label\" for=\"input_9_191\">Gi\u1edbi t\u00ednh *<\/label><select name=\"input_191\" id=\"input_9_191\" class=\"large gfield_select\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"\" selected=\"selected\"><\/option><option value=\"Male\">Nam gi\u1edbi<\/option><option value=\"Female\">Gi\u1ed1ng c\u00e1i<\/option><option value=\"Prefer not to answer\">kh\u00f4ng th\u00edch tr\u1ea3 l\u1eddi<\/option><\/select><label class=\"gfield_label gform-field-label\" for=\"input_9_110\">T\u00ecnh tr\u1ea1ng h\u00f4n nh\u00e2n*<\/label><select name=\"input_110\" id=\"input_9_110\" class=\"large gfield_select\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"\" selected=\"selected\"><\/option><option value=\"Single\">\u0110\u1ed9c th\u00e2n<\/option><option value=\"Married\">C\u01b0\u1edbi nhau<\/option><option value=\"Divorced\">\u0110\u00e3 ly h\u00f4n<\/option><option value=\"Widowed\">G\u00f3a v\u1ee3<\/option><option value=\"Partnered\">H\u1ee3p t\u00e1c<\/option><\/select><label class=\"gfield_label gform-field-label\" for=\"input_9_28\">Spouse\/Partner&#8217;s Name<\/label><input name=\"input_28\" id=\"input_9_28\" type=\"text\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_29\">Ng\u00e0y sinh*<\/label>\n                            <input name=\"input_29\" id=\"input_9_29\" type=\"text\" value=\"\" class=\"datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon\" placeholder=\"mm\/dd\/yyyy\" aria-describedby=\"input_9_29_date_format\" aria-invalid=\"false\" aria-required=\"true\">\n                            MM slash DD slash YYYY\n                        <input type=\"hidden\" id=\"gforms_calendar_icon_input_9_29\" class=\"gform_hidden\" value=\"https:\/\/gatransplant.blackbaudwp.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg\"><label class=\"gfield_label gform-field-label\" for=\"input_9_31\">S\u1ed1 an sinh x\u00e3 h\u1ed9i *<\/label><input name=\"input_31\" id=\"input_9_31\" type=\"text\" value=\"\" class=\"large\" aria-required=\"true\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_119\"># Ng\u01b0\u1eddi l\u1edbn trong h\u1ed9 gia \u0111\u00ecnh *<\/label><input name=\"input_119\" id=\"input_9_119\" type=\"number\" step=\"any\" value=\"\" class=\"large\" aria-required=\"true\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_120\"># of children living in household*<\/label><input name=\"input_120\" id=\"input_9_120\" type=\"number\" step=\"any\" value=\"\" class=\"large\" aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_9_120\">18 tu\u1ed5i tr\u1edf xu\u1ed1ng<label class=\"gfield_label gform-field-label\" for=\"input_9_118\">T\u1ed5ng s\u1ed1 # ng\u01b0\u1eddi s\u1ed1ng trong h\u1ed9 gia \u0111\u00ecnh<\/label><input name=\"input_118\" id=\"input_9_118\" type=\"text\" step=\"any\" value=\"\" class=\"large gform-text-input-reset\" readonly=\"readonly\" aria-invalid=\"false\">\n                         <input type=\"button\" id=\"gform_next_button_9_10\" class=\"gform_next_button gform-theme-button button\" onclick=\"gform.submission.handleButtonClick(this);\" data-submission-type=\"next\" value=\"K\u1ebf ti\u1ebfp\"> <button type=\"button\" id=\"gform_save_9_2_link\" onclick=\"gform.submission.handleButtonClick(this);\" data-submission-type=\"save-continue\" class=\"gform_save_link gform-theme-button gform-theme-button--secondary button\"> L\u01b0u v\u00e0 ti\u1ebfp t\u1ee5c sau<\/button>\n                        <label class=\"gfield_label gform-field-label\" for=\"input_9_114\">Cu\u1ed9c \u0111ua (t\u00f9y ch\u1ecdn)<\/label><select name=\"input_114\" id=\"input_9_114\" class=\"large gfield_select\" aria-invalid=\"false\"><option value=\"\" selected=\"selected\"><\/option><option value=\"African American\">Ng\u01b0\u1eddi M\u1ef9 g\u1ed1c Phi<\/option><option value=\"Asian-American\">Ng\u01b0\u1eddi M\u1ef9 g\u1ed1c \u00c1<\/option><option value=\"Asian-Pacific Islander\">Ch\u00e2u \u00c1 \/ Th\u00e1i B\u00ecnh D\u01b0\u01a1ng<\/option><option value=\"Black\">\u0110en<\/option><option value=\"Hispanic\">Ng\u01b0\u1eddi T\u00e2y Ban Nha<\/option><option value=\"Native American\">Ng\u01b0\u1eddi M\u1ef9 b\u1ea3n x\u1ee9<\/option><option value=\"White, Non-Hispanic\">Da tr\u1eafng, kh\u00f4ng ph\u1ea3i g\u1ed1c T\u00e2y Ban Nha<\/option><option value=\"Other\">Kh\u00e1c<\/option><\/select><label class=\"gfield_label gform-field-label\" for=\"input_9_115\">Ch\u1ee7ng t\u1ed9c kh\u00e1c<\/label><input name=\"input_115\" id=\"input_9_115\" type=\"text\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_116\">Tr\u00ecnh \u0111\u1ed9 h\u1ecdc v\u1ea5n (t\u00f9y ch\u1ecdn)<\/label><select name=\"input_116\" id=\"input_9_116\" class=\"large gfield_select\" aria-invalid=\"false\"><option value=\"\" selected=\"selected\"><\/option><option value=\"GED\">GED<\/option><option value=\"Attended High School\">\u0110i h\u1ecdc trung h\u1ecdc<\/option><option value=\"High School Graduate\">T\u1ed1t nghi\u1ec7p trung h\u1ecdc<\/option><option value=\"Technical Certificate\/Diploma\">Ch\u1ee9ng ch\u1ec9 k\u1ef9 thu\u1eadt \/ V\u0103n b\u1eb1ng<\/option><option value=\"Currently Enrolled in College\">Hi\u1ec7n \u0111\u00e3 \u0111\u0103ng k\u00fd v\u00e0o tr\u01b0\u1eddng cao \u0111\u1eb3ng<\/option><option value=\"Attended College\">H\u1ecdc \u0111\u1ea1i h\u1ecdc<\/option><option value=\"Associates Degree\">M\u1ee9c \u0111\u1ed9<\/option><option value=\"Bachelors Degree\">B\u1eb1ng c\u1eed nh\u00e2n<\/option><option value=\"Post-Graduate Degree\">Ch\u1ee9ng ch\u1ec9 sau t\u1ed1t nghi\u1ec7p<\/option><\/select><label class=\"gfield_label gform-field-label\" for=\"input_9_22\"># trong n\u0103m<\/label><input name=\"input_22\" id=\"input_9_22\" type=\"text\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_117\">Work Status*<\/label><select name=\"input_117\" id=\"input_9_117\" class=\"large gfield_select\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"\" selected=\"selected\"><\/option><option value=\"Currently Employed\">Hi\u1ec7n \u0111ang l\u00e0m vi\u1ec7c<\/option><option value=\"Medically Disabled\">Khuy\u1ebft t\u1eadt v\u1ec1 m\u1eb7t y t\u1ebf<\/option><option value=\"Retired\">V\u1ec1 h\u01b0u<\/option><option value=\"Unemployed\">Th\u1ea5t nghi\u1ec7p<\/option><\/select><label class=\"gfield_label gform-field-label\" for=\"input_9_40\">K\u1ec3 t\u1eeb khi (Ng\u00e0y) *<\/label>\n                            <input name=\"input_40\" id=\"input_9_40\" type=\"text\" value=\"\" class=\"datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon\" placeholder=\"mm\/dd\/yyyy\" aria-describedby=\"input_9_40_date_format\" aria-invalid=\"false\" aria-required=\"true\">\n                            MM slash DD slash YYYY\n                        <input type=\"hidden\" id=\"gforms_calendar_icon_input_9_40\" class=\"gform_hidden\" value=\"https:\/\/gatransplant.blackbaudwp.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg\"><label class=\"gfield_label gform-field-label\" for=\"input_9_39\">T\u00ean nh\u00e0 tuy\u1ec3n d\u1ee5ng<\/label><input name=\"input_39\" id=\"input_9_39\" type=\"text\" value=\"\" class=\"large\" aria-invalid=\"false\"><fieldset id=\"field_9_42\"><legend class=\"gfield_label gform-field-label gfield_label_before_complex\">Ngu\u1ed3n thu nh\u1eadp hi\u1ec7n t\u1ea1i<\/legend>(Vui l\u00f2ng ki\u1ec3m tra t\u1ea5t c\u1ea3 nh\u1eefng g\u00ec \u00e1p d\u1ee5ng)\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_42.1\" type=\"checkbox\" value=\"Full-Time Employment\" id=\"choice_9_42_1\" aria-describedby=\"gfield_description_9_42\">\n\t\t\t\t\t\t\t\t<label for=\"choice_9_42_1\" id=\"label_9_42_1\" class=\"gform-field-label gform-field-label--type-inline\">Vi\u1ec7c l\u00e0m to\u00e0n th\u1eddi gian<\/label>\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_42.2\" type=\"checkbox\" value=\"Working Spouse\" id=\"choice_9_42_2\">\n\t\t\t\t\t\t\t\t<label for=\"choice_9_42_2\" id=\"label_9_42_2\" class=\"gform-field-label gform-field-label--type-inline\">V\u1ee3 \/ ch\u1ed3ng \u0111ang \u0111i l\u00e0m<\/label>\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_42.3\" type=\"checkbox\" value=\"Part-Time Employment\" id=\"choice_9_42_3\">\n\t\t\t\t\t\t\t\t<label for=\"choice_9_42_3\" id=\"label_9_42_3\" class=\"gform-field-label gform-field-label--type-inline\">Vi\u1ec7c l\u00e0m b\u00e1n th\u1eddi gian<\/label>\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_42.4\" type=\"checkbox\" value=\"Parent(s) Income\" id=\"choice_9_42_4\">\n\t\t\t\t\t\t\t\t<label for=\"choice_9_42_4\" id=\"label_9_42_4\" class=\"gform-field-label gform-field-label--type-inline\">Thu nh\u1eadp c\u1ee7a (c\u00e1c) ph\u1ee5 huynh<\/label>\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_42.5\" type=\"checkbox\" value=\"Retirement Pension\" id=\"choice_9_42_5\">\n\t\t\t\t\t\t\t\t<label for=\"choice_9_42_5\" id=\"label_9_42_5\" class=\"gform-field-label gform-field-label--type-inline\">L\u01b0\u01a1ng h\u01b0u<\/label>\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_42.6\" type=\"checkbox\" value=\"Social Security Retirement\" id=\"choice_9_42_6\">\n\t\t\t\t\t\t\t\t<label for=\"choice_9_42_6\" id=\"label_9_42_6\" class=\"gform-field-label gform-field-label--type-inline\">H\u01b0u tr\u00ed An sinh X\u00e3 h\u1ed9i<\/label>\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_42.7\" type=\"checkbox\" value=\"Social Security Disability (SSDI)\" id=\"choice_9_42_7\">\n\t\t\t\t\t\t\t\t<label for=\"choice_9_42_7\" id=\"label_9_42_7\" class=\"gform-field-label gform-field-label--type-inline\">Ng\u01b0\u1eddi khuy\u1ebft t\u1eadt v\u1ec1 an sinh x\u00e3 h\u1ed9i (SSDI)<\/label>\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_42.8\" type=\"checkbox\" value=\"Supplemental Security Income (SSI)\" id=\"choice_9_42_8\">\n\t\t\t\t\t\t\t\t<label for=\"choice_9_42_8\" id=\"label_9_42_8\" class=\"gform-field-label gform-field-label--type-inline\">Thu nh\u1eadp An sinh B\u1ed5 sung (SSI)<\/label>\n\t\t\t\t\t\t\t<\/fieldset><fieldset id=\"field_9_43\"><legend class=\"gfield_label gform-field-label gfield_label_before_complex\">Ngu\u1ed3n b\u1ea3o hi\u1ec3m ch\u0103m s\u00f3c s\u1ee9c kh\u1ecfe hi\u1ec7n t\u1ea1i<\/legend>(Vui l\u00f2ng ki\u1ec3m tra t\u1ea5t c\u1ea3 nh\u1eefng g\u00ec \u00e1p d\u1ee5ng)\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_43.1\" type=\"checkbox\" value=\"Insurance\" id=\"choice_9_43_1\" aria-describedby=\"gfield_description_9_43\">\n\t\t\t\t\t\t\t\t<label for=\"choice_9_43_1\" id=\"label_9_43_1\" class=\"gform-field-label gform-field-label--type-inline\">B\u1ea3o hi\u1ec3m<\/label>\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_43.2\" type=\"checkbox\" value=\"Spouse's Insurance\" id=\"choice_9_43_2\">\n\t\t\t\t\t\t\t\t<label for=\"choice_9_43_2\" id=\"label_9_43_2\" class=\"gform-field-label gform-field-label--type-inline\">B\u1ea3o hi\u1ec3m v\u1ee3 \/ ch\u1ed3ng<\/label>\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_43.3\" type=\"checkbox\" value=\"Medicare\" id=\"choice_9_43_3\">\n\t\t\t\t\t\t\t\t<label for=\"choice_9_43_3\" id=\"label_9_43_3\" class=\"gform-field-label gform-field-label--type-inline\">Medicare<\/label>\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_43.4\" type=\"checkbox\" value=\"Medicaid\" id=\"choice_9_43_4\">\n\t\t\t\t\t\t\t\t<label for=\"choice_9_43_4\" id=\"label_9_43_4\" class=\"gform-field-label gform-field-label--type-inline\">Medicaid<\/label>\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_43.5\" type=\"checkbox\" value=\"QMB Medicaid\" id=\"choice_9_43_5\">\n\t\t\t\t\t\t\t\t<label for=\"choice_9_43_5\" id=\"label_9_43_5\" class=\"gform-field-label gform-field-label--type-inline\">QMB Medicaid<\/label>\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_43.6\" type=\"checkbox\" value=\"Spend-down Medicaid\" id=\"choice_9_43_6\">\n\t\t\t\t\t\t\t\t<label for=\"choice_9_43_6\" id=\"label_9_43_6\" class=\"gform-field-label gform-field-label--type-inline\">Medicaid gi\u1ea3m chi ti\u00eau<\/label>\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_43.7\" type=\"checkbox\" value=\"COBRA\" id=\"choice_9_43_7\">\n\t\t\t\t\t\t\t\t<label for=\"choice_9_43_7\" id=\"label_9_43_7\" class=\"gform-field-label gform-field-label--type-inline\">COBRA<\/label>\n\t\t\t\t\t\t\t<\/fieldset><label class=\"gfield_label gform-field-label\" for=\"input_9_192\">Nh\u00e0 cung c\u1ea5p d\u1ecbch v\u1ee5 b\u1ea3o hi\u1ec3m<\/label><select name=\"input_192\" id=\"input_9_192\" class=\"large gfield_select\" aria-invalid=\"false\"><option value=\"\" selected=\"selected\"><\/option><option value=\"BCBS\">BCBS<\/option><option value=\"United Healthcare\">United Healthcare<\/option><option value=\"Humana\">Humana<\/option><option value=\"Kaiser\">Kaiser<\/option><option value=\"Aetna\">Aetna<\/option><option value=\"Other\">Kh\u00e1c<\/option><\/select><fieldset id=\"field_9_45\"><legend class=\"gfield_label gform-field-label gfield_label_before_complex\">Ch\u1ecdn t\u1ea5t c\u1ea3 nh\u1eefng g\u00ec \u00e1p d\u1ee5ng cho b\u1ea1n:<\/legend>\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_45.1\" type=\"checkbox\" value=\"Recipient\" id=\"choice_9_45_1\">\n\t\t\t\t\t\t\t\t<label for=\"choice_9_45_1\" id=\"label_9_45_1\" class=\"gform-field-label gform-field-label--type-inline\">Ng\u01b0\u1eddi nh\u1eadn<\/label>\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_45.2\" type=\"checkbox\" value=\"Candidate\" id=\"choice_9_45_2\">\n\t\t\t\t\t\t\t\t<label for=\"choice_9_45_2\" id=\"label_9_45_2\" class=\"gform-field-label gform-field-label--type-inline\">\u1ee8ng c\u1eed vi\u00ean<\/label>\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_45.3\" type=\"checkbox\" value=\"Living Donor\" id=\"choice_9_45_3\">\n\t\t\t\t\t\t\t\t<label for=\"choice_9_45_3\" id=\"label_9_45_3\" class=\"gform-field-label gform-field-label--type-inline\">Ng\u01b0\u1eddi hi\u1ebfn t\u1eb7ng c\u00f2n s\u1ed1ng<\/label>\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_45.4\" type=\"checkbox\" value=\"JumpStart Client\" id=\"choice_9_45_4\">\n\t\t\t\t\t\t\t\t<label for=\"choice_9_45_4\" id=\"label_9_45_4\" class=\"gform-field-label gform-field-label--type-inline\">\u1ee8ng d\u1ee5ng kh\u00e1ch JumpStart<\/label>\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_45.5\" type=\"checkbox\" value=\"TNT Attendee\" id=\"choice_9_45_5\">\n\t\t\t\t\t\t\t\t<label for=\"choice_9_45_5\" id=\"label_9_45_5\" class=\"gform-field-label gform-field-label--type-inline\">Ng\u01b0\u1eddi tham d\u1ef1 TNT<\/label>\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_45.6\" type=\"checkbox\" value=\"Fundraising Workshop Attendee\" id=\"choice_9_45_6\">\n\t\t\t\t\t\t\t\t<label for=\"choice_9_45_6\" id=\"label_9_45_6\" class=\"gform-field-label gform-field-label--type-inline\">Ng\u01b0\u1eddi tham d\u1ef1 h\u1ed9i th\u1ea3o g\u00e2y qu\u1ef9<\/label>\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_45.7\" type=\"checkbox\" value=\"Mentor\/Mentee\" id=\"choice_9_45_7\">\n\t\t\t\t\t\t\t\t<label for=\"choice_9_45_7\" id=\"label_9_45_7\" class=\"gform-field-label gform-field-label--type-inline\">C\u1ed1 v\u1ea5n \/ Ng\u01b0\u1eddi h\u01b0\u1edbng d\u1eabn<\/label>\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_45.8\" type=\"checkbox\" value=\"GTF Volunteer\/ Board Member\/ Committee Member\" id=\"choice_9_45_8\">\n\t\t\t\t\t\t\t\t<label for=\"choice_9_45_8\" id=\"label_9_45_8\" class=\"gform-field-label gform-field-label--type-inline\">T\u00ecnh nguy\u1ec7n vi\u00ean GTF \/ Th\u00e0nh vi\u00ean H\u1ed9i \u0111\u1ed3ng Qu\u1ea3n tr\u1ecb \/ Th\u00e0nh vi\u00ean \u1ee6y ban<\/label>\n\t\t\t\t\t\t\t<\/fieldset><fieldset id=\"field_9_48\"><legend class=\"gfield_label gform-field-label gfield_label_before_complex\">How did you hear about GTF services?*<\/legend>\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_48.1\" type=\"checkbox\" value=\"GTF Website\" id=\"choice_9_48_1\">\n\t\t\t\t\t\t\t\t<label for=\"choice_9_48_1\" id=\"label_9_48_1\" class=\"gform-field-label gform-field-label--type-inline\">Trang web GTF<\/label>\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_48.2\" type=\"checkbox\" value=\"IMPRINT Magazine\" id=\"choice_9_48_2\">\n\t\t\t\t\t\t\t\t<label for=\"choice_9_48_2\" id=\"label_9_48_2\" class=\"gform-field-label gform-field-label--type-inline\">T\u1ea1p ch\u00ed IMPRINT<\/label>\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_48.3\" type=\"checkbox\" value=\"GTF Staff\" id=\"choice_9_48_3\">\n\t\t\t\t\t\t\t\t<label for=\"choice_9_48_3\" id=\"label_9_48_3\" class=\"gform-field-label gform-field-label--type-inline\">Nh\u00e2n vi\u00ean GTF<\/label>\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_48.4\" type=\"checkbox\" value=\"GTF Volunteer\" id=\"choice_9_48_4\">\n\t\t\t\t\t\t\t\t<label for=\"choice_9_48_4\" id=\"label_9_48_4\" class=\"gform-field-label gform-field-label--type-inline\">T\u00ecnh nguy\u1ec7n vi\u00ean GTF<\/label>\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_48.5\" type=\"checkbox\" value=\"Transplant Staff\" id=\"choice_9_48_5\">\n\t\t\t\t\t\t\t\t<label for=\"choice_9_48_5\" id=\"label_9_48_5\" class=\"gform-field-label gform-field-label--type-inline\">Nh\u00e2n vi\u00ean c\u1ea5y gh\u00e9p<\/label>\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_48.6\" type=\"checkbox\" value=\"Other\" id=\"choice_9_48_6\">\n\t\t\t\t\t\t\t\t<label for=\"choice_9_48_6\" id=\"label_9_48_6\" class=\"gform-field-label gform-field-label--type-inline\">Kh\u00e1c<\/label>\n\t\t\t\t\t\t\t<\/fieldset><label class=\"gfield_label gform-field-label\" for=\"input_9_46\">T\u00ean c\u1ee7a ng\u01b0\u1eddi b\u1ea1n \u0111\u00e3 nghe v\u1ec1 c\u00e1c d\u1ecbch v\u1ee5 GTF t\u1eeb:<\/label><input name=\"input_46\" id=\"input_9_46\" type=\"text\" value=\"\" class=\"large\" aria-invalid=\"false\">\n                        <input type=\"button\" id=\"gform_previous_button_9_60\" class=\"gform_previous_button gform-theme-button gform-theme-button--secondary button\" onclick=\"gform.submission.handleButtonClick(this);\" data-submission-type=\"previous\" value=\"Tr\u01b0\u1edbc\"> <input type=\"button\" id=\"gform_next_button_9_60\" class=\"gform_next_button gform-theme-button button\" onclick=\"gform.submission.handleButtonClick(this);\" data-submission-type=\"next\" value=\"K\u1ebf ti\u1ebfp\"> <button type=\"button\" id=\"gform_save_9_3_link\" onclick=\"gform.submission.handleButtonClick(this);\" data-submission-type=\"save-continue\" class=\"gform_save_link gform-theme-button gform-theme-button--secondary button\"> L\u01b0u v\u00e0 ti\u1ebfp t\u1ee5c sau<\/button>\n                        <label class=\"gfield_label gform-field-label\" for=\"input_9_123\">Trung t\u00e2m C\u1ea5y gh\u00e9p *<\/label><select name=\"input_123\" id=\"input_9_123\" class=\"large gfield_select\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"\" selected=\"selected\"><\/option><option value=\"Augusta University Health\">\u0110\u1ea1i h\u1ecdc Augusta S\u1ee9c kh\u1ecfe<\/option><option value=\"Children's Healthcare of Atlanta\">Ch\u0103m s\u00f3c s\u1ee9c kh\u1ecfe tr\u1ebb em c\u1ee7a Atlanta<\/option><option value=\"Duke Health\">Duke Health<\/option><option value=\"Emory Healthcare\">Emory Healthcare<\/option><option value=\"Mayo Clinic (Jacksonville)\">Ph\u00f2ng kh\u00e1m Mayo (Jacksonville)<\/option><option value=\"MUSC Health\">MUSC S\u1ee9c kh\u1ecfe<\/option><option value=\"Piedmont Healthcare\">Piedmont Healthcare<\/option><option value=\"UAB Medicine\">Thu\u1ed1c UAB<\/option><option value=\"Other\">Kh\u00e1c<\/option><\/select><label class=\"gfield_label gform-field-label\" for=\"input_9_124\">Trung t\u00e2m c\u1ea5y gh\u00e9p kh\u00e1c<\/label><input name=\"input_124\" id=\"input_9_124\" type=\"text\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_126\">I am&#8230;*<\/label><select name=\"input_126\" id=\"input_9_126\" class=\"large gfield_select\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"\" selected=\"selected\"><\/option><option value=\"Currently being evaluated for transplant\">Hi\u1ec7n \u0111ang \u0111\u01b0\u1ee3c \u0111\u00e1nh gi\u00e1 \u0111\u1ec3 c\u1ea5y gh\u00e9p<\/option><option value=\"Listed for transplant\">\u0110\u01b0\u1ee3c li\u1ec7t k\u00ea \u0111\u1ec3 c\u1ea5y gh\u00e9p<\/option><option value=\"Transplanted\">C\u1ea5y gh\u00e9p<\/option><\/select><label class=\"gfield_label gform-field-label\" for=\"input_9_127\">Ng\u00e0y c\u1ea5y gh\u00e9p<\/label>\n                            <input name=\"input_127\" id=\"input_9_127\" type=\"text\" value=\"\" class=\"datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon\" placeholder=\"mm\/dd\/yyyy\" aria-describedby=\"input_9_127_date_format\" aria-invalid=\"false\">\n                            MM slash DD slash YYYY\n                        <input type=\"hidden\" id=\"gforms_calendar_icon_input_9_127\" class=\"gform_hidden\" value=\"https:\/\/gatransplant.blackbaudwp.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg\"><fieldset id=\"field_9_193\"><legend class=\"gfield_label gform-field-label gfield_label_before_complex\">\u0110\u00e0n organ*<\/legend>\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_193.1\" type=\"checkbox\" value=\"Kidney\" id=\"choice_9_193_1\">\n\t\t\t\t\t\t\t\t<label for=\"choice_9_193_1\" id=\"label_9_193_1\" class=\"gform-field-label gform-field-label--type-inline\">Th\u1eadn<\/label>\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_193.2\" type=\"checkbox\" value=\"Liver\" id=\"choice_9_193_2\">\n\t\t\t\t\t\t\t\t<label for=\"choice_9_193_2\" id=\"label_9_193_2\" class=\"gform-field-label gform-field-label--type-inline\">Gan<\/label>\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_193.3\" type=\"checkbox\" value=\"Lung(s)\" id=\"choice_9_193_3\">\n\t\t\t\t\t\t\t\t<label for=\"choice_9_193_3\" id=\"label_9_193_3\" class=\"gform-field-label gform-field-label--type-inline\">(C\u00e1c) ph\u1ed5i<\/label>\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_193.4\" type=\"checkbox\" value=\"Pancreas\" id=\"choice_9_193_4\">\n\t\t\t\t\t\t\t\t<label for=\"choice_9_193_4\" id=\"label_9_193_4\" class=\"gform-field-label gform-field-label--type-inline\">Tuy\u1ebfn t\u1ee5y<\/label>\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_193.5\" type=\"checkbox\" value=\"Heart\" id=\"choice_9_193_5\">\n\t\t\t\t\t\t\t\t<label for=\"choice_9_193_5\" id=\"label_9_193_5\" class=\"gform-field-label gform-field-label--type-inline\">Tim<\/label>\n\t\t\t\t\t\t\t<\/fieldset><fieldset id=\"field_9_190\"><legend class=\"gfield_label gform-field-label gfield_label_before_complex\">T\u00f4i \u0111ang g\u00e2y qu\u1ef9 cho: *<\/legend>\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_190.1\" type=\"checkbox\" value=\"Prescription medications\" id=\"choice_9_190_1\">\n\t\t\t\t\t\t\t\t<label for=\"choice_9_190_1\" id=\"label_9_190_1\" class=\"gform-field-label gform-field-label--type-inline\">Thu\u1ed1c k\u00ea \u0111\u01a1n<\/label>\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_190.2\" type=\"checkbox\" value=\"Medical insurance premiums\" id=\"choice_9_190_2\">\n\t\t\t\t\t\t\t\t<label for=\"choice_9_190_2\" id=\"label_9_190_2\" class=\"gform-field-label gform-field-label--type-inline\">Ph\u00ed b\u1ea3o hi\u1ec3m y t\u1ebf<\/label>\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_190.3\" type=\"checkbox\" value=\"Other transplant-related expenses\" id=\"choice_9_190_3\">\n\t\t\t\t\t\t\t\t<label for=\"choice_9_190_3\" id=\"label_9_190_3\" class=\"gform-field-label gform-field-label--type-inline\">C\u00e1c chi ph\u00ed kh\u00e1c li\u00ean quan \u0111\u1ebfn c\u1ea5y gh\u00e9p<\/label>\n\t\t\t\t\t\t\t<\/fieldset><label class=\"gfield_label gform-field-label\" for=\"input_9_125\">\u0110i\u1ec1u ph\u1ed1i vi\u00ean T\u00e0i ch\u00ednh \/ Nh\u00e2n vi\u00ean X\u00e3 h\u1ed9i T\u00ean: *<\/label><input name=\"input_125\" id=\"input_9_125\" type=\"text\" value=\"\" class=\"large\" aria-required=\"true\" aria-invalid=\"false\">\n                        <input type=\"button\" id=\"gform_previous_button_9_122\" class=\"gform_previous_button gform-theme-button gform-theme-button--secondary button\" onclick=\"gform.submission.handleButtonClick(this);\" data-submission-type=\"previous\" value=\"Tr\u01b0\u1edbc\"> <input type=\"button\" id=\"gform_next_button_9_122\" class=\"gform_next_button gform-theme-button button\" onclick=\"gform.submission.handleButtonClick(this);\" data-submission-type=\"next\" value=\"K\u1ebf ti\u1ebfp\"> <button type=\"button\" id=\"gform_save_9_4_link\" onclick=\"gform.submission.handleButtonClick(this);\" data-submission-type=\"save-continue\" class=\"gform_save_link gform-theme-button gform-theme-button--secondary button\"> L\u01b0u v\u00e0 ti\u1ebfp t\u1ee5c sau<\/button>\n                        <h3>Th\u00f4ng tin b\u1ea3o hi\u1ec3m<\/h3>N\u1ebfu b\u1ea1n c\u00f3 th\u1eafc m\u1eafc v\u1ec1 b\u1ea3o hi\u1ec3m c\u1ee7a m\u00ecnh, vui l\u00f2ng li\u00ean h\u1ec7 v\u1edbi c\u00f4ng ty b\u1ea3o hi\u1ec3m ho\u1eb7c \u0111i\u1ec1u ph\u1ed1i vi\u00ean t\u00e0i ch\u00ednh \/ nh\u00e2n vi\u00ean x\u00e3 h\u1ed9i c\u1ee7a trung t\u00e2m c\u1ea5y gh\u00e9p.<label class=\"gfield_label gform-field-label\" for=\"input_9_130\">Medical Insurance (Primary):*<\/label><input name=\"input_130\" id=\"input_9_130\" type=\"text\" value=\"\" class=\"large\" aria-required=\"true\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_131\">B\u1ea3o hi\u1ec3m y t\u1ebf (Ph\u1ee5):<\/label><input name=\"input_131\" id=\"input_9_131\" type=\"text\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_132\">Lo\u1ea1i b\u1ea3o hi\u1ec3m:<\/label><select name=\"input_132\" id=\"input_9_132\" class=\"large gfield_select\" aria-invalid=\"false\"><option value=\"\" selected=\"selected\"><\/option><option value=\"Medicare\">Medicare<\/option><option value=\"Medicare Advantage\">Medicare Advantage<\/option><option value=\"Medicare Supplement\">Medicare b\u1ed5 sung<\/option><option value=\"Katie Beckett\">Katie Beckett<\/option><option value=\"Medicaid\">Medicaid<\/option><option value=\"Medicaid Spend-Down\">Gi\u1ea3m chi ti\u00eau Medicaid<\/option><option value=\"QMB Medicaid\">QMB Medicaid<\/option><\/select><label class=\"gfield_label gform-field-label\" for=\"input_9_133\">Lo\u1ea1i Medicare<\/label><select name=\"input_133\" id=\"input_9_133\" class=\"large gfield_select\" aria-invalid=\"false\"><option value=\"\" selected=\"selected\"><\/option><option value=\"Medicare A\">Medicare A<\/option><option value=\"Medicare B\">Medicare B<\/option><option value=\"Medicare D\">Medicare D<\/option><\/select><label class=\"gfield_label gform-field-label\" for=\"input_9_134\">Th\u00f4ng tin B\u1ed5 sung Medicare<\/label><input name=\"input_134\" id=\"input_9_134\" type=\"text\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_135\">L\u00e0m th\u1ebf n\u00e0o \u0111\u1ec3 b\u1ea1n c\u00f3 b\u1ea3o hi\u1ec3m n\u00e0y?<\/label><select name=\"input_135\" id=\"input_9_135\" class=\"large gfield_select\" aria-invalid=\"false\"><option value=\"\" selected=\"selected\"><\/option><option value=\"ESRD\">ESRD<\/option><option value=\"My Employment\">Vi\u1ec7c l\u00e0m c\u1ee7a t\u00f4i<\/option><option value=\"Spouse's Employment\">Spouse&#8217;s Employment<\/option><option value=\"Private Policy\">Ch\u00ednh s\u00e1ch ri\u00eang t\u01b0<\/option><option value=\"COBRA\">COBRA<\/option><option value=\"Retirement\">S\u1ef1 ngh\u1ec9 h\u01b0u<\/option><option value=\"Disabled\">T\u00e0n t\u1eadt<\/option><option value=\"Other\">Kh\u00e1c<\/option><\/select><label class=\"gfield_label gform-field-label\" for=\"input_9_136\">B\u1ea3o hi\u1ec3m kh\u00e1c<\/label><input name=\"input_136\" id=\"input_9_136\" type=\"text\" value=\"\" class=\"large\" aria-invalid=\"false\"><h3>B\u1ea3o hi\u1ec3m c\u1ee7a b\u1ea1n bao g\u1ed3m nh\u1eefng g\u00ec cho vi\u1ec7c c\u1ea5y gh\u00e9p?<\/h3><label class=\"gfield_label gform-field-label\" for=\"input_9_139\">Kh\u1ea5u tr\u1eeb h\u00e0ng n\u0103m ($)<\/label><input name=\"input_139\" id=\"input_9_139\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_140\">S\u1ed1 ti\u1ec1n b\u1ecf t\u00fai h\u00e0ng n\u0103m t\u1ed1i \u0111a ($)<\/label><input name=\"input_140\" id=\"input_9_140\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_141\">L\u1ee3i \u00edch t\u1ed1i \u0111a h\u00e0ng n\u0103m ($)<\/label><input name=\"input_141\" id=\"input_9_141\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_142\">L\u1ee3i \u00edch t\u1ed1i \u0111a tr\u1ecdn \u0111\u1eddi ($)<\/label><input name=\"input_142\" id=\"input_9_142\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_143\">\u0110\u1ed3ng thanh to\u00e1n thu\u1ed1c \u1ee9c ch\u1ebf mi\u1ec5n d\u1ecbch<\/label><input name=\"input_143\" id=\"input_9_143\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-invalid=\"false\" aria-describedby=\"gfield_description_9_143\">(\u01af\u1edbc t\u00ednh $ h\u00e0ng th\u00e1ng)<h3>Kho\u1ea3n kh\u1ea5u tr\u1eeb h\u00e0ng n\u0103m c\u1ee7a Medicare:<\/h3><label class=\"gfield_label gform-field-label\" for=\"input_9_144\">Ph\u1ea7n A ($)<\/label><input name=\"input_144\" id=\"input_9_144\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_147\">Ph\u1ea7n B ($)<\/label><input name=\"input_147\" id=\"input_9_147\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_148\">Ph\u1ea7n D ($)<\/label><input name=\"input_148\" id=\"input_9_148\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_146\">\u0110\u1ed3ng thanh to\u00e1n thu\u1ed1c \u1ee9c ch\u1ebf mi\u1ec5n d\u1ecbch ($ h\u00e0ng th\u00e1ng):<\/label><input name=\"input_146\" id=\"input_9_146\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-invalid=\"false\"><h3>S\u1ebd c\u00f3 B\u1ea4T K\u1ef2 thay \u0111\u1ed5i n\u00e0o trong ph\u1ea1m vi b\u1ea3o hi\u1ec3m c\u1ee7a b\u1ea1n sau khi c\u1ea5y gh\u00e9p?<\/h3><label class=\"gfield_label gform-field-label\" for=\"input_9_155\">Ch\u1ecdn lo\u1ea1i b\u1ea3o hi\u1ec3m<\/label><select name=\"input_155\" id=\"input_9_155\" class=\"large gfield_select\" aria-invalid=\"false\"><option value=\"\" selected=\"selected\"><\/option><option value=\"Eligible for\/accepting Medicare, Medicare benefits\">\u0110\u1ee7 \u0111i\u1ec1u ki\u1ec7n cho \/ ch\u1ea5p nh\u1eadn Medicare, c\u00e1c quy\u1ec1n l\u1ee3i c\u1ee7a Medicare<\/option><option value=\"Medicare terminates 3 years post-transplant (kidney)\">Medicare ch\u1ea5m d\u1ee9t 3 n\u0103m sau khi gh\u00e9p (th\u1eadn)<\/option><option value=\"COBRA benefits terminate on\">Quy\u1ec1n l\u1ee3i COBRA ch\u1ea5m d\u1ee9t v\u00e0o<\/option><option value=\"Insurance is dependent on disability status\">B\u1ea3o hi\u1ec3m ph\u1ee5 thu\u1ed9c v\u00e0o t\u00ecnh tr\u1ea1ng khuy\u1ebft t\u1eadt<\/option><option value=\"Other\">Kh\u00e1c<\/option><\/select><label class=\"gfield_label gform-field-label\" for=\"input_9_156\">Ng\u00e0y<\/label>\n                            <input name=\"input_156\" id=\"input_9_156\" type=\"text\" value=\"\" class=\"datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon\" placeholder=\"mm\/dd\/yyyy\" aria-describedby=\"input_9_156_date_format\" aria-invalid=\"false\">\n                            MM slash DD slash YYYY\n                        <input type=\"hidden\" id=\"gforms_calendar_icon_input_9_156\" class=\"gform_hidden\" value=\"https:\/\/gatransplant.blackbaudwp.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg\"><label class=\"gfield_label gform-field-label\" for=\"input_9_154\">Kh\u00e1c:<\/label><input name=\"input_154\" id=\"input_9_154\" type=\"text\" value=\"\" class=\"large\" aria-invalid=\"false\">\n                        <input type=\"button\" id=\"gform_previous_button_9_157\" class=\"gform_previous_button gform-theme-button gform-theme-button--secondary button\" onclick=\"gform.submission.handleButtonClick(this);\" data-submission-type=\"previous\" value=\"Tr\u01b0\u1edbc\"> <input type=\"button\" id=\"gform_next_button_9_157\" class=\"gform_next_button gform-theme-button button\" onclick=\"gform.submission.handleButtonClick(this);\" data-submission-type=\"next\" value=\"K\u1ebf ti\u1ebfp\"> <button type=\"button\" id=\"gform_save_9_5_link\" onclick=\"gform.submission.handleButtonClick(this);\" data-submission-type=\"save-continue\" class=\"gform_save_link gform-theme-button gform-theme-button--secondary button\"> L\u01b0u v\u00e0 ti\u1ebfp t\u1ee5c sau<\/button>\n                        <label class=\"gfield_label gform-field-label\" for=\"input_9_194\">Has your transplant center required you to prepare a financial plan for your transplant?*<\/label><select name=\"input_194\" id=\"input_9_194\" class=\"large gfield_select\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">\u0110\u00fang<\/option><option value=\"No\">Kh\u00f4ng<\/option><\/select><label class=\"gfield_label gform-field-label\" for=\"input_9_195\">Have you attended a GTF Fundraising Workshop?*<\/label><select name=\"input_195\" id=\"input_9_195\" class=\"medium gfield_select\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">\u0110\u00fang<\/option><option value=\"No\">Kh\u00f4ng<\/option><\/select><label class=\"gfield_label gform-field-label\" for=\"input_9_159\">What have you done to plan for your transplant?*<\/label><textarea name=\"input_159\" id=\"input_9_159\" class=\"textarea medium\" aria-required=\"true\" aria-invalid=\"false\" rows=\"10\" cols=\"50\"><\/textarea>\n                        <input type=\"button\" id=\"gform_previous_button_9_129\" class=\"gform_previous_button gform-theme-button gform-theme-button--secondary button\" onclick=\"gform.submission.handleButtonClick(this);\" data-submission-type=\"previous\" value=\"Tr\u01b0\u1edbc\"> <input type=\"button\" id=\"gform_next_button_9_129\" class=\"gform_next_button gform-theme-button button\" onclick=\"gform.submission.handleButtonClick(this);\" data-submission-type=\"next\" value=\"K\u1ebf ti\u1ebfp\"> <button type=\"button\" id=\"gform_save_9_6_link\" onclick=\"gform.submission.handleButtonClick(this);\" data-submission-type=\"save-continue\" class=\"gform_save_link gform-theme-button gform-theme-button--secondary button\"> L\u01b0u v\u00e0 ti\u1ebfp t\u1ee5c sau<\/button>\n                        <h3>T\u00e0i s\u1ea3n:<\/h3><label class=\"gfield_label gform-field-label\" for=\"input_9_52\">Checking ($)*<\/label><input name=\"input_52\" id=\"input_9_52\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-required=\"true\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_55\">Savings ($)*<\/label><input name=\"input_55\" id=\"input_9_55\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-required=\"true\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_56\">Stocks &amp; Bonds ($)*<\/label><input name=\"input_56\" id=\"input_9_56\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-required=\"true\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_57\">Retirement Accounts ($)*<\/label><input name=\"input_57\" id=\"input_9_57\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-required=\"true\" aria-invalid=\"false\"><fieldset id=\"field_9_196\"><legend class=\"gfield_label gform-field-label gfield_label_before_complex\">\u00d4 t\u00f4<\/legend>YearMake&nbsp;<input aria-invalid=\"false\" aria-label=\"Year, Row 1\" data-aria-label-template=\"Year, Row {0}\" type=\"text\" name=\"input_196[]\" value=\"\"><input aria-invalid=\"false\" aria-label=\"Make, Row 1\" data-aria-label-template=\"Make, Row {0}\" type=\"text\" name=\"input_196[]\" value=\"\">   <button type=\"button\" class=\"add_list_item\" aria-label=\"Add another row\" onclick=\"gformAddListItem(this, 0)\">Add<\/button>   <button type=\"button\" class=\"delete_list_item\" aria-label=\"Remove row 1\" data-aria-label-template=\"Remove row {0}\" onclick=\"gformDeleteListItem(this, 0)\">Remove<\/button><\/fieldset><h3>Thu nh\u1eadp r\u00f2ng h\u00e0ng th\u00e1ng c\u1ee7a h\u1ed9 gia \u0111\u00ecnh (vui l\u00f2ng s\u1eed d\u1ee5ng m\u00f4 t\u1ea3 \u0111\u01b0\u1ee3c li\u1ec7t k\u00ea b\u00ean d\u01b0\u1edbi)<\/h3><strong>H\u1ed9 gia \u0111\u00ecnh:<\/strong> T\u1ea5t c\u1ea3 nh\u1eefng ng\u01b0\u1eddi s\u1ed1ng trong nh\u00e0 c\u1ee7a b\u1ea1n (bao g\u1ed3m t\u1ea5t c\u1ea3 tr\u1ebb em, ng\u01b0\u1eddi l\u1edbn ho\u1eb7c tr\u1ebb v\u1ecb th\u00e0nh ni\u00ean), c\u00e1c th\u00e0nh vi\u00ean kh\u00f4ng c\u00f3 li\u00ean quan trong gia \u0111\u00ecnh, cha m\u1eb9, ch\u00e1u, anh ch\u1ecb em, ng\u01b0\u1eddi thu\u00ea nh\u00e0, v.v.<br><br>\n<strong>Thu nh\u1eadp = earnings:<\/strong> T\u1ed5ng s\u1ed1 ti\u1ec1n cho ti\u1ec1n l\u01b0\u01a1ng ho\u1eb7c thu nh\u1eadp t\u1eeb ti\u1ec1n l\u01b0\u01a1ng, thu nh\u1eadp t\u1ef1 doanh, ti\u1ec1n l\u00e3i, c\u1ed5 t\u1ee9c v\u00e0 thu nh\u1eadp cho thu\u00ea, Thu nh\u1eadp t\u1eeb h\u01b0u tr\u00ed v\u00e0 an sinh x\u00e3 h\u1ed9i cho ng\u01b0\u1eddi khuy\u1ebft t\u1eadt, Thu nh\u1eadp an sinh b\u1ed5 sung, c\u1ea5p d\u01b0\u1ee1ng nu\u00f4i con, tr\u1ee3 c\u1ea5p c\u00f4ng c\u1ed9ng, TANF, phi\u1ebfu th\u1ef1c ph\u1ea9m, tr\u1ee3 gi\u00fap t\u00e0i ch\u00ednh c\u1ee7a gia \u0111\u00ecnh, thu nh\u1eadp t\u1eeb con c\u00e1i \u0111ang \u0111i l\u00e0m, cha m\u1eb9, anh ch\u1ecb em, v.v. c\u01b0 tr\u00fa trong h\u1ed9 gia \u0111\u00ecnh c\u1ee7a b\u1ea1n. <br><br>\n<strong>Chi ph\u00ed:<\/strong> C\u00e1c chi ph\u00ed chung c\u1ee7a h\u1ed9 gia \u0111\u00ecnh m\u1ed7i th\u00e1ng - ti\u1ec1n thu\u00ea nh\u00e0 \/ th\u1ebf ch\u1ea5p, ti\u1ec1n \u0103n, ti\u1ec1n \u0111i\u1ec7n trung b\u00ecnh, ti\u1ec1n \u0111i\u1ec7n tho\u1ea1i - ti\u1ec1n \u0111i\u1ec7n tho\u1ea1i c\u01a1 b\u1ea3n, \u0111i\u1ec7n tho\u1ea1i di \u0111\u1ed9ng, thanh to\u00e1n b\u1eb1ng th\u1ebb t\u00edn d\u1ee5ng - s\u1ed1 ti\u1ec1n h\u00e0ng th\u00e1ng, kh\u00f4ng ph\u1ea3i t\u1ed5ng s\u1ed1 d\u01b0 n\u1ee3.\n<label class=\"gfield_label gform-field-label\" for=\"input_9_62\">Wages (net $)*<\/label><input name=\"input_62\" id=\"input_9_62\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-required=\"true\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_63\">Spouse&#8217;s Income ($)<\/label><input name=\"input_63\" id=\"input_9_63\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_69\">Family Member&#8217;s Income ($)<\/label><input name=\"input_69\" id=\"input_9_69\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_68\">An sinh x\u00e3 h\u1ed9i ($)<\/label><input name=\"input_68\" id=\"input_9_68\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_67\">Khuy\u1ebft t\u1eadt b\u1ed5 sung ($)<\/label><input name=\"input_67\" id=\"input_9_67\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_66\">L\u01b0\u01a1ng h\u01b0u ($)<\/label><input name=\"input_66\" id=\"input_9_66\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_71\">Thu nh\u1eadp h\u01b0u tr\u00ed ($)<\/label><input name=\"input_71\" id=\"input_9_71\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_70\">Tr\u1ee3 c\u1ea5p C\u1ef1u chi\u1ebfn binh ($)<\/label><input name=\"input_70\" id=\"input_9_70\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_65\">TANF ($)<\/label><input name=\"input_65\" id=\"input_9_65\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_64\">Tem phi\u1ebfu th\u1ef1c ph\u1ea9m ($)<\/label><input name=\"input_64\" id=\"input_9_64\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_75\">Thu nh\u1eadp cho thu\u00ea ($)<\/label><input name=\"input_75\" id=\"input_9_75\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_74\">C\u1ed5 t\u1ee9c ($)<\/label><input name=\"input_74\" id=\"input_9_74\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_76\">Kh\u00e1c ($)<\/label><input name=\"input_76\" id=\"input_9_76\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_77\">T\u1ed5ng thu nh\u1eadp h\u00e0ng th\u00e1ng<\/label><input name=\"input_77\" id=\"input_9_77\" type=\"text\" step=\"any\" value=\"\" class=\"large gform-text-input-reset\" readonly=\"readonly\" aria-invalid=\"false\"><h3>Chi ph\u00ed gia \u0111\u00ecnh h\u00e0ng th\u00e1ng:<\/h3><label class=\"gfield_label gform-field-label\" for=\"input_9_73\">Rent or Mortgage ($)*<\/label><input name=\"input_73\" id=\"input_9_73\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-required=\"true\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_91\">Food ($)*<\/label><input name=\"input_91\" id=\"input_9_91\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-required=\"true\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_90\">Home Phone and Internet ($)*<\/label><input name=\"input_90\" id=\"input_9_90\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-required=\"true\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_89\">Gas and Electric ($)*<\/label><input name=\"input_89\" id=\"input_9_89\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-required=\"true\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_88\">Cell Phone ($)*<\/label><input name=\"input_88\" id=\"input_9_88\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-required=\"true\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_87\">Water ($)*<\/label><input name=\"input_87\" id=\"input_9_87\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-required=\"true\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_86\">Giao th\u00f4ng c\u00f4ng c\u1ed9ng ($)<\/label><input name=\"input_86\" id=\"input_9_86\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_85\">Thanh to\u00e1n t\u1ef1 \u0111\u1ed9ng ($)<\/label><input name=\"input_85\" id=\"input_9_85\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_72\">X\u0103ng ($)<\/label><input name=\"input_72\" id=\"input_9_72\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_84\">Ph\u00ed b\u00e1c s\u0129 ($)<\/label><input name=\"input_84\" id=\"input_9_84\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_83\">Thanh to\u00e1n vi\u1ec7n ph\u00ed ($)<\/label><input name=\"input_83\" id=\"input_9_83\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_82\">Thu\u1ed1c theo toa ($)<\/label><input name=\"input_82\" id=\"input_9_82\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_81\">Nha khoa ($)<\/label><input name=\"input_81\" id=\"input_9_81\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_80\">B\u1ea3o hi\u1ec3m y t\u1ebf ($)<\/label><input name=\"input_80\" id=\"input_9_80\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_94\">B\u1ea3o hi\u1ec3m nh\u00e2n th\u1ecd ($)<\/label><input name=\"input_94\" id=\"input_9_94\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_93\">B\u1ea3o hi\u1ec3m \u00f4 t\u00f4 ($)<\/label><input name=\"input_93\" id=\"input_9_93\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_92\">Th\u1ebb ng\u00e2n h\u00e0ng ($)<\/label><input name=\"input_92\" id=\"input_9_92\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-invalid=\"false\" aria-describedby=\"gfield_description_9_92\">thanh to\u00e1n h\u00e0ng th\u00e1ng<label class=\"gfield_label gform-field-label\" for=\"input_9_97\">Kh\u00e1c<\/label><input name=\"input_97\" id=\"input_9_97\" type=\"text\" step=\"any\" value=\"\" class=\"large\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_96\">T\u1ed5ng chi ph\u00ed h\u00e0ng th\u00e1ng<\/label><input name=\"input_96\" id=\"input_9_96\" type=\"text\" step=\"any\" value=\"\" class=\"large gform-text-input-reset\" readonly=\"readonly\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_98\">N\u1ebfu b\u1ea1n kh\u00f4ng tr\u1ea3 ti\u1ec1n thu\u00ea nh\u00e0 ho\u1eb7c th\u1ebf ch\u1ea5p, vui l\u00f2ng gi\u1ea3i th\u00edch:<\/label><textarea name=\"input_98\" id=\"input_9_98\" class=\"textarea medium\" aria-invalid=\"false\" rows=\"10\" cols=\"50\"><\/textarea><label class=\"gfield_label gform-field-label\" for=\"input_9_99\">N\u1ebfu chi ph\u00ed h\u00e0ng th\u00e1ng c\u1ee7a b\u1ea1n nhi\u1ec1u h\u01a1n thu nh\u1eadp h\u00e0ng th\u00e1ng, vui l\u00f2ng gi\u1ea3i th\u00edch c\u00e1ch b\u1ea1n thanh to\u00e1n h\u00f3a \u0111\u01a1n h\u00e0ng th\u00e1ng:<\/label><textarea name=\"input_99\" id=\"input_9_99\" class=\"textarea medium\" aria-invalid=\"false\" rows=\"10\" cols=\"50\"><\/textarea>\n                        <input type=\"button\" id=\"gform_previous_button_9_100\" class=\"gform_previous_button gform-theme-button gform-theme-button--secondary button\" onclick=\"gform.submission.handleButtonClick(this);\" data-submission-type=\"previous\" value=\"Tr\u01b0\u1edbc\"> <input type=\"button\" id=\"gform_next_button_9_100\" class=\"gform_next_button gform-theme-button button\" onclick=\"gform.submission.handleButtonClick(this);\" data-submission-type=\"next\" value=\"K\u1ebf ti\u1ebfp\"> <button type=\"button\" id=\"gform_save_9_7_link\" onclick=\"gform.submission.handleButtonClick(this);\" data-submission-type=\"save-continue\" class=\"gform_save_link gform-theme-button gform-theme-button--secondary button\"> L\u01b0u v\u00e0 ti\u1ebfp t\u1ee5c sau<\/button>\n                        <b>T\u00c0I KHO\u1ea2N \u0110\u00c3 K\u1ebeT H\u1ee2P<\/b>\n<ul>\n<li>S\u1ed1 ti\u1ec1n huy \u0111\u1ed9ng \u0111\u01b0\u1ee3c trong v\u00f2ng m\u1ed9t (1) n\u0103m k\u1ec3 t\u1eeb khi ch\u1ea5p nh\u1eadn tham gia Ch\u01b0\u01a1ng tr\u00ecnh \u0111\u01b0\u1ee3c kh\u1edbp v\u1edbi s\u1ed1 ti\u1ec1n t\u1ed1i \u0111a l\u00e0 $10.000.<\/li>\n<li>Ph\u1ea3i \u0111\u01b0\u1ee3c ch\u1ea5p nh\u1eadn v\u00e0o ch\u01b0\u01a1ng tr\u00ecnh gh\u00e9p tr\u01b0\u1edbc.<\/li>\n<li>Ng\u00e2n qu\u1ef9 \u0111\u01b0\u1ee3c gi\u1edbi h\u1ea1n \u1edf $1,000 cho chi ph\u00ed thu\u1ed1c kh\u00f4ng theo \u0111\u01a1n.<\/li>\n<li>Ph\u00ed b\u1ea3o hi\u1ec3m y t\u1ebf kh\u00f4ng b\u1ecb gi\u1edbi h\u1ea1n $1,000.<\/li>\n<\/ul>\nGTF t\u00ednh ph\u00ed qu\u1ea3n tr\u1ecb 3% cho m\u1ed7i l\u1ea7n g\u1eedi ti\u1ec1n v\u00e0o t\u00e0i kho\u1ea3n.\n\n<b>T\u00c0I KHO\u1ea2N KH\u00d4NG H\u1ee2P L\u1ec6<\/b>\n<ul>\n<li>\u0110\u1ee7 \u0111i\u1ec1u ki\u1ec7n \u0111\u1ec3 \u00e1p d\u1ee5ng tr\u01b0\u1edbc ho\u1eb7c sau khi gh\u00e9p.<\/li>\n<li>C\u00f3 s\u1eb5n ng\u00e2n qu\u1ef9 cho c\u00e1c chi ph\u00ed h\u1ee3p l\u00fd tr\u01b0\u1edbc v\u00e0 sau khi c\u1ea5y gh\u00e9p.<\/li>\n<li>\u0110\u00e3 m\u1edf r\u1ed9ng gi\u1edbi h\u1ea1n \u0111\u1ed1i v\u1edbi c\u00e1c chi ph\u00ed li\u00ean quan \u0111\u1ebfn c\u1ea5y gh\u00e9p thu\u1ed1c kh\u00f4ng k\u00ea \u0111\u01a1n.<\/li>\n<li>GTF t\u00ednh ph\u00ed qu\u1ea3n tr\u1ecb 3% cho m\u1ed7i l\u1ea7n g\u1eedi ti\u1ec1n v\u00e0o t\u00e0i kho\u1ea3n.<\/li>\n<\/ul><label class=\"gfield_label gform-field-label\" for=\"input_9_164\">Please choose ONE type of account.*<\/label><select name=\"input_164\" id=\"input_9_164\" class=\"large gfield_select\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"\" selected=\"selected\"><\/option><option value=\"Matched Account\">T\u00e0i kho\u1ea3n ph\u00f9 h\u1ee3p<\/option><option value=\"Unmatched Account\">T\u00e0i kho\u1ea3n ch\u01b0a t\u1eebng c\u00f3<\/option><\/select>\n                        <input type=\"button\" id=\"gform_previous_button_9_166\" class=\"gform_previous_button gform-theme-button gform-theme-button--secondary button\" onclick=\"gform.submission.handleButtonClick(this);\" data-submission-type=\"previous\" value=\"Tr\u01b0\u1edbc\"> <input type=\"button\" id=\"gform_next_button_9_166\" class=\"gform_next_button gform-theme-button button\" onclick=\"gform.submission.handleButtonClick(this);\" data-submission-type=\"next\" value=\"K\u1ebf ti\u1ebfp\"> <button type=\"button\" id=\"gform_save_9_8_link\" onclick=\"gform.submission.handleButtonClick(this);\" data-submission-type=\"save-continue\" class=\"gform_save_link gform-theme-button gform-theme-button--secondary button\"> L\u01b0u v\u00e0 ti\u1ebfp t\u1ee5c sau<\/button>\n                        <fieldset id=\"field_9_168\"><legend class=\"gfield_label gform-field-label\">Please choose one PHARMACY OPTION:*<\/legend>\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_168\" type=\"radio\" value=\"I CHOOSE TO use the direct billing process for my post-transplant prescription medications. Prescription medications are supplied by a GTF-approved pharmacy.  This process will allow the GTF-approved pharmacy to bill my insurance, Medicare or Medicaid for the cost of my post-transplant prescription medications. The balance or co-pay will then be directly taken from my TFP account.  This process will allow me to have my fundraising account directly billed so that I do not have to pay upfront for my prescription medications.  It is my responsibility to notify my transplant center that I have chosen this option at the time of transplant.  It is my responsibility to monitor this billing process by contacting the pharmacy directly as needed.\" id=\"choice_9_168_0\" onchange=\"gformToggleRadioOther( this )\">\n\t\t\t\t\t<label for=\"choice_9_168_0\" id=\"label_9_168_0\" class=\"gform-field-label gform-field-label--type-inline\">T\u00d4I CH\u1eccN s\u1eed d\u1ee5ng quy tr\u00ecnh thanh to\u00e1n tr\u1ef1c ti\u1ebfp cho c\u00e1c lo\u1ea1i thu\u1ed1c k\u00ea \u0111\u01a1n sau c\u1ea5y gh\u00e9p c\u1ee7a t\u00f4i. Thu\u1ed1c theo toa do nh\u00e0 thu\u1ed1c \u0111\u01b0\u1ee3c GTF ph\u00ea duy\u1ec7t cung c\u1ea5p. Quy tr\u00ecnh n\u00e0y s\u1ebd cho ph\u00e9p nh\u00e0 thu\u1ed1c \u0111\u01b0\u1ee3c GTF ch\u1ea5p thu\u1eadn l\u1eadp h\u00f3a \u0111\u01a1n cho b\u1ea3o hi\u1ec3m, Medicare ho\u1eb7c Medicaid c\u1ee7a t\u00f4i \u0111\u1ed1i v\u1edbi chi ph\u00ed thu\u1ed1c theo toa sau c\u1ea5y gh\u00e9p c\u1ee7a t\u00f4i. S\u1ed1 d\u01b0 ho\u1eb7c \u0111\u1ed3ng thanh to\u00e1n sau \u0111\u00f3 s\u1ebd \u0111\u01b0\u1ee3c l\u1ea5y tr\u1ef1c ti\u1ebfp t\u1eeb t\u00e0i kho\u1ea3n TFP c\u1ee7a t\u00f4i. Quy tr\u00ecnh n\u00e0y s\u1ebd cho ph\u00e9p t\u00f4i thanh to\u00e1n tr\u1ef1c ti\u1ebfp t\u00e0i kho\u1ea3n g\u00e2y qu\u1ef9 c\u1ee7a m\u00ecnh \u0111\u1ec3 t\u00f4i kh\u00f4ng ph\u1ea3i tr\u1ea3 tr\u01b0\u1edbc cho c\u00e1c lo\u1ea1i thu\u1ed1c theo toa c\u1ee7a m\u00ecnh. T\u00f4i c\u00f3 tr\u00e1ch nhi\u1ec7m th\u00f4ng b\u00e1o cho trung t\u00e2m c\u1ea5y gh\u00e9p c\u1ee7a m\u00ecnh r\u1eb1ng t\u00f4i \u0111\u00e3 ch\u1ecdn t\u00f9y ch\u1ecdn n\u00e0y t\u1ea1i th\u1eddi \u0111i\u1ec3m c\u1ea5y gh\u00e9p. T\u00f4i c\u00f3 tr\u00e1ch nhi\u1ec7m theo d\u00f5i qu\u00e1 tr\u00ecnh thanh to\u00e1n n\u00e0y b\u1eb1ng c\u00e1ch li\u00ean h\u1ec7 tr\u1ef1c ti\u1ebfp v\u1edbi nh\u00e0 thu\u1ed1c n\u1ebfu c\u1ea7n.<\/label>\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_168\" type=\"radio\" value=\"I DO NOT CHOOSE to participate in Direct Billing with any of the Georgia Transplant Foundation\" s=\"\" partner=\"\" pharmacies=\"\" at=\"\" this=\"\" time.=\"\" i=\"\" understand=\"\" that=\"\" choice=\"\" means=\"\" will=\"\" have=\"\" to=\"\" pay=\"\" for=\"\" my=\"\" prescriptions=\"\" out=\"\" of=\"\" pocket=\"\" time=\"\" refill=\"\" and=\"\" be=\"\" reimbursed=\"\" from=\"\" tfp=\"\" account=\"\" a=\"\" later=\"\" time.'=\"\" id=\"choice_9_168_1\" onchange=\"gformToggleRadioOther( this )\">\n\t\t\t\t\t<label for=\"choice_9_168_1\" id=\"label_9_168_1\" class=\"gform-field-label gform-field-label--type-inline\">T\u00f4i KH\u00d4NG CH\u1eccN tham gia Thanh to\u00e1n Tr\u1ef1c ti\u1ebfp v\u1edbi b\u1ea5t k\u1ef3 hi\u1ec7u thu\u1ed1c \u0111\u1ed1i t\u00e1c n\u00e0o c\u1ee7a T\u1ed5 ch\u1ee9c C\u1ea5y gh\u00e9p Georgia v\u00e0o l\u00fac n\u00e0y. T\u00f4i hi\u1ec3u r\u1eb1ng l\u1ef1a ch\u1ecdn n\u00e0y c\u00f3 ngh\u0129a l\u00e0 t\u00f4i s\u1ebd ph\u1ea3i t\u1ef1 b\u1ecf ti\u1ec1n t\u00fai tr\u1ea3 ti\u1ec1n cho c\u00e1c \u0111\u01a1n thu\u1ed1c c\u1ee7a m\u00ecnh t\u1ea1i th\u1eddi \u0111i\u1ec3m n\u1ea1p ti\u1ec1n v\u00e0 s\u1ebd \u0111\u01b0\u1ee3c ho\u00e0n tr\u1ea3 t\u1eeb t\u00e0i kho\u1ea3n TFP c\u1ee7a t\u00f4i sau \u0111\u00f3.<\/label>\n\t\t\t<\/fieldset>\n                        <input type=\"button\" id=\"gform_previous_button_9_161\" class=\"gform_previous_button gform-theme-button gform-theme-button--secondary button\" onclick=\"gform.submission.handleButtonClick(this);\" data-submission-type=\"previous\" value=\"Tr\u01b0\u1edbc\"> <input type=\"button\" id=\"gform_next_button_9_161\" class=\"gform_next_button gform-theme-button button\" onclick=\"gform.submission.handleButtonClick(this);\" data-submission-type=\"next\" value=\"K\u1ebf ti\u1ebfp\"> <button type=\"button\" id=\"gform_save_9_9_link\" onclick=\"gform.submission.handleButtonClick(this);\" data-submission-type=\"save-continue\" class=\"gform_save_link gform-theme-button gform-theme-button--secondary button\"> L\u01b0u v\u00e0 ti\u1ebfp t\u1ee5c sau<\/button>\n                        <h3>X\u00c1C NH\u1eacN: Ngo\u00e0i b\u1ea3n th\u00e2n b\u1ea1n, h\u00e3y x\u00e1c \u0111\u1ecbnh ai \u0111\u01b0\u1ee3c \u1ee7y quy\u1ec1n \u0111\u1ec3 x\u1eed l\u00fd c\u00e1c v\u1ea5n \u0111\u1ec1 t\u00e0i ch\u00ednh c\u1ee7a b\u1ea1n. Ng\u01b0\u1eddi n\u00e0y c\u00f3 th\u1ec3 l\u00e0 v\u1ee3 \/ ch\u1ed3ng, h\u1ecd h\u00e0ng ho\u1eb7c b\u1ea1n b\u00e8, nh\u01b0ng s\u1ebd l\u00e0 ng\u01b0\u1eddi duy nh\u1ea5t GTF th\u1ea3o lu\u1eadn v\u1ec1 t\u00e0i kho\u1ea3n g\u00e2y qu\u1ef9 c\u1ee7a b\u1ea1n.<\/h3><fieldset id=\"field_9_170\"><legend class=\"gfield_label gform-field-label gfield_label_before_complex\">T\u00ean*<\/legend>\n                                                    <select name=\"input_170.2\" id=\"input_9_170_2\" aria-required=\"false\">\n                          <option value=\"\"><\/option><option value=\"Dr.\">Dr.<\/option><option value=\"Miss\">C\u00f4<\/option><option value=\"Mr.\">\u00d4ng.<\/option><option value=\"Mrs.\">B\u00e0.<\/option><option value=\"Ms.\">B\u1ec7nh \u0111a x\u01a1 c\u1ee9ng.<\/option><option value=\"Prof.\">GS.<\/option><option value=\"Rev.\">Rev.<\/option>\n                      <\/select>\n                                                    <label for=\"input_9_170_2\" class=\"gform-field-label gform-field-label--type-sub\">Ti\u1ebfp \u0111\u1ea7u ng\u1eef<\/label>\n                                                    <input type=\"text\" name=\"input_170.3\" id=\"input_9_170_3\" value=\"\" aria-required=\"true\">\n                                                    <label for=\"input_9_170_3\" class=\"gform-field-label gform-field-label--type-sub\">\u0110\u1ea7u ti\u00ean<\/label>\n                                                    <input type=\"text\" name=\"input_170.4\" id=\"input_9_170_4\" value=\"\" aria-required=\"false\">\n                                                    <label for=\"input_9_170_4\" class=\"gform-field-label gform-field-label--type-sub\">\u1ede gi\u1eefa<\/label>\n                                                    <input type=\"text\" name=\"input_170.6\" id=\"input_9_170_6\" value=\"\" aria-required=\"true\">\n                                                    <label for=\"input_9_170_6\" class=\"gform-field-label gform-field-label--type-sub\">Cu\u1ed1i c\u00f9ng<\/label>\n                        <\/fieldset><fieldset id=\"field_9_171\"><legend class=\"gfield_label gform-field-label gfield_label_before_complex\">\u0110\u1ecba ch\u1ec9*<\/legend>    \n                                        <input type=\"text\" name=\"input_171.1\" id=\"input_9_171_1\" value=\"\" aria-required=\"true\">\n                                        <label for=\"input_9_171_1\" id=\"input_9_171_1_label\" class=\"gform-field-label gform-field-label--type-sub\">\u0110\u1ecba ch\u1ec9 \u0111\u01b0\u1eddng ph\u1ed1<\/label>\n                                    <input type=\"text\" name=\"input_171.3\" id=\"input_9_171_3\" value=\"\" aria-required=\"true\">\n                                    <label for=\"input_9_171_3\" id=\"input_9_171_3_label\" class=\"gform-field-label gform-field-label--type-sub\">Tp.<\/label>\n                                        <select name=\"input_171.4\" id=\"input_9_171_4\" aria-required=\"true\"><option value=\"\"><\/option><option value=\"Alabama\">Alabama<\/option><option value=\"Alaska\">Alaska<\/option><option value=\"American Samoa\">American Samoa<\/option><option value=\"Arizona\">Arizona<\/option><option value=\"Arkansas\">Arkansas<\/option><option value=\"California\">California<\/option><option value=\"Colorado\">Colorado<\/option><option value=\"Connecticut\">Connecticut<\/option><option value=\"Delaware\">Delaware<\/option><option value=\"District of Columbia\">\u0110\u1eb7c khu Columbia<\/option><option value=\"Florida\">Florida<\/option><option value=\"Georgia\" selected=\"selected\">Georgia<\/option><option value=\"Guam\">Guam<\/option><option value=\"Hawaii\">Hawaii<\/option><option value=\"Idaho\">Idaho<\/option><option value=\"Illinois\">Illinois<\/option><option value=\"Indiana\">Indiana<\/option><option value=\"Iowa\">Iowa<\/option><option value=\"Kansas\">Kansas<\/option><option value=\"Kentucky\">Kentucky<\/option><option value=\"Louisiana\">Louisiana<\/option><option value=\"Maine\">Maine<\/option><option value=\"Maryland\">Maryland<\/option><option value=\"Massachusetts\">Massachusetts<\/option><option value=\"Michigan\">Michigan<\/option><option value=\"Minnesota\">Minnesota<\/option><option value=\"Mississippi\">Mississippi<\/option><option value=\"Missouri\">Missouri<\/option><option value=\"Montana\">Montana<\/option><option value=\"Nebraska\">Nebraska<\/option><option value=\"Nevada\">Nevada<\/option><option value=\"New Hampshire\">M\u1edbi Hampshire<\/option><option value=\"New Jersey\">\u00c1o m\u1edbi<\/option><option value=\"New Mexico\">New Mexico<\/option><option value=\"New York\">Newyork<\/option><option value=\"North Carolina\">b\u1eafc Carolina<\/option><option value=\"North Dakota\">B\u1eafc Dakota<\/option><option value=\"Northern Mariana Islands\">Qu\u1ea7n \u0111\u1ea3o B\u1eafc Mariana<\/option><option value=\"Ohio\">Ohio<\/option><option value=\"Oklahoma\">Oklahoma<\/option><option value=\"Oregon\">Oregon<\/option><option value=\"Pennsylvania\">Pennsylvania<\/option><option value=\"Puerto Rico\">Puerto Rico<\/option><option value=\"Rhode Island\">\u0111\u1ea3o Rhode<\/option><option value=\"South Carolina\">ph\u00eda Nam Carolina<\/option><option value=\"South Dakota\">Nam Dakota<\/option><option value=\"Tennessee\">Tennessee<\/option><option value=\"Texas\">Texas<\/option><option value=\"Utah\">Utah<\/option><option value=\"U.S. Virgin Islands\">U.S. Virgin Islands<\/option><option value=\"Vermont\">Vermont<\/option><option value=\"Virginia\">Virginia<\/option><option value=\"Washington\">Washington<\/option><option value=\"West Virginia\">phia T\u00e2y Virginia<\/option><option value=\"Wisconsin\">Wisconsin<\/option><option value=\"Wyoming\">Wyoming<\/option><option value=\"Armed Forces Americas\">Qu\u00e2n \u0111\u1ed9i M\u1ef9<\/option><option value=\"Armed Forces Europe\">L\u1ef1c l\u01b0\u1ee3ng v\u0169 trang Ch\u00e2u \u00c2u<\/option><option value=\"Armed Forces Pacific\">L\u1ef1c l\u01b0\u1ee3ng v\u0169 trang Th\u00e1i B\u00ecnh D\u01b0\u01a1ng<\/option><\/select>\n                                        <label for=\"input_9_171_4\" id=\"input_9_171_4_label\" class=\"gform-field-label gform-field-label--type-sub\">Ti\u1ec3u bang<\/label>\n                                    <input type=\"text\" name=\"input_171.5\" id=\"input_9_171_5\" value=\"\" aria-required=\"true\">\n                                    <label for=\"input_9_171_5\" id=\"input_9_171_5_label\" class=\"gform-field-label gform-field-label--type-sub\">M\u00e3 B\u01b0u Ch\u00ednh<\/label>\n                                <input type=\"hidden\" class=\"gform_hidden\" name=\"input_171.6\" id=\"input_9_171_6\" value=\"United States\">\n                <\/fieldset><label class=\"gfield_label gform-field-label\" for=\"input_9_172\">S\u1ed1 \u0111i\u1ec7n tho\u1ea1i ch\u00ednh*<\/label><input name=\"input_172\" id=\"input_9_172\" type=\"tel\" value=\"\" class=\"large\" aria-required=\"true\" aria-invalid=\"false\"><label class=\"gfield_label gform-field-label\" for=\"input_9_175\">E-mail*<\/label>\n                            <input name=\"input_175\" id=\"input_9_175\" type=\"email\" value=\"\" class=\"large\" aria-required=\"true\" aria-invalid=\"false\">\n                        <label class=\"gfield_label gform-field-label\" for=\"input_9_176\">M\u1ed1i quan h\u1ec7 v\u1edbi kh\u00e1ch h\u00e0ng *<\/label><input name=\"input_176\" id=\"input_9_176\" type=\"text\" value=\"\" class=\"large\" aria-required=\"true\" aria-invalid=\"false\"><fieldset id=\"field_9_177\"><legend class=\"gfield_label gform-field-label gfield_label_before_complex\">B\u1eb1ng l\u00f2ng*<\/legend><input name=\"input_177.1\" id=\"input_9_177_1\" type=\"checkbox\" value=\"1\" aria-describedby=\"gfield_consent_description_9_177\" aria-required=\"true\" aria-invalid=\"false\"> <label for=\"input_9_177_1\">T\u00f4i \u0111\u1ed3ng \u00fd v\u1edbi nh\u1eefng \u0111i\u1ec1u sau:<\/label><input type=\"hidden\" name=\"input_177.2\" value=\"I agree to the following:\" class=\"gform_hidden\"><input type=\"hidden\" name=\"input_177.3\" value=\"7\" class=\"gform_hidden\">T\u00f4i hi\u1ec3u r\u1eb1ng n\u1ebfu \u0111\u01a1n \u0111\u0103ng k\u00fd t\u00e0i kho\u1ea3n MATCHED \/ UNMATCHED c\u1ee7a t\u00f4i \u0111\u01b0\u1ee3c ch\u1ea5p thu\u1eadn, GTF s\u1ebd t\u00ednh ph\u00ed qu\u1ea3n tr\u1ecb 3% cho m\u1ed7i kho\u1ea3n ti\u1ec1n g\u1eedi v\u00e0o t\u00e0i kho\u1ea3n c\u1ee7a t\u00f4i.<\/fieldset><fieldset id=\"field_9_179\"><legend class=\"gfield_label gform-field-label gfield_label_before_complex\">B\u1eb1ng l\u00f2ng*<\/legend><input name=\"input_179.1\" id=\"input_9_179_1\" type=\"checkbox\" value=\"1\" aria-describedby=\"gfield_consent_description_9_179\" aria-required=\"true\" aria-invalid=\"false\"> <label for=\"input_9_179_1\">T\u00f4i \u0111\u1ed3ng \u00fd v\u1edbi nh\u1eefng \u0111i\u1ec1u sau:<\/label><input type=\"hidden\" name=\"input_179.2\" value=\"I agree to the following:\" class=\"gform_hidden\"><input type=\"hidden\" name=\"input_179.3\" value=\"7\" class=\"gform_hidden\">T\u00f4i hi\u1ec3u r\u1eb1ng n\u1ebfu \u0111\u01a1n \u0111\u0103ng k\u00fd t\u00e0i kho\u1ea3n g\u00e2y qu\u1ef9 TFP c\u1ee7a t\u00f4i \u0111\u01b0\u1ee3c ch\u1ea5p thu\u1eadn, t\u00f4i s\u1ebd \u0111\u01b0\u1ee3c ho\u00e0n tr\u1ea3 v\u00e0 ph\u00f9 h\u1ee3p SAU KHI t\u00f4i nh\u1eadn \u0111\u01b0\u1ee3c ca c\u1ea5y gh\u00e9p c\u1ee7a m\u00ecnh, khi t\u00f4i b\u1eaft \u0111\u1ea7u mua \/ thanh to\u00e1n c\u00e1c lo\u1ea1i thu\u1ed1c theo toa sau c\u1ea5y gh\u00e9p v\u00e0 \/ ho\u1eb7c c\u00e1c chi ph\u00ed li\u00ean quan \u0111\u1ebfn sau c\u1ea5y gh\u00e9p \u0111\u01b0\u1ee3c ch\u1ea5p thu\u1eadn v\u00e0 ph\u00ed b\u1ea3o hi\u1ec3m y t\u1ebf.<\/fieldset><fieldset id=\"field_9_178\"><legend class=\"gfield_label gform-field-label gfield_label_before_complex\">B\u1eb1ng l\u00f2ng*<\/legend><input name=\"input_178.1\" id=\"input_9_178_1\" type=\"checkbox\" value=\"1\" aria-describedby=\"gfield_consent_description_9_178\" aria-required=\"true\" aria-invalid=\"false\"> <label for=\"input_9_178_1\">T\u00f4i \u0111\u1ed3ng \u00fd v\u1edbi nh\u1eefng \u0111i\u1ec1u sau:<\/label><input type=\"hidden\" name=\"input_178.2\" value=\"I agree to the following:\" class=\"gform_hidden\"><input type=\"hidden\" name=\"input_178.3\" value=\"7\" class=\"gform_hidden\">T\u00f4i hi\u1ec3u r\u1eb1ng n\u1ebfu \u0111\u01a1n \u0111\u0103ng k\u00fd T\u00e0i kho\u1ea3n \u0111\u01b0\u1ee3c so kh\u1edbp TFP c\u1ee7a t\u00f4i \u0111\u01b0\u1ee3c ch\u1ea5p thu\u1eadn, t\u00f4i s\u1ebd \u0111\u01b0\u1ee3c ho\u00e0n tr\u1ea3 v\u00e0 ph\u00f9 h\u1ee3p v\u1edbi nh\u1eefng \u0111i\u1ec1u sau:<br>\n- Thu\u1ed1c theo toa c\u1ea7n thi\u1ebft cho ca c\u1ea5y gh\u00e9p c\u1ee7a t\u00f4i.<br>\n- Ph\u00ed b\u1ea3o hi\u1ec3m y t\u1ebf.<br>\n- T\u1ed5ng c\u1ed9ng $1.000 cho b\u1ea5t k\u1ef3 danh m\u1ee5c n\u00e0o sau \u0111\u00e2y:<br>\n- C\u00e1c h\u00f3a \u0111\u01a1n y t\u1ebf v\u00e0 \u0111\u1ed3ng thanh to\u00e1n li\u00ean quan \u0111\u1ebfn vi\u1ec7c c\u1ea5y gh\u00e9p c\u1ee7a t\u00f4i, v\u00e0 \/ ho\u1eb7c<br>\n- Chi ph\u00ed \u0111i l\u1ea1i v\u00e0 \u0103n \u1edf trong th\u1eddi gian c\u1ea5y gh\u00e9p c\u1ee7a t\u00f4i cho m\u1ed9t (1) ng\u01b0\u1eddi ch\u0103m s\u00f3c v\u00e0 \/ ho\u1eb7c<br>\n- Chi ph\u00ed \u0111i l\u1ea1i v\u00e0 \u0103n \u1edf cho vi\u1ec7c ch\u0103m s\u00f3c y t\u1ebf theo d\u00f5i c\u1ee7a t\u00f4i<\/fieldset><h3>T\u00e0i li\u1ec7u h\u1ed7 tr\u1ee3<\/h3><label class=\"gfield_label gform-field-label\" for=\"gform_browse_button_9_185\">B\u1eb1ng ch\u1ee9ng c\u01b0 tr\u00fa Georgia *<\/label>\n\t\t\t\t\t\t\t\t\t\t\tTh\u1ea3 t\u1ec7p v\u00e0o \u0111\u00e2y ho\u1eb7c \n\t\t\t\t\t\t\t\t\t\t\t<button type=\"button\" id=\"gform_browse_button_9_185\" class=\"button gform_button_select_files gform-theme-button gform-theme-button--control\" aria-describedby=\"gfield_upload_rules_9_185 gfield_description_9_185\">Ch\u1ecdn t\u1ec7p tin<\/button>\n\t\t\t\t\t\t\t\t\tMax. file size: 16 MB.<ul class=\"validation_message--hidden-on-empty gform-ul-reset\" id=\"gform_multifile_messages_9_185\"><\/ul> <!-- Leave <ul> empty to support CSS :empty selector. -->B\u1eb1ng ch\u1ee9ng v\u1ec1 vi\u1ec7c c\u01b0 tr\u00fa t\u1ea1i Georgia trong s\u00e1u (6) th\u00e1ng qua tr\u01b0\u1edbc ng\u00e0y n\u1ed9p \u0111\u01a1n (\u0111\u00e2y c\u00f3 th\u1ec3 l\u00e0 m\u1ed9t trong nh\u1eefng \u0111i\u1ec1u sau: b\u1ea3n sao b\u1eb1ng l\u00e1i xe c\u1ee7a b\u1ea1n \u0111\u01b0\u1ee3c c\u1ea5p \u00edt nh\u1ea5t s\u00e1u th\u00e1ng tr\u01b0\u1edbc \u0111\u00f3; m\u1ed9t t\u00e0i li\u1ec7u c\u0169 s\u00e1u th\u00e1ng c\u00f3 \u0111\u1ecba ch\u1ec9 hi\u1ec7n t\u1ea1i c\u1ee7a b\u1ea1n, ch\u1eb3ng h\u1ea1n nh\u01b0 m\u1ed9t b\u1ea3ng sao k\u00ea ng\u00e2n h\u00e0ng ho\u1eb7c h\u00f3a \u0111\u01a1n \u0111i\u1ec7n n\u01b0\u1edbc). N\u1ebfu b\u1ea1n \u0111ang \u0111\u0103ng k\u00fd m\u1ed9t t\u00e0i kho\u1ea3n kh\u00f4ng kh\u1edbp v\u00e0 kh\u00f4ng c\u01b0 tr\u00fa \u1edf Georgia, b\u1ea1n ph\u1ea3i cung c\u1ea5p b\u1eb1ng ch\u1ee9ng r\u1eb1ng b\u1ea1n \u0111ang \u0111\u01b0\u1ee3c c\u1ea5y gh\u00e9p t\u1ea1i m\u1ed9t b\u1ec7nh vi\u1ec7n \u1edf Georgia.<label class=\"gfield_label gform-field-label\" for=\"gform_browse_button_9_197\">B\u1eb1ng ch\u1ee9ng thu nh\u1eadp h\u1ed9 gia \u0111\u00ecnh *<\/label>\n\t\t\t\t\t\t\t\t\t\t\tTh\u1ea3 t\u1ec7p v\u00e0o \u0111\u00e2y ho\u1eb7c \n\t\t\t\t\t\t\t\t\t\t\t<button type=\"button\" id=\"gform_browse_button_9_197\" class=\"button gform_button_select_files gform-theme-button gform-theme-button--control\" aria-describedby=\"gfield_upload_rules_9_197 gfield_description_9_197\">Ch\u1ecdn t\u1ec7p tin<\/button>\n\t\t\t\t\t\t\t\t\tMax. file size: 16 MB.<ul class=\"validation_message--hidden-on-empty gform-ul-reset\" id=\"gform_multifile_messages_9_197\"><\/ul> <!-- Leave <ul> empty to support CSS :empty selector. -->This can be one of the following: a Social Security Income statement; your most recent pay stub; or a copy of your most recent Federal Income Tax Return.<label class=\"gfield_label gform-field-label\" for=\"input_9_198\">\u0110i\u1ec7n tho\u1ea1i<\/label><input name=\"input_198\" id=\"input_9_198\" type=\"text\" value=\"\" autocomplete=\"new-password\">Tr\u01b0\u1eddng n\u00e0y d\u00e0nh cho m\u1ee5c \u0111\u00edch x\u00e1c th\u1ef1c v\u00e0 n\u00ean \u0111\u01b0\u1ee3c gi\u1eef nguy\u00ean.\n        <input type=\"submit\" id=\"gform_previous_button_9\" class=\"gform_previous_button gform-theme-button gform-theme-button--secondary button\" onclick=\"gform.submission.handleButtonClick(this);\" data-submission-type=\"previous\" value=\"Tr\u01b0\u1edbc\"> <input type=\"submit\" id=\"gform_submit_button_9\" class=\"gform_button button\" onclick=\"gform.submission.handleButtonClick(this);\" data-submission-type=\"submit\" value=\"G\u1eedi \u0111i\"> <button type=\"button\" id=\"gform_save_9_footer_link\" onclick=\"gform.submission.handleButtonClick(this);\" data-submission-type=\"save-continue\" class=\"gform_save_link gform-theme-button gform-theme-button--secondary button\"> L\u01b0u v\u00e0 ti\u1ebfp t\u1ee5c sau<\/button><input type=\"hidden\" name=\"gform_ajax\" value=\"form_id=9&amp;title=&amp;description=1&amp;tabindex=0&amp;theme=gravity-theme&amp;styles=[]&amp;hash=e5787c5c10fd9527b52110afb4e34a12\">\n            <input type=\"hidden\" class=\"gform_hidden\" name=\"gform_submission_method\" data-js=\"gform_submission_method_9\" value=\"iframe\">\n            <input type=\"hidden\" class=\"gform_hidden\" name=\"gform_theme\" data-js=\"gform_theme_9\" id=\"gform_theme_9\" value=\"gravity-theme\">\n            <input type=\"hidden\" class=\"gform_hidden\" name=\"gform_style_settings\" data-js=\"gform_style_settings_9\" id=\"gform_style_settings_9\" value=\"[]\">\n            <input type=\"hidden\" class=\"gform_hidden\" name=\"is_submit_9\" value=\"1\">\n            <input type=\"hidden\" class=\"gform_hidden\" name=\"gform_submit\" value=\"9\">\n            <input type=\"hidden\" class=\"gform_hidden\" name=\"gform_save\" id=\"gform_save_9\" value=\"\">\n                             <input type=\"hidden\" class=\"gform_hidden\" name=\"gform_resume_token\" id=\"gform_resume_token_9\" value=\"\">\n            <input type=\"hidden\" class=\"gform_hidden\" name=\"gform_unique_id\" value=\"\">\n            <input type=\"hidden\" class=\"gform_hidden\" name=\"state_9\" value=\"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\">\n            <input type=\"hidden\" autocomplete=\"off\" class=\"gform_hidden\" name=\"gform_target_page_number_9\" id=\"gform_target_page_number_9\" value=\"2\">\n            <input type=\"hidden\" autocomplete=\"off\" class=\"gform_hidden\" name=\"gform_source_page_number_9\" id=\"gform_source_page_number_9\" value=\"1\">\n            <input type=\"hidden\" name=\"gform_field_values\" value=\"\">\n            <input type=\"hidden\" name=\"gform_uploaded_files\" id=\"gform_uploaded_files_9\" value=\"\">\n                        <input type=\"hidden\" name=\"trp-form-language\" value=\"vi\"\/><\/form>\n\t\t                <iframe style=\"display:none;width:0px;height:0px;\" src=\"about:blank\" name=\"gform_ajax_frame_9\" id=\"gform_ajax_frame_9\" title=\"Khung n\u1ed9i tuy\u1ebfn n\u00e0y ch\u1ee9a logic c\u1ea7n thi\u1ebft \u0111\u1ec3 x\u1eed l\u00fd c\u00e1c Bi\u1ec3u m\u1eabu tr\u1ecdng l\u1ef1c do Ajax cung c\u1ea5p.\"><\/iframe>","protected":false},"excerpt":{"rendered":"<p>Transplant Fundraising Program Application You must complete this application to the best of your ability and provide all supporting documents in order to be reviewed for assistance.&nbsp;&nbsp;Please note: you can&hellip;<\/p>","protected":false},"author":43,"featured_media":0,"parent":6841,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"footnotes":""},"class_list":["post-62225","page","type-page","status-publish","hentry"],"acf":[],"aioseo_notices":[],"_links":{"self":[{"href":"https:\/\/gatransplant.blackbaudwp.com\/vi\/wp-json\/wp\/v2\/pages\/62225","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/gatransplant.blackbaudwp.com\/vi\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/gatransplant.blackbaudwp.com\/vi\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/gatransplant.blackbaudwp.com\/vi\/wp-json\/wp\/v2\/users\/43"}],"replies":[{"embeddable":true,"href":"https:\/\/gatransplant.blackbaudwp.com\/vi\/wp-json\/wp\/v2\/comments?post=62225"}],"version-history":[{"count":4,"href":"https:\/\/gatransplant.blackbaudwp.com\/vi\/wp-json\/wp\/v2\/pages\/62225\/revisions"}],"predecessor-version":[{"id":62263,"href":"https:\/\/gatransplant.blackbaudwp.com\/vi\/wp-json\/wp\/v2\/pages\/62225\/revisions\/62263"}],"up":[{"embeddable":true,"href":"https:\/\/gatransplant.blackbaudwp.com\/vi\/wp-json\/wp\/v2\/pages\/6841"}],"wp:attachment":[{"href":"https:\/\/gatransplant.blackbaudwp.com\/vi\/wp-json\/wp\/v2\/media?parent=62225"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}