{"xsrfToken":"51d0220ee099ac011a5f0d58149dae17a0b0ecff_lout","branding":{"id":"10","key":"csup","name":"Clinical Operations Support","portalBaseUrl":"/servicedesk/customer/portal/10","logoUrl":"/rest/servicedesk/1/customer/viewport-resources/portal-logo/10/11","theme":{"headerBGColor":"#ffffff","headerLinkColor":"#292929","headerLinkHoverColor":"#071936","headerLinkHoverBGColor":"#071936","headerBadgeColor":"#071936"}},"helpCenterBranding":{"logoUrl":"https://api.media.atlassian.com/file/51a1cabd-679f-4ac3-9bcb-ee34a1b2ceb7/image?token=eyJhbGciOiJIUzI1NiJ9.eyJpc3MiOiI1MDBlZGJkNi1jMmU3LTQ1YWEtYTEyMC1mMDI0ZjY0MDZiOWUiLCJhY2Nlc3MiOnsidXJuOmZpbGVzdG9yZTpmaWxlOjUxYTFjYWJkLTY3OWYtNGFjMy05YmNiLWVlMzRhMWIyY2ViNyI6WyJyZWFkIl19LCJleHAiOjE3MzM5MjE5NTMsIm5iZiI6MTczMzkyMTM1M30.C2OUD2YQBd6vrG-ZnjFhSQ3xJFQILcnr6zG64NlSwcY&client=500edbd6-c2e7-45aa-a120-f024f6406b9e&mode=fit","logoId":"51a1cabd-679f-4ac3-9bcb-ee34a1b2ceb7","isLogoAvailable":true,"helpCenterTitle":"Welcome to MD Ally's Help Desk!","sharedPortalName":"MD Ally Support Center","userInitialAnnouncementHeader":"","userInitialAnnouncementMessageWiki":"","translations":{"en-US":{"helpCenterTitle":"Welcome to MD Ally's Help Desk!","sharedPortalName":"MD Ally Support Center","localeDisplayName":"English (United States)"},"es-ES":{"localeDisplayName":"Spanish (Spain)"}},"canEditAnnouncement":false,"siteDefaultLanguageTag":"en-US","userLanguageTag":"en-US","portalThemeColor":"#0d2a46","helpCenterTitleColor":"#ffffff","useDefaultBanner":false,"isBannerAvailable":false},"portal":{"id":"10","key":"csup","projectId":10103,"serviceDeskId":10,"name":"Clinical Operations Support","description":"<p>Welcome! You can raise a request for Clinical Operations Support using the options provided.</p>","portalBaseUrl":"/servicedesk/customer/portal/10","onlyPortal":false,"reqTypes":[{"id":"129","name":"Commercial Disclosure Request Form","descriptionHtml":"","callToAction":"Commercial Disclosure Request Form","introHtml":"","icon":10481,"iconUrl":"https://mdally.atlassian.net/rest/servicedeskapi/requesttype/icon/type/SD_REQTYPE/id/10481","groups":[32],"key":""},{"id":"130","name":"Complaint Submission Form","descriptionHtml":"","callToAction":"Complaint Submission Form","introHtml":"","icon":10493,"iconUrl":"https://mdally.atlassian.net/rest/servicedeskapi/requesttype/icon/type/SD_REQTYPE/id/10493","groups":[32],"key":""},{"id":"113","name":"Cloned Partner Telehealth Incidents","descriptionHtml":"","callToAction":"Cloned Partner Telehealth Incidents","introHtml":"<p>Request received from your email support channel.</p>","icon":10530,"iconUrl":"https://mdally.atlassian.net/rest/servicedeskapi/requesttype/icon/type/SD_REQTYPE/id/10530","groups":[],"key":""},{"id":"114","name":"Incident Investigation","descriptionHtml":"","callToAction":"Incident Investigation","introHtml":"","icon":10482,"iconUrl":"https://mdally.atlassian.net/rest/servicedeskapi/requesttype/icon/type/SD_REQTYPE/id/10482","groups":[],"key":""}],"reqGroups":[{"id":32,"name":"General"}],"orderMapping":{"32":[130,129]},"kbs":{"kbEnabled":false,"serviceDeskId":-1},"createPermission":true,"portalAnnouncement":{"portalId":10,"canEditAnnouncement":false,"canAdministerProject":false,"portalProjectKey":"CSUP","userLanguageHeader":"","userLanguageMessageWiki":"","defaultLanguageHeader":"","defaultLanguageMessage":"","defaultLanguageDisplayName":"English (United States)","isUsingLanguageSupport":true,"translations":{}},"canViewCreateRequestForm":true,"isProjectSimplified":false,"mediaApiUploadInformation":{"token":"eyJhbGciOiJIUzI1NiJ9.eyJpc3MiOiI1MDBlZGJkNi1jMmU3LTQ1YWEtYTEyMC1mMDI0ZjY0MDZiOWUiLCJhY2Nlc3MiOnsidXJuOmZpbGVzdG9yZTp1cGxvYWQ6KiI6WyJyZWFkIiwiY3JlYXRlIiwidXBkYXRlIl0sInVybjpmaWxlc3RvcmU6Y29sbGVjdGlvbjp1cGxvYWQtcHJvamVjdC0xMDEwMyI6WyJyZWFkIiwiY3JlYXRlIiwidXBkYXRlIl0sInVybjpmaWxlc3RvcmU6Y2h1bms6KiI6WyJyZWFkIiwiY3JlYXRlIl19LCJleHAiOjE3MzM5MjI1NTMsIm5iZiI6MTczMzkyMTM1M30.yQwrDQgYzmG-iZv7zKOjLFajwzGHGCD4s4ejNj-UlwI","targetCollection":"upload-project-10103","endpointUrl":"https://api.media.atlassian.com","clientId":"500edbd6-c2e7-45aa-a120-f024f6406b9e","tokenDurationInMins":20}},"reqCreate":{"id":129,"projectId":10103,"form":{"name":"Commercial Disclosure Request Form","descriptionHtml":"","callToAction":"Commercial Disclosure Request Form","intro":"","instructions":"","icon":10481,"iconUrl":"https://mdally.atlassian.net/rest/servicedeskapi/requesttype/icon/type/SD_REQTYPE/id/10481","key":""},"fields":[{"fieldType":"text","fieldId":"email","fieldConfigId":"","label":"Email confirmation to","description":"","descriptionHtml":"","required":true,"displayed":true,"presetValues":[]},{"fieldType":"text","jiraFieldType":"summary","fieldId":"summary","fieldConfigId":"","label":"Summary","description":"","descriptionHtml":"","required":true,"displayed":false,"presetValues":["Commercial Disclosure Form"]}],"userOrganisations":[],"canBrowseUsers":false,"requestCreateBaseUrl":"/servicedesk/customer/portal/10/create/129","requestValidateBaseUrl":"/servicedesk/customer/portal/10/validate/129","calendarParams":{"firstDay":0,"date":"2024-12-11T07:49:13-0500","useISO8601WeekNumbers":false,"dateIfFormat":"%e/%b/%y","dateTimeIfFormat":"%e/%b/%y %I:%M %p","timeFormat":"12"},"kbs":{"kbEnabled":false,"serviceDeskId":-1},"canRaiseOnBehalf":false,"canSignupCustomers":false,"canCreateAttachments":true,"attachmentRequiredField":false,"hasGroups":true,"canSubmitWithEmailAddress":false,"showRecaptcha":false,"siteKey":"","mediaApiUploadInformation":{"token":"eyJhbGciOiJIUzI1NiJ9.eyJpc3MiOiI1MDBlZGJkNi1jMmU3LTQ1YWEtYTEyMC1mMDI0ZjY0MDZiOWUiLCJhY2Nlc3MiOnsidXJuOmZpbGVzdG9yZTp1cGxvYWQ6KiI6WyJyZWFkIiwiY3JlYXRlIiwidXBkYXRlIl0sInVybjpmaWxlc3RvcmU6Y29sbGVjdGlvbjp1cGxvYWQtcHJvamVjdC0xMDEwMyI6WyJyZWFkIiwiY3JlYXRlIiwidXBkYXRlIl0sInVybjpmaWxlc3RvcmU6Y2h1bms6KiI6WyJyZWFkIiwiY3JlYXRlIl19LCJleHAiOjE3MzM5MjI1NTMsIm5iZiI6MTczMzkyMTM1M30.yQwrDQgYzmG-iZv7zKOjLFajwzGHGCD4s4ejNj-UlwI","targetCollection":"upload-project-10103","endpointUrl":"https://api.media.atlassian.com","clientId":"500edbd6-c2e7-45aa-a120-f024f6406b9e","tokenDurationInMins":20},"hasProformaForm":true,"proformaTemplateForm":{"id":1,"updated":"2024-11-04T13:21:49.748893644Z","publish":{"jira":{"newIssueIssueTypeIds":[],"newIssueRequestTypeIds":[129],"submitOnCreate":true,"validateOnCreate":true},"portal":{"portalRequestTypeIds":[129],"submitOnCreate":true,"validateOnCreate":true}},"design":{"settings":{"templateId":1,"name":"COMMERCIAL DISCLOSURE REQUEST FORM","submit":{"lock":true,"pdf":true},"templateFormUuid":"0295d87d-c0aa-4015-b371-199b8d3bff5e"},"layout":[{"version":1,"type":"doc","content":[{"type":"heading","attrs":{"level":2,"localId":"ce1e36ec-a43b-441a-9400-aee3dfc1a628"},"content":[{"type":"text","text":"Purpose"}]},{"type":"paragraph","attrs":{"localId":"b09ca043-a89a-4b62-9ee0-d3ef1bdf5b74"},"content":[{"type":"text","text":"This form is used to request information regarding the legal identity, white-label provider relationships, and relevant commercial affiliations related to MD Ally’s telehealth services."}]},{"type":"heading","attrs":{"level":2,"localId":"ea99be4d-b264-4af0-9cc5-a3de1765a6c4"},"content":[{"type":"text","text":"Requestor Information"}]},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":2},"layout":"default","localId":"aa8e8b6a-6def-47e9-b2b5-814816344172"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":9},"layout":"default","localId":"be304d96-abbc-4acb-9aeb-3162b9e12be7"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":12},"layout":"default","localId":"4f3b9aea-6e45-45e9-b9d7-f56fe0122e83"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":13},"layout":"default","localId":"269df86e-aea6-455f-a45d-7798e77ff296"}},{"type":"heading","attrs":{"level":2,"localId":"cae1c406-b21f-4d09-81e9-547f7e62ad36"},"content":[{"type":"text","text":"Information Requested"}]},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":14},"layout":"default","localId":"bfb637b4-8631-4cc6-8e9e-6adc9c4fc452"}},{"type":"heading","attrs":{"level":2,"localId":"6494e151-9eb6-4fba-a0e7-6897424803da"},"content":[{"type":"text","text":"Reason for Request (Optional)"}]},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":17},"layout":"default","localId":"8ed97c76-692e-4ee0-8b6f-3a21fc8675e9"}}]}],"conditions":{},"sections":{},"questions":{"12":{"type":"te","label":"Email","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"9":{"type":"tl","label":"Organization (if applicable)","description":"","validation":{"rq":false},"choices":[],"questionKey":""},"13":{"type":"ts","label":"Phone Number","description":"","validation":{"rq":false},"choices":[],"questionKey":""},"2":{"type":"tl","label":"Full Name","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"17":{"type":"rt","label":"Please provide any additional context or reasons for your request (optional but appreciated)","description":"","validation":{"rq":false},"choices":[],"questionKey":""},"14":{"type":"cm","label":"Please check the specific information you are requesting:","description":"","validation":{"rq":false},"choices":[{"id":"1","label":"Legal Identity: Disclosure of the legal entity responsible for providing telehealth services.","other":false},{"id":"2","label":"White-Label Provider Relationship: Disclosure of any white-label providers involved in delivering telehealth services.","other":false},{"id":"3","label":"Relevant Commercial Affiliations: Disclosure of commercial affiliations related to MD Ally’s telehealth services.","other":false}],"questionKey":""}}},"uuid":"0295d87d-c0aa-4015-b371-199b8d3bff5e"},"proforma":{"formExists":true,"formValid":true,"formTemplateData":{"id":1,"updated":"2024-11-04T13:21:49.748893644Z","publish":{"jira":{"newIssueIssueTypeIds":[],"newIssueRequestTypeIds":[129],"submitOnCreate":true,"validateOnCreate":true},"portal":{"portalRequestTypeIds":[129],"submitOnCreate":true,"validateOnCreate":true}},"design":{"settings":{"templateId":1,"name":"COMMERCIAL DISCLOSURE REQUEST FORM","submit":{"lock":true,"pdf":true},"templateFormUuid":"0295d87d-c0aa-4015-b371-199b8d3bff5e"},"layout":[{"version":1,"type":"doc","content":[{"type":"heading","attrs":{"level":2,"localId":"ce1e36ec-a43b-441a-9400-aee3dfc1a628"},"content":[{"type":"text","text":"Purpose"}]},{"type":"paragraph","attrs":{"localId":"b09ca043-a89a-4b62-9ee0-d3ef1bdf5b74"},"content":[{"type":"text","text":"This form is used to request information regarding the legal identity, white-label provider relationships, and relevant commercial affiliations related to MD Ally’s telehealth services."}]},{"type":"heading","attrs":{"level":2,"localId":"ea99be4d-b264-4af0-9cc5-a3de1765a6c4"},"content":[{"type":"text","text":"Requestor Information"}]},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":2},"layout":"default","localId":"aa8e8b6a-6def-47e9-b2b5-814816344172"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":9},"layout":"default","localId":"be304d96-abbc-4acb-9aeb-3162b9e12be7"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":12},"layout":"default","localId":"4f3b9aea-6e45-45e9-b9d7-f56fe0122e83"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":13},"layout":"default","localId":"269df86e-aea6-455f-a45d-7798e77ff296"}},{"type":"heading","attrs":{"level":2,"localId":"cae1c406-b21f-4d09-81e9-547f7e62ad36"},"content":[{"type":"text","text":"Information Requested"}]},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":14},"layout":"default","localId":"bfb637b4-8631-4cc6-8e9e-6adc9c4fc452"}},{"type":"heading","attrs":{"level":2,"localId":"6494e151-9eb6-4fba-a0e7-6897424803da"},"content":[{"type":"text","text":"Reason for Request (Optional)"}]},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","parameters":{"id":17},"layout":"default","localId":"8ed97c76-692e-4ee0-8b6f-3a21fc8675e9"}}]}],"conditions":{},"sections":{},"questions":{"12":{"type":"te","label":"Email","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"9":{"type":"tl","label":"Organization (if applicable)","description":"","validation":{"rq":false},"choices":[],"questionKey":""},"13":{"type":"ts","label":"Phone Number","description":"","validation":{"rq":false},"choices":[],"questionKey":""},"2":{"type":"tl","label":"Full Name","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"17":{"type":"rt","label":"Please provide any additional context or reasons for your request (optional but appreciated)","description":"","validation":{"rq":false},"choices":[],"questionKey":""},"14":{"type":"cm","label":"Please check the specific information you are requesting:","description":"","validation":{"rq":false},"choices":[{"id":"1","label":"Legal Identity: Disclosure of the legal entity responsible for providing telehealth services.","other":false},{"id":"2","label":"White-Label Provider Relationship: Disclosure of any white-label providers involved in delivering telehealth services.","other":false},{"id":"3","label":"Relevant Commercial Affiliations: Disclosure of commercial affiliations related to MD Ally’s telehealth services.","other":false}],"questionKey":""}}},"uuid":"0295d87d-c0aa-4015-b371-199b8d3bff5e"},"linkedJiraFields":[]},"key":""},"portalWebFragments":{"headerPanels":[],"subheaderPanels":[],"footerPanels":[],"pagePanels":{"propertyPanels":[],"legacyPropertyPanels":[]}}}