{"id":4092,"date":"2020-05-14T13:01:35","date_gmt":"2020-05-14T17:01:35","guid":{"rendered":"https:\/\/www.bu.edu\/danielsen\/?page_id=4092"},"modified":"2024-04-24T18:10:31","modified_gmt":"2024-04-24T22:10:31","slug":"online-payment","status":"publish","type":"page","link":"https:\/\/www.bu.edu\/danielsen\/online-payment\/","title":{"rendered":"Online Payment"},"content":{"rendered":"<link rel='stylesheet' id='gforms_reset_css-css'  href='https:\/\/www.bu.edu\/danielsen\/wp-content\/plugins\/gravityforms\/css\/formreset.min.css?ver=2.2.6' type='text\/css' media='all' >\n<link rel='stylesheet' id='gforms_formsmain_css-css'  href='https:\/\/www.bu.edu\/danielsen\/wp-content\/plugins\/gravityforms\/css\/formsmain.min.css?ver=2.2.6' type='text\/css' media='all' >\n<link rel='stylesheet' id='gforms_ready_class_css-css'  href='https:\/\/www.bu.edu\/danielsen\/wp-content\/plugins\/gravityforms\/css\/readyclass.min.css?ver=2.2.6' type='text\/css' media='all' >\n<link rel='stylesheet' id='gforms_browsers_css-css'  href='https:\/\/www.bu.edu\/danielsen\/wp-content\/plugins\/gravityforms\/css\/browsers.min.css?ver=2.2.6' type='text\/css' media='all' >\n<link rel='stylesheet' id='bu_gforms-css'  href='https:\/\/www.bu.edu\/danielsen\/wp-content\/mu-plugins\/bu-gf-customizations\/css\/bu_base_gf.css?ver=BU-0.6.13' type='text\/css' media='all' >\n<script src='https:\/\/www.bu.edu\/danielsen\/wp-includes\/js\/jquery\/jquery.js?ver=1.12.4'><\/script><br \/>\n<script src='https:\/\/www.bu.edu\/danielsen\/wp-includes\/js\/jquery\/jquery-migrate.min.js?ver=1.4.1'><\/script><br \/>\n<script src='https:\/\/www.bu.edu\/danielsen\/wp-content\/plugins\/gtm4wp\/js\/gtm4wp-form-move-tracker.js?ver=1.4'><\/script><br \/>\n<script src='https:\/\/www.bu.edu\/danielsen\/wp-content\/themes\/responsive-framework\/js\/vendor\/modernizer.min.js?ver=2.8.3'><\/script><br \/>\n<script src='https:\/\/www.bu.edu\/danielsen\/wp-content\/plugins\/gravityforms\/js\/jquery.json.min.js?ver=2.2.6'><\/script><br \/>\n<script src='https:\/\/www.bu.edu\/danielsen\/wp-content\/plugins\/gravityforms\/js\/gravityforms.min.js?ver=2.2.6'><\/script><\/p>\n<div class='gform_wrapper' id='gform_wrapper_nutrition' >\n<form method='post' enctype='multipart\/form-data'  id='gform_1'  action=\"https:\/\/www.bu.edu\/phpbin\/marconi\/\" accept-charset=\"UTF-8\">\n    <input type='hidden' class='gform_hidden' name='form_id' value='danielsen' ><\/p>\n<div class='gform_heading'>\n<h3 class='gform_title'>Danielsen Institute &#8211; Online Payments<\/h3>\n<p>      <span class='gform_description'>Dear Clients,<\/p>\n<p>      In order to credit your payment appropriately, please provide the information below so that we know for which service(s) you are paying.  You do not need to enter information into every field, but please tell us enough to reflect your payment properly in your account.  Thank you! <\/span> <\/div>\n<div class='gform_body'>\n<ul id='gform_fields_nutrition' class='gform_fields top_label form_sublabel_below description_below'>\n<li id='field_name' class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' >\n          <label class='gfield_label gfield_label_before_complex'  >Name of Payer<span class='gfield_required'>*<\/span><\/label><\/p>\n<div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gfield_trigger_change' id='input_payer_name'> <span id='firstname_container' class='name_first' ><br \/>\n            <input type='text' name='firstname' id='firstname' value='' aria-label='Payer First name'  aria-required=\"true\" aria-invalid=\"false\" required ><br \/>\n            <label for='firstname' >First<\/label><br \/>\n            <\/span> <span id='lastname_container' class='name_last' ><br \/>\n            <input type='text' name='lastname' id='lastname' value='' aria-label='Payer Last name'  aria-required=\"true\" aria-invalid=\"false\" required ><br \/>\n            <label for='lastname' >Last<\/label><br \/>\n            <\/span> <\/div>\n<\/li>\n<li id='field_email' class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' >\n          <label class='gfield_label' for='email' >Email<span class='gfield_required'>*<\/span><\/label><\/p>\n<div class='ginput_container ginput_container_email'>\n            <input name='email' id='email' type='email' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\" required >\n          <\/div>\n<\/li>\n<li id='field_payment_amount' class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' >\n          <label class='gfield_label' for='payment_amount' >Payment Amount in USD $<span class='gfield_required'>*<\/span><\/label><\/p>\n<div class='ginput_container ginput_container_number'>\n            <input name='payment_amount' id='payment_amount' type='text'  placeholder=\"0.00\"  value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\" required >\n          <\/div>\n<\/li>\n<li id='field_client_name' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' >\n          <label class='gfield_label gfield_label_before_complex'  >Client Name (if different than Payer)<\/label><\/p>\n<div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gfield_trigger_change' id='input_client_name'> <span id='client_firstname_container' class='name_first' ><br \/>\n            <input type='text' name='client_firstname' id='client_firstname' value='' aria-label='Client First name'  aria-required=\"false\" aria-invalid=\"false\" ><br \/>\n            <label for='client_firstname' >First<\/label><br \/>\n            <\/span> <span id='client_lastname_container' class='client_name_last' ><br \/>\n            <input type='text' name='client_lastname' id='client_lastname' value='' aria-label='Client Last name'  aria-required=\"false\" aria-invalid=\"false\" ><br \/>\n            <label for='client_lastname' >Last<\/label><br \/>\n            <\/span> <\/div>\n<\/li>\n<li id='field_account_number' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' >\n          <label class='gfield_label' for='account_number' >Danielsen Account Number<\/label><\/p>\n<div class='ginput_container ginput_container_text' >\n            <input name='account_number' id='account_number' type='text' value='' class='medium' aria-invalid=\"false\" >\n          <\/div>\n<div class=\"gfield_description\">Your account number is listed on all statements from Danielsen. Please enter 0000 if the account number is not known.<\/div>\n<\/li>\n<li id='field_clinician_name' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' >\n          <label class='gfield_label gfield_label_before_complex'  >Clinician Name<\/label><\/p>\n<div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gfield_trigger_change' id='input_clinician_name'> <span id='clinician_firstname_container' class='name_first' ><br \/>\n            <input type='text' name='clinician_firstname' id='clinician_firstname' value='' aria-label='Clinician First name'   aria-invalid=\"false\" ><br \/>\n            <label for='clinician_firstname' >First<\/label><br \/>\n            <\/span> <span id='clinician_lastname_container' class='clinician_name_last' ><br \/>\n            <input type='text' name='clinician_lastname' id='clinician_lastname' value='' aria-label='Clinician Last name' aria-invalid=\"false\" ><br \/>\n            <label for='clinician_lastname' >Last<\/label><br \/>\n            <\/span> <\/div>\n<\/li>\n<li id='field_date_of_service' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' >\n          <label class='gfield_label' for='date_of_service' >Date of Service<\/label><\/p>\n<div class='ginput_container ginput_container_text'>\n            <input name='date_of_service' id='date_of_service' type='date' value='' class='medium' aria-invalid=\"false\" >\n          <\/div>\n<div class=\"gfield_description\">MM\/DD\/YYYY<\/div>\n<\/li>\n<li id='field_type_of_service' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' >\n          <label class='gfield_label' for='account_number' >Type of Service<\/label><\/p>\n<div class='ginput_container ginput_container_radio' >\n<p>\n              <label><br \/>\n                <input type=\"radio\" name=\"service_type\" value=\"Individual\" id=\"service_type_individual\"><br \/>\n                Individual<\/label><br \/>\n              <br \/>\n              <label><br \/>\n                <input type=\"radio\" name=\"service_type\" value=\"Couples\/Family\" id=\"service_type_couples_family\"><br \/>\n                Couples\/Family<\/label><br \/>\n              <br \/>\n              <label><br \/>\n                <input type=\"radio\" name=\"service_type\" value=\"Medication Management\" id=\"service_type_medication_management\"><br \/>\n                Medication Management<\/label><br \/>\n              <br \/>\n              <label><br \/>\n                <input type=\"radio\" name=\"service_type\" value=\"Group\" id=\"service_type_group\"><br \/>\n                Group<\/label><br \/>\n              <br \/>\n              <label><br \/>\n                <input type=\"radio\" name=\"service_type\" value=\"Testing\" id=\"service_type_testing\"><br \/>\n                Testing<\/label><br \/>\n              \n            <\/p>\n<\/p><\/div>\n<div class=\"gfield_description\"><\/div>\n<\/li>\n<\/ul><\/div>\n<div>\n<p><strong>Refund Policy:<\/strong> Overpayments will be reviewed and refunded as soon as possible.<\/p>\n<p>Please verify that the information is correct above and then press <strong>Submit<\/strong> and you will proceed to the secure Nelnet Payment form where you can enter your credit card information.<\/p>\n<\/p><\/div>\n<div class='gform_footer top_label'>\n      <input type='submit' id='gform_submit_button_nutrition' class='gform_button button' value='Submit' >\n    <\/div>\n<\/p><\/form>\n<\/div>\n","protected":false},"excerpt":{"rendered":"<p>Danielsen Institute &#8211; Online Payments Dear Clients, In order to credit your payment appropriately, please provide the information below so that we know for which service(s) you are paying. You do not need to enter information into every field, but please tell us enough to reflect your payment properly in your account. Thank you! Name [&hellip;]<\/p>\n","protected":false},"author":1251,"featured_media":0,"parent":0,"menu_order":24,"comment_status":"closed","ping_status":"closed","template":"","meta":[],"_links":{"self":[{"href":"https:\/\/www.bu.edu\/danielsen\/wp-json\/wp\/v2\/pages\/4092"}],"collection":[{"href":"https:\/\/www.bu.edu\/danielsen\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.bu.edu\/danielsen\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.bu.edu\/danielsen\/wp-json\/wp\/v2\/users\/1251"}],"replies":[{"embeddable":true,"href":"https:\/\/www.bu.edu\/danielsen\/wp-json\/wp\/v2\/comments?post=4092"}],"version-history":[{"count":9,"href":"https:\/\/www.bu.edu\/danielsen\/wp-json\/wp\/v2\/pages\/4092\/revisions"}],"predecessor-version":[{"id":5541,"href":"https:\/\/www.bu.edu\/danielsen\/wp-json\/wp\/v2\/pages\/4092\/revisions\/5541"}],"wp:attachment":[{"href":"https:\/\/www.bu.edu\/danielsen\/wp-json\/wp\/v2\/media?parent=4092"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}