newsights.org

<!DOCTYPE html>
<html lang="en">
<head>
  <meta charset="UTF-8">
  <meta name="viewport" content="width=device-width, initial-scale=1.0">
  <title>Submit Data</title>
  <style>
    body {
      font-family: Roboto, Arial, sans-serif;
    }

    h1 {
      font-size: 16px;
      font-weight: bold;
      line-height: 1.5;
    }
  </style>
  <script>
    async function submitData(event) {
      event.preventDefault();

      // Collect form data
      const dollarAmount = document.getElementById("dollarAmount").value;
      const zipCode = document.getElementById("zipCode").value;
      const date = document.getElementById("date").value;

      // Validate inputs
      if (!dollarAmount || !zipCode || !date) {
        alert("Please fill out all fields.");
        return;
      }

      // Submit data to the Google Sheets Web App
      const response = await fetch("https://script.google.com/macros/s/AKfycbzloWEofZqXuHuL-jexHe7fviDlf1mVNw__c-P02W4aWL1znX_wjUziAKFkJos38JCDCw/exec", {
        method: "POST",
        headers: {
          "Content-Type": "application/json",
        },
        body: JSON.stringify({ dollarAmount, zipCode, date }),
      });

      const result = await response.json();
      if (result.status === "success") {
        alert("Data submitted successfully!");
        document.getElementById("dataForm").reset();
      } else {
        alert("Error submitting data.");
      }
    }
  </script>
</head>
<body>
  <h1>Has United Health Care, Optum, United Health or other UHC companies stole from you as a patient or a provider? If so, enter below the amount they have stolen by denying claims, not reimbursing your practice at the contracted rate, or simply just taking back funds.</h1>

  <form id="dataForm" onsubmit="submitData(event)">
    <label for="dollarAmount">Dollar Amount:</label>
    <input type="number" id="dollarAmount" name="dollarAmount" required>
    <br><br>

    <label for="zipCode">ZIP Code:</label>
    <input type="text" id="zipCode" name="zipCode" required>
    <br><br>

    <label for="date">Date:</label>
    <input type="date" id="date" name="date" required>
    <br><br>

    <button type="submit">Submit</button>
  </form>
</body>
</html>

Find your water table







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