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{
"id": 80,
"img": "/data/upload/2/9272456c-es_2.jpg",
"original_width": 864,
"original_height": 1232,
"fields": [
{
"semantic_key": "Please indicate with a mark which plan you want to enroll in:",
"original_label": "Indique con una marca en qué plan quiere inscribirse:",
"bbox": [
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"data_type": "text",
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},
{
"semantic_key": "Middle initial",
"original_label": "Inicial del 2.º nombre: M",
"bbox": [
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"data_type": "text",
"values": [
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},
{
"semantic_key": "Surname:",
"original_label": "APELLIDO:",
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"value": {
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},
{
"semantic_key": "First name:",
"original_label": "PRIMER nombre:",
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"data_type": "text",
"value": {
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}
},
{
"semantic_key": "Date of birth",
"original_label": "Fecha de nacimiento",
"bbox": [
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],
"data_type": "text",
"value": null,
"keys": [
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"original_label": "Day",
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"data_type": "number"
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},
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"semantic_key": null,
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"semantic_key": null,
"original_label": "Year",
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},
{
"semantic_key": "Private phone number",
"original_label": "Número de teléfono particular",
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],
"data_type": "text",
"value": {
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"data_type": "number"
}
},
{
"semantic_key": "Alternative phone number",
"original_label": "Número de teléfono alternativo",
"bbox": [
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],
"data_type": "text",
"value": {
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},
{
"semantic_key": "sex",
"original_label": "Sexo",
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"data_type": "text",
"values": [
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]
},
{
"semantic_key": "Permanent residence address (P.O. boxes are not accepted)",
"original_label": "Dirección de residencia permanente (no se admiten casillas de correo)",
"bbox": [
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425,
462,
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],
"data_type": "text",
"value": {
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},
{
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"original_label": "Estado",
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"data_type": "text",
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},
{
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"original_label": "Ciudad",
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89,
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"data_type": "text",
"value": {
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99,
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},
{
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"original_label": "Código postal",
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"data_type": "text",
"value": {
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},
{
"semantic_key": "Mailing address (only if different from the permanent residence address)",
"original_label": "Dirección postal (solamente si es distinta de la dirección de residencia permanente)",
"bbox": [
36,
492,
551,
512
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"data_type": "text",
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{
"semantic_key": "Direction",
"original_label": "Dirección",
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"data_type": "text",
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108,
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},
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},
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"semantic_key": "Postal code",
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},
{
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"original_label": "Contacto para emergencias",
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},
{
"semantic_key": "Relationship to you",
"original_label": "Relación con usted",
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"value": {
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},
{
"semantic_key": "Phone number",
"original_label": "Número de teléfono",
"bbox": [
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"data_type": "text",
"value": {
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},
{
"semantic_key": "Email address",
"original_label": "Dirección de correo electrónico",
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"data_type": "text",
"value": {
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},
{
"semantic_key": "Provide the Medicare insurance information",
"original_label": "PROPORCIONE LA INFORMACIÓN DEL SEGURO DE MEDICARE",
"bbox": [
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"data_type": "text",
"values": [
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"data_type": "checkbox_multi",
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"data_type": "checkbox_multi",
"mark": "check"
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],
"keys": [
{
"semantic_key": "Name (as it appears on your Medicare card):",
"original_label": "Nombre (tal como aparece en su tarjeta de Medicare):",
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751,
663
],
"data_type": "text",
"value": {
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},
{
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"original_label": "Número de Medicare",
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426,
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"data_type": "text",
"value": {
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434,
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},
{
"semantic_key": "Effective Date",
"original_label": "Fecha de entrada en vigencia",
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"data_type": "text",
"value": {
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"data_type": "date"
}
}
]
}
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