{% comment %} {% assign groupValidator = false %} {% for group in current_person.groups %} {% if group %} {% assign groupValidator = true %} {% endif %} {% endfor %} {% if current_person.signed_in? %} {% if groupValidator == true %} {% endif %} {% endif %} {% endcomment %} {% include "header_minimal" %} {% comment %} {% endcomment %} Please enter a valid, 5-12 digit Medicaid ID number Please enter a valid, 1-10 digit Provider ID number {% comment %} Role: {% endcomment %} {% include "sign_up_follow_up_roles_dropdown" %} {% comment %} State: {% endcomment %} {% include "sign_up_follow_up_states_dropdown" %} Please enter a valid, 10 digit California EVV ID Number Agency EVV Non-Agency EVV Alt EVV Aggregator Please select your affiliation {% comment %} Submit {% endcomment %} Submit