interface/usergroup/facility_admin.php

   1 <?php
   2 include_once("../globals.php");
   3 include_once("$srcdir/md5.js");
   4 include_once("$srcdir/sql.inc");
   5 require_once("$srcdir/classes/POSRef.class.php");
   6
   7 if (isset($_GET["fid"])) {
   8         $my_fid = $_GET["fid"];
   9 }
  10
  11 if (isset($_POST["fid"])) {
  12         $my_fid = $_POST["fid"];
  13 }
  14 if ($_POST["mode"] == "facility")
  15 {
  16
  17         echo '
  18 <script type="text/javascript">
  19 <!--
  20 parent.$.fn.fancybox.close();
  21 //-->
  22 </script>
  23
  24         ';
  25 }
  26 ?>
  27 <html>
  28 <head>
  29
  30 <link rel="stylesheet" href="<?php echo $css_header;?>" type="text/css">
  31 <link rel="stylesheet" type="text/css" href="../../library/js/fancybox/jquery.fancybox-1.2.6.css" media="screen" />
  32 <script type="text/javascript" src="../../library/dialog.js"></script>
  33 <script type="text/javascript" src="../../library/js/jquery.1.3.2.js"></script>
  34 <script type="text/javascript" src="../../library/js/common.js"></script>
  35 <script type="text/javascript" src="../../library/js/fancybox/jquery.fancybox-1.2.6.js"></script>
  36 <script type="text/javascript">
  37 function submitform() {
  38     if (document.forms[0].facility.value.length>0) {
  39         top.restoreSession();
  40         document.forms[0].submit();
  41     } else {
  42         document.forms[0].facility.style.backgroundColor="red";
  43         document.forms[0].facility.focus();
  44     }
  45 }
  46
  47 $(document).ready(function(){
  48     $("#cancel").click(function() {
  49                   parent.$.fn.fancybox.close();
  50          });
  51 });
  52
  53 </script>
  54
  55 </head>
  56 <body class="body_top" style="width:600px;height:330px !important;">
  57
  58 <table>
  59     <tr>
  60         <td>
  61         <span class="title"><?php xl('Edit Facility','e'); ?></span>&nbsp;&nbsp;&nbsp;</td><td>
  62         <a class="css_button large_button" name='form_save' id='form_save' onclick='submitform()' href='#' >
  63             <span class='css_button_span large_button_span'><?php xl('Save','e');?></span>
  64         </a>
  65         <a class="css_button large_button" id='cancel' href='#'>
  66             <span class='css_button_span large_button_span'><?php xl('Cancel','e');?></span>
  67         </a>
  68      </td>
  69   </tr>
  70 </table>
  71
  72 <form name='facility' method='post' action="facilities.php" target="_parent">
  73     <input type=hidden name=mode value="facility">
  74     <input type=hidden name=newmode value="admin_facility">     <!--    Diffrentiate Admin and add post backs -->
  75     <input type=hidden name=fid value="<?php echo $my_fid;?>">
  76     <?php $facility = sqlQuery("select * from facility where id='$my_fid'"); ?>
  77
  78     <table border=0 cellpadding=0 cellspacing=1 style="width:630px;">
  79          <tr>
  80           <td width='150px'><span class='text'><?php xl('Name','e'); ?>: </span></td>
  81           <td width='220px'><input type='entry' name='facility' size='20' value='<?php echo htmlspecialchars($facility['name'], ENT_QUOTES) ?>'><font class="mandatory">&nbsp;*</font></td>
  82           <td width='200px'><span class='text'><?php xl('Phone','e'); ?> <?php xl('as','e'); ?> (000) 000-0000:</span></td>
  83           <td width='220px'><input type='entry' name='phone' size='20' value='<?php echo htmlspecialchars($facility['phone'], ENT_QUOTES) ?>'></td>
  84          </tr>
  85          <tr>
  86           <td><span class=text><?php xl('Address','e'); ?>: </span></td><td><input type=entry size=20 name=street value="<?php echo htmlspecialchars($facility["street"], ENT_QUOTES) ?>"></td>
  87           <td><span class='text'><?php xl('Fax','e'); ?> <?php xl('as','e'); ?> (000) 000-0000:</span></td>
  88           <td><input type='entry' name='fax' size='20' value='<?php echo htmlspecialchars($facility['fax'], ENT_QUOTES) ?>'></td>
  89          </tr>
  90         <tr>
  91
  92             <td><span class=text><?php xl('City','e'); ?>: </span></td>
  93             <td><input type=entry size=20 name=city value="<?php echo htmlspecialchars($facility{"city"}, ENT_QUOTES) ?>"></td>
  94             <td><span class=text><?php xl('Zip Code','e'); ?>: </span></td><td><input type=entry size=20 name=postal_code value="<?php echo htmlspecialchars($facility{"postal_code"}, ENT_QUOTES) ?>"></td>
  95         </tr>
  96         <?php
  97                 $ssn='';
  98                 $ein='';
  99                 if($facility['tax_id_type']=='SY'){
 100                 $ssn='selected';
 101                 }
 102                 else{
 103                 $ein='selected';
 104                 }
 105         ?>
 106         <tr>
 107             <td><span class=text><?php xl('State','e'); ?>: </span></td><td><input type=entry size=20 name=state value="<?php echo htmlspecialchars($facility{"state"}, ENT_QUOTES) ?>"></td>
 108             <td><span class=text><?php xl('Tax ID','e'); ?>: </span></td><td><select name=tax_id_type><option value="EI" <?php echo $ein;?>><?php xl('EIN','e'); ?></option><option value="SY" <?php echo $ssn;?>><?php xl('SSN','e'); ?></option></select><input type=entry size=11 name=federal_ein value="<?php echo htmlspecialchars($facility{"federal_ein"}, ENT_QUOTES) ?>"></td>
 109         </tr>
 110         <tr>
 111             <td><span class=text><?php xl('Country','e'); ?>: </span></td><td><input type=entry size=20 name=country_code value="<?php echo htmlspecialchars($facility{"country_code"}, ENT_QUOTES) ?>"></td>
 112             <td width="21"><span class=text><?php ($GLOBALS['simplified_demographics'] ? xl('Facility Code','e') : xl('Facility NPI','e')); ?>:
 113           </span></td><td><input type=entry size=20 name=facility_npi value="<?php echo htmlspecialchars($facility{"facility_npi"}, ENT_QUOTES) ?>"></td>
 114         </tr>
 115          <tr>
 116           <td><span class='text'><?php xl('Billing Location','e'); ?>: </span></td>
 117           <td><input type='checkbox' name='billing_location' value='1' <?php if ($facility['billing_location'] == 1) echo 'checked'; ?>></td>
 118           <td rowspan='2'><span class='text'><?php xl('Accepts Assignment','e'); ?><br>(<?php xl('only if billing location','e'); ?>): </span></td>
 119           <td><input type='checkbox' name='accepts_assignment' value='1' <?php if ($facility['accepts_assignment'] == 1) echo 'checked'; ?>></td>
 120          </tr>
 121          <tr>
 122           <td><span class='text'><?php xl('Service Location','e'); ?>: </span></td>
 123           <td><input type='checkbox' name='service_location' value='1' <?php if ($facility['service_location'] == 1) echo 'checked'; ?>></td>
 124           <td>&nbsp;</td>
 125          </tr>
 126
 127         <tr>
 128             <td><span class=text><?php xl('POS Code','e'); ?>: </span></td>
 129             <td colspan="6">
 130                 <select name="pos_code">
 131                 <?php
 132                 $pc = new POSRef();
 133
 134                 foreach ($pc->get_pos_ref() as $pos) {
 135                     echo "<option value=\"" . $pos["code"] . "\" ";
 136                     if ($facility['pos_code'] == $pos['code']) {
 137                         echo "selected";
 138                     }
 139                     echo ">" . $pos['code']  . ": ". $pos['title'];
 140                     echo "</option>\n";
 141                 }
 142
 143                 ?>
 144                 </select>
 145             </td>
 146         </tr>
 147         <tr>
 148             <td><span class="text"><?php xl('Billing Attn','e'); ?>:</span></td>
 149             <td colspan="4"><input type="text" name="attn" size="45" value="<?php echo htmlspecialchars($facility['attn'], ENT_QUOTES) ?>"></td>
 150         </tr>
 151         <tr>
 152             <td><span class="text"><?php xl('CLIA Number','e'); ?>:</span></td>
 153             <td colspan="4"><input type="text" name="domain_identifier" size="45" value="<?php echo htmlspecialchars($facility['domain_identifier'], ENT_QUOTES) ?>"></td>
 154         </tr>
 155         <tr height="20" valign="bottom">
 156             <td colspan=2><span class="text"><font class="mandatory">*</font> <?php echo xl('Required','e');?></span></td>
 157         </tr>
 158
 159     </table>
 160 </form>
 161
 162 </body>
 163 </html>