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("$srcdir/classes/POSRef.class.php");
   6 require_once("$srcdir/formdata.inc.php");
   7
   8 if ($_POST["mode"] == "facility")
   9 {
  10         sqlStatement("update facility set
  11                 name='"              . formData('facility','P',true) . "',
  12                 phone='"             . formData('phone','P',true) . "',
  13                 fax='"               . formData('fax','P',true) . "',
  14                 street='"            . formData('street','P',true) . "',
  15                 city='"              . formData('city','P',true) . "',
  16                 state='"             . formData('state','P',true) . "',
  17                 postal_code='"       . formData('postal_code','P',true) . "',
  18                 country_code='"      . formData('country_code','P',true) . "',
  19                 federal_ein='"       . formData('federal_ein','P',true) . "',
  20                 service_location='"  . formData('service_location','P',true) . "',
  21                 billing_location='"  . formData('billing_location','P',true) . "',
  22                 accepts_assignment='". formData('accepts_assignment','P',true) . "',
  23                 pos_code='"          . formData('pos_code','P',true) . "',
  24                 domain_identifier='" . formData('domain_identifier','P',true) . "',
  25                 facility_npi='"      . formData('facility_npi','P',true) . "',
  26                 attn='"              . formData('attn','P',true) . "'
  27                 where id='"          . formData('fid','P',true) . "'");
  28 }
  29
  30 if (isset($_GET["fid"])) {
  31         $my_fid = $_GET["fid"];
  32 }
  33
  34 if (isset($_POST["fid"])) {
  35         $my_fid = $_POST["fid"];
  36 }
  37
  38 ?>
  39 <html>
  40 <head>
  41
  42 <link rel="stylesheet" href="<?php echo $css_header;?>" type="text/css">
  43
  44 </head>
  45 <body class="body_top">
  46
  47 <span class="title"><?php xl('Edit Facility Information','e'); ?></span>
  48
  49 <form name='facility' method='post' action="facility_admin.php">
  50 <input type=hidden name=mode value="facility">
  51 <input type=hidden name=fid value="<?php echo $my_fid;?>">
  52 <?php $facility = sqlQuery("select * from facility where id='$my_fid'"); ?>
  53 <br><br>
  54 <table border=0 cellpadding=0 cellspacing=0>
  55  <tr>
  56   <td width='24'><span class='text'><?php xl('Name','e'); ?>: </span></td>
  57   <td width='120'><input type='entry' name='facility' size='20' value='<?php echo htmlspecialchars($facility['name'], ENT_QUOTES) ?>'></td>
  58   <td rowspan='10' width='15'></td>
  59   <td><span class='text'><?php xl('Phone','e'); ?> <?php xl('as','e'); ?> (000) 000-0000:</span></td>
  60   <td width='210'><input type='entry' name='phone' size='20' value='<?php echo htmlspecialchars($facility['phone'], ENT_QUOTES) ?>'></td>
  61  </tr>
  62  <tr>
  63   <td>&nbsp;</td>
  64   <td>&nbsp;</td>
  65   <td><span class='text'><?php xl('Fax','e'); ?> <?php xl('as','e'); ?> (000) 000-0000:</span></td>
  66   <td width='210'><input type='entry' name='fax' size='20' value='<?php echo htmlspecialchars($facility['fax'], ENT_QUOTES) ?>'></td>
  67  </tr>
  68 <tr>
  69         <td><span class=text><?php xl('Address','e'); ?>: </span></td><td><input type=entry size=20 name=street value="<?php echo htmlspecialchars($facility["street"], ENT_QUOTES) ?>"></td>
  70         <td><span class=text><?php xl('City','e'); ?>: </span></td><td><input type=entry size=20 name=city value="<?php echo htmlspecialchars($facility{"city"}, ENT_QUOTES) ?>"></td>
  71 </tr>
  72 <tr>
  73         <td><span class=text><?php xl('State','e'); ?>: </span></td><td><input type=entry size=20 name=state value="<?php echo htmlspecialchars($facility{"state"}, ENT_QUOTES) ?>"></td>
  74         <td><span class=text><?php xl('Zip Code','e'); ?>: </span></td><td><input type=entry size=20 name=postal_code value="<?php echo htmlspecialchars($facility{"postal_code"}, ENT_QUOTES) ?>"></td>
  75 </tr>
  76 <tr>
  77         <td><span class=text><?php xl('Country','e'); ?>: </span></td><td><input type=entry size=20 name=country_code value="<?php echo htmlspecialchars($facility{"country_code"}, ENT_QUOTES) ?>"></td>
  78         <td><span class=text><?php xl('Federal EIN','e'); ?>: </span></td><td><input type=entry size=20 name=federal_ein value="<?php echo htmlspecialchars($facility{"federal_ein"}, ENT_QUOTES) ?>"></td>
  79 </tr>
  80 <tr>
  81          <td>&nbsp;</td><td>&nbsp;</td>
  82         <td width="21"><span class=text><?php ($GLOBALS['simplified_demographics'] ? xl('Facility Code','e') : xl('Facility NPI','e')); ?>:
  83   </span></td><td><input type=entry size=20 name=facility_npi value="<?php echo htmlspecialchars($facility{"facility_npi"}, ENT_QUOTES) ?>"></td>
  84 </tr>
  85  <tr>
  86   <td><span class='text'><?php xl('Billing Location','e'); ?>: </span></td>
  87   <td><input type='checkbox' name='billing_location' value='1' <?php if ($facility['billing_location'] == 1) echo 'checked'; ?>></td>
  88   <td rowspan='2'><span class='text'><?php xl('Accepts Assignment','e'); ?><br>(<?php xl('only if billing location','e'); ?>): </span></td>
  89   <td><input type='checkbox' name='accepts_assignment' value='1' <?php if ($facility['accepts_assignment'] == 1) echo 'checked'; ?>></td>
  90  </tr>
  91  <tr>
  92   <td><span class='text'><?php xl('Service Location','e'); ?>: </span></td>
  93   <td><input type='checkbox' name='service_location' value='1' <?php if ($facility['service_location'] == 1) echo 'checked'; ?>></td>
  94   <td>&nbsp;</td>
  95  </tr>
  96 <tr>
  97         <td><span class=text><?php xl('POS Code','e'); ?>: </span></td>
  98         <td colspan="6">
  99                 <select name="pos_code">
 100                 <?php
 101                 $pc = new POSRef();
 102
 103                 foreach ($pc->get_pos_ref() as $pos) {
 104                         echo "<option value=\"" . $pos["code"] . "\" ";
 105                         if ($facility['pos_code'] == $pos['code']) {
 106                                 echo "selected";
 107                         }
 108                         echo ">" . $pos['code']  . ": ". $pos['title'];
 109                         echo "</option>\n";
 110                 }
 111
 112                 ?>
 113                 </select>
 114         </td>
 115 </tr>
 116 <tr>
 117         <td><span class="text"><?php xl('Billing Attn','e'); ?>:</span></td>
 118         <td colspan="4"><input type="text" name="attn" size="45" value="<?php echo htmlspecialchars($facility['attn'], ENT_QUOTES) ?>"></td>
 119 </tr>
 120 <tr>
 121         <td><span class="text"><?php xl('CLIA Number','e'); ?>:</span></td>
 122         <td colspan="4"><input type="text" name="domain_identifier" size="45" value="<?php echo htmlspecialchars($facility['domain_identifier'], ENT_QUOTES) ?>"></td>
 123 </tr>
 124 <tr>
 125         <td>&nbsp;</td><td>&nbsp;</td>
 126         <td>&nbsp;</td><td><br><br><input type="submit" value=<?php xl('Update Info','e'); ?>>&nbsp;&nbsp;&nbsp;<a href="facilities.php" class=link_submit>[<?php xl('Back','e'); ?>]</font></a></td>
 127 </tr>
 128 </table>
 129 </form>
 130
 131 </body>
 132 </html>