templates/insurance_companies/general_edit.html

   1 <form name="insurancecompany" method="post" action="{$FORM_ACTION}" onsubmit="return top.restoreSession()">
   2 <!-- it is important that the hidden form_id field be listed first, when it is called it populates any old information attached with the id, this allows for partial edits
   3                 if it were called last, the settings from the form would be overwritten with the old information-->
   4 <input type="hidden" name="form_id" value="{$insurancecompany->id}" />
   5 <table CELLSPACING="0" CELLPADDING="3">
   6 <tr>
   7         <td COLSPAN="1" ALIGN="LEFT" VALIGN="MIDDLE" >{xl t='Name'}</td>
   8         <td COLSPAN="2" ALIGN="LEFT" VALIGN="MIDDLE" >
   9                 <input type="text" size="40" name="name" value="{$insurancecompany->get_name()}"/>
  10         </td>
  11 </tr>
  12 <tr>
  13         <td COLSPAN="1" ALIGN="LEFT" VALIGN="MIDDLE" >{xl t='Attn'}</td>
  14         <td COLSPAN="2" ALIGN="LEFT" VALIGN="MIDDLE" >
  15                 <input type="text" size="40" name="attn" value="{$insurancecompany->get_attn()}"/>
  16         </td>
  17 </tr>
  18
  19 <tr>
  20         <td COLSPAN="1" ALIGN="LEFT" VALIGN="MIDDLE" >{xl t='Address'}</td>
  21         <td COLSPAN="2" ALIGN="LEFT" VALIGN="MIDDLE" >
  22                 <input type="text" size="40" name="address_line1" value="{$insurancecompany->address->line1}"/>
  23         </td>
  24 </tr>
  25 <tr>
  26         <td COLSPAN="1" ALIGN="LEFT" VALIGN="MIDDLE" >{xl t='Address'}</td>
  27         <td COLSPAN="2" ALIGN="LEFT" VALIGN="MIDDLE" >
  28                 <input type="text" size="40" name="address_line2" value="{$insurancecompany->address->line2}"/>
  29         </td>
  30 </tr>
  31 <tr>
  32         <td COLSPAN="1" ALIGN="LEFT" VALIGN="MIDDLE" >{xl t='City, State Zip'}</td>
  33         <td COLSPAN="2" ALIGN="LEFT" VALIGN="MIDDLE" >
  34                 <input type="text" size="25" name="city" value="{$insurancecompany->address->city}"/> , <input type="text" size="2" maxlength="2" name="state" value="{$insurancecompany->address->state}"/> <input type="text" size="5" name="zip" value="{$insurancecompany->address->zip}"/>
  35         </td>
  36 </tr>
  37 <tr>
  38         <td COLSPAN="1" ALIGN="LEFT" VALIGN="MIDDLE" >{xl t='Phone'}</td>
  39         <td COLSPAN="2" ALIGN="LEFT" VALIGN="MIDDLE" >
  40                 <input TYPE="TEXT" NAME="phone" SIZE="12" VALUE="{$insurancecompany->get_phone()}"/>
  41         </td>
  42 </tr>
  43 <tr>
  44         <td COLSPAN="1" ALIGN="LEFT" VALIGN="MIDDLE" >{xl t='CMS ID'}</td>
  45         <td COLSPAN="2" ALIGN="LEFT" VALIGN="MIDDLE" >
  46                 <input type="text" size="15" name="cms_id" value="{$insurancecompany->get_cms_id()}"/>
  47         </td>
  48 </tr>
  49 <tr>
  50         <td COLSPAN="1" ALIGN="LEFT" VALIGN="MIDDLE">{xl t='Payer Type'}</td>
  51         <td COLSPAN="2" ALIGN="LEFT" VALIGN="MIDDLE">
  52                 {html_options name="freeb_type" options=$insurancecompany->freeb_type_array selected=$insurancecompany->get_freeb_type()}
  53         </td>
  54 </tr>
  55 <!--
  56 This is now deprecated use the newer x12 partner code instead
  57 <tr>
  58         <td COLSPAN="1" ALIGN="LEFT" VALIGN="MIDDLE">X12 Receiver ID</td>
  59         <td COLSPAN="2" ALIGN="LEFT" VALIGN="MIDDLE">
  60                 <input type="text" name="x12_receiver_id" value="{$insurancecompany->get_x12_receiver_id()}" >
  61         </td>
  62 </tr>-->
  63 <tr>
  64         <td COLSPAN="1" ALIGN="LEFT" VALIGN="MIDDLE">{xl t='Default X12 Partner'}</td>
  65         <td COLSPAN="2" ALIGN="LEFT" VALIGN="MIDDLE">
  66                 {html_options name="x12_default_partner_id" options=$x12_partners selected=$insurancecompany->get_x12_default_partner_id()}
  67         </td>
  68 </tr>
  69 <tr>
  70         <td><br /><input type="submit" value="{xl t='Update'}" /></td>
  71 </tr>
  72 </table>
  73 <input type="hidden" name="id" value="{$insurancecompany->id}" />
  74 <input type="hidden" name="process" value="{$PROCESS}" />
  75 </form>