interface/forms/misc_billing_options/new.php

   1 <?php
   2 require_once("../../globals.php");
   3 require_once("$srcdir/api.inc");
   4 require_once("$srcdir/formdata.inc.php");
   5
   6 if (! $encounter) { // comes from globals.php
   7  die(xl("Internal error: we do not seem to be in an encounter!"));
   8 }
   9
  10 $formid   = 0 + formData('id', 'G');
  11 $obj = $formid ? formFetch("form_misc_billing_options", $formid) : array();
  12
  13 formHeader("Form: misc_billing_options");
  14 ?>
  15 <html><head>
  16 <?php html_header_show(); ?>
  17 <link rel="stylesheet" href="<?php echo $css_header;?>" type="text/css">
  18 </head>
  19 <body class="body_top">
  20 <?php
  21 echo "<form method='post' name='my_form' " .
  22   "action='$rootdir/forms/misc_billing_options/save.php?id=$formid'>\n";
  23 ?>
  24 <span class="title"><?php xl('Misc Billing Options for HCFA-1500','e'); ?></span><Br><br>
  25 <span class=text><?php xl('Checked box = yes ,  empty = no', 'e');?><br><br>
  26 <span class=text><?php xl('BOX 10 A. Employment related ','e'); ?>: </span><input type=checkbox name="employment_related" value="1" <?php if ($obj['employment_related'] == "1") echo "checked";?>><br><br>
  27 <span class=text><?php xl('BOX 10 B. Auto Accident ','e'); ?>: </span><input type=checkbox name="auto_accident" value="1" <?php if ($obj['auto_accident'] == "1") echo "checked";?>>
  28 <span class=text><?php xl('State','e'); ?>: </span><input type=entry name="accident_state" size=1 value="<?php echo $obj{"accident_state"};?>" ><br><br>
  29 <span class=text><?php xl('BOX 10 C. Other Accident ','e'); ?>: </span><input type=checkbox name="other_accident" value="1" <?php if ($obj['other_accident'] == "1") echo "checked";?>><br><br>
  30 <span class=text><?php xl('BOX 15. Date of same or similar illness (yyyy-mm-dd):','e');?> </span><input type='entry' size='9' name="date_initial_treatment" value="<?php echo $obj{"date_initial_treatment"};?>" /><br><br>
  31 <span class=text><?php xl('BOX 16. Date unable to work from (yyyy-mm-dd):','e');?> </span><input type=entry size=9 name="off_work_from" value="<?php echo $obj{"off_work_from"};?>" >
  32 <span class=text><?php xl('BOX 16. Date unable to work to (yyyy-mm-dd):','e');?> </span><input type=entry size=9 name="off_work_to" value="<?php echo $obj{"off_work_to"};?>" ><br><br>
  33 <span class=text><?php xl('BOX 18. Hospitalization date from (yyyy-mm-dd): ','e');?></span><input type=entry size=9 name="hospitalization_date_from" value="<?php echo $obj{"hospitalization_date_from"};?>" >
  34 <span class=text><?php xl('BOX 18. Hospitalization date to (yyyy-mm-dd): ','e');?></span><input type=entry size=9 name="hospitalization_date_to" value="<?php echo $obj{"hospitalization_date_to"};?>" ><br><br>
  35 <span class=text><?php xl('BOX 20. Is Outside Lab used?','e'); ?>: </span><input type=checkbox name="outside_lab" value="1" <?php if ($obj['outside_lab'] == "1") echo "checked";?>>
  36 <span class=text><?php xl('Amount Charges','e'); ?>: </span><input type=entry size=7 align='right' name="lab_amount" value="<?php echo $obj{"lab_amount"};?>" ><br><br>
  37 <span class=text><?php xl('BOX 22. Medicaid Resubmission Code (ICD-9) ','e');?></span><input type=entry size=9 name="medicaid_resubmission_code" value="<?php echo $obj{"medicaid_resubmission_code"};?>" >
  38 <span class=text><?php xl(' Medicaid Original Reference No. ','e');?></span><input type=entry size=15 name="medicaid_original_reference" value="<?php echo $obj{"medicaid_original_reference"};?>" ><br><br>
  39 <span class=text><?php xl('BOX 23. Prior Authorization No. ','e');?></span><input type=entry size=15 name="prior_auth_number" value="<?php echo $obj{"prior_auth_number"};?>" ><br><br>
  40 <span class=text><?php xl('X12 only: Replacement Claim ','e'); ?>: </span><input type=checkbox name="replacement_claim" value="1" <?php if ($obj['replacement_claim'] == "1") echo "checked";?>><br><br>
  41
  42 <table>
  43 <tr>
  44 <td valign=top>
  45 <span class=text><?php xl('Additional Notes','e'); ?>: </span><br><textarea cols=40 rows=8 wrap=virtual name="comments" ><?php echo $obj{"comments"};?></textarea><br>
  46 </td>
  47 </table>
  48 <br>
  49 </tr>
  50
  51 <a href="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[<?php xl('Save','e'); ?>]</a>
  52 <br>
  53 <a href="<?php echo "$rootdir/patient_file/encounter/encounter_top.php";?>"
  54  class="link" onclick="top.restoreSession()">[<?php xl('Don\'t Save Changes','e'); ?>]</a>
  55 </form>
  56 <?php
  57 formFooter();
  58 ?>