interface/cmsportal/insurance_form.php

   1 <?php
   2 /**
   3  * Insurance form posting for the WordPress Patient Portal.
   4  *
   5  * LICENSE: This program is free software; you can redistribute it and/or
   6  * modify it under the terms of the GNU General Public License
   7  * as published by the Free Software Foundation; either version 2
   8  * of the License, or (at your option) any later version.
   9  * This program is distributed in the hope that it will be useful,
  10  * but WITHOUT ANY WARRANTY; without even the implied warranty of
  11  * MERCHANTABILITY or FITNESS FOR A PARTICULAR PURPOSE. See the
  12  * GNU General Public License for more details.
  13  * You should have received a copy of the GNU General Public License
  14  * along with this program. If not, see <http://opensource.org/licenses/gpl-license.php>;.
  15  *
  16  * @package OpenEMR
  17  * @author  Rod Roark <rod@sunsetsystems.com>
  18  */
  19
  20 $sanitize_all_escapes = true;
  21 $fake_register_globals = false;
  22
  23 require_once("../globals.php");
  24 require_once("$srcdir/patient.inc");
  25 require_once("$srcdir/options.inc.php");
  26 require_once("portal.inc.php");
  27
  28 // Consider this a step towards converting the insurance form to layout-based.
  29 // Faking it here makes things easier.
  30 // Also note that some fields like SSN and most of the subscriber employer
  31 // items have been omitted because they are not relevant for claims.
  32 //
  33 $insurance_layout = array(
  34   array('field_id'     => 'type',
  35         'title'        => 'Type',
  36         'uor'          => '2',
  37         'data_type'    => '1',
  38         'list_id'      => 'insurance_types',
  39         'edit_options' => '',
  40        ),
  41   array('field_id'     => 'date',
  42         'title'        => 'Effective Date',
  43         'uor'          => '2',
  44         'data_type'    => '4',               // Text-date
  45         'list_id'      => '',
  46         'edit_options' => '',
  47        ),
  48   array('field_id'     => 'provider',
  49         'title'        => 'Provider',
  50         'uor'          => '2',
  51         'data_type'    => '16',              // Insurance Providers
  52         'list_id'      => '',
  53         'edit_options' => '',
  54        ),
  55   array('field_id'     => 'plan_name',
  56         'title'        => 'Plan Name',
  57         'uor'          => '1',
  58         'data_type'    => '2',               // Text
  59         'list_id'      => '',
  60         'edit_options' => '',
  61        ),
  62   array('field_id'     => 'policy_number',
  63         'title'        => 'Policy Number',
  64         'uor'          => '1',
  65         'data_type'    => '2',               // Text
  66         'list_id'      => '',
  67         'edit_options' => '',
  68        ),
  69   array('field_id'     => 'group_number',
  70         'title'        => 'Group Number',
  71         'uor'          => '1',
  72         'data_type'    => '2',               // Text
  73         'list_id'      => '',
  74         'edit_options' => '',
  75        ),
  76   array('field_id'     => 'subscriber_employer',
  77         'title'        => 'Group Name',
  78         'uor'          => '1',
  79         'data_type'    => '2',               // Text
  80         'list_id'      => '',
  81         'edit_options' => '',
  82        ),
  83   array('field_id'     => 'subscriber_lname',
  84         'title'        => 'Subscriber Last Name',
  85         'uor'          => '2',
  86         'data_type'    => '2',               // Text
  87         'list_id'      => '',
  88         'edit_options' => '',
  89        ),
  90   array('field_id'     => 'subscriber_fname',
  91         'title'        => 'Subscriber First Name',
  92         'uor'          => '1',
  93         'data_type'    => '2',               // Text
  94         'list_id'      => '',
  95         'edit_options' => '',
  96        ),
  97   array('field_id'     => 'subscriber_mname',
  98         'title'        => 'Subscriber Middle Name',
  99         'uor'          => '1',
 100         'data_type'    => '2',               // Text
 101         'list_id'      => '',
 102         'edit_options' => '',
 103        ),
 104   array('field_id'     => 'subscriber_DOB',
 105         'title'        => 'Subscriber DOB',
 106         'uor'          => '2',
 107         'data_type'    => '4',               // Text-date
 108         'list_id'      => '',
 109         'edit_options' => '',
 110        ),
 111   array('field_id'     => 'subscriber_sex',
 112         'title'        => 'Subscriber Sex',
 113         'uor'          => '2',
 114         'data_type'    => '1',               // List
 115         'list_id'      => 'sex',
 116         'edit_options' => '',
 117        ),
 118   array('field_id'     => 'subscriber_relationship',
 119         'title'        => 'Subscriber Relationship',
 120         'uor'          => '2',
 121         'data_type'    => '1',               // List
 122         'list_id'      => 'sub_relation',
 123         'edit_options' => '',
 124        ),
 125   array('field_id'     => 'subscriber_street',
 126         'title'        => 'Subscriber Street',
 127         'uor'          => '1',
 128         'data_type'    => '2',               // Text
 129         'list_id'      => '',
 130         'edit_options' => '',
 131        ),
 132   array('field_id'     => 'subscriber_city',
 133         'title'        => 'Subscriber City',
 134         'uor'          => '1',
 135         'data_type'    => '2',               // Text
 136         'list_id'      => '',
 137         'edit_options' => '',
 138        ),
 139   array('field_id'     => 'subscriber_state',
 140         'title'        => 'Subscriber State',
 141         'uor'          => '1',
 142         'data_type'    => '1',               // List
 143         'list_id'      => 'state',
 144         'edit_options' => '',
 145        ),
 146   array('field_id'     => 'subscriber_postal_code',
 147         'title'        => 'Subscriber Zip',
 148         'uor'          => '1',
 149         'data_type'    => '2',               // Text
 150         'list_id'      => '',
 151         'edit_options' => '',
 152        ),
 153   array('field_id'     => 'subscriber_phone',
 154         'title'        => 'Subscriber Phone',
 155         'uor'          => '1',
 156         'data_type'    => '2',               // Text
 157         'list_id'      => '',
 158         'edit_options' => '',
 159        ),
 160 );
 161
 162 $postid = intval($_REQUEST['postid']);
 163
 164 if ($_POST['bn_save']) {
 165   $newdata = array();
 166   $ptid = intval($_POST['ptid']);
 167   foreach ($insurance_layout as $frow) {
 168     $data_type = $frow['data_type'];
 169     $field_id  = $frow['field_id'];
 170     // newInsuranceData() does not escape for mysql so we have to do it here.
 171     $newdata[$field_id] = add_escape_custom(get_layout_form_value($frow));
 172   }
 173   newInsuranceData(
 174     $ptid,
 175     $newdata['type'],
 176     $newdata['provider'],
 177     $newdata['policy_number'],
 178     $newdata['group_number'],
 179     $newdata['plan_name'],
 180     $newdata['subscriber_lname'],
 181     $newdata['subscriber_mname'],
 182     $newdata['subscriber_fname'],
 183     $newdata['subscriber_relationship'],
 184     '',                                    // subscriber_ss
 185     fixDate($newdata['subscriber_DOB']),
 186     $newdata['subscriber_street'],
 187     $newdata['subscriber_postal_code'],
 188     $newdata['subscriber_city'],
 189     $newdata['subscriber_state'],
 190     '',                                    // subscriber_country
 191     $newdata['subscriber_phone'],
 192     $newdata['subscriber_employer'],
 193     '',                                    // subscriber_employer_street
 194     '',                                    // subscriber_employer_city
 195     '',                                    // subscriber_employer_postal_code
 196     '',                                    // subscriber_employer_state
 197     '',                                    // subscriber_employer_country
 198     '',                                    // copay
 199     $newdata['subscriber_sex'],
 200     fixDate($newdata['date']),
 201     'TRUE',                                // accept_assignment
 202     ''                                     // policy_type
 203   );
 204   // Finally, delete the request from the portal.
 205   $result = cms_portal_call(array('action' => 'delpost', 'postid' => $postid));
 206   if ($result['errmsg']) {
 207     die(text($result['errmsg']));
 208   }
 209   echo "<html><body><script language='JavaScript'>\n";
 210   echo "if (top.restoreSession) top.restoreSession(); else opener.top.restoreSession();\n";
 211   echo "document.location.href = 'list_requests.php';\n";
 212   echo "</script></body></html>\n";
 213   exit();
 214 }
 215
 216 // Get the portal request data.
 217 if (!$postid) die(xlt('Request ID is missing!'));
 218 $result = cms_portal_call(array('action' => 'getpost', 'postid' => $postid));
 219 if ($result['errmsg']) {
 220   die(text($result['errmsg']));
 221 }
 222
 223 // Look up the patient in OpenEMR.
 224 $ptid = lookup_openemr_patient($result['post']['user']);
 225 ?>
 226 <html>
 227 <head>
 228 <?php html_header_show(); ?>
 229 <link rel=stylesheet href="<?php echo $css_header; ?>" type="text/css">
 230
 231 <style type="text/css">@import url(../../library/dynarch_calendar.css);</style>
 232 <style>
 233
 234 tr.head   { font-size:10pt; background-color:#cccccc; text-align:center; }
 235 tr.detail { font-size:10pt; background-color:#ddddff; }
 236 td input  { background-color:transparent; }
 237
 238 </style>
 239
 240 <script type="text/javascript" src="../../library/textformat.js"></script>
 241 <script type="text/javascript" src="../../library/dynarch_calendar.js"></script>
 242 <?php include_once("{$GLOBALS['srcdir']}/dynarch_calendar_en.inc.php"); ?>
 243 <script type="text/javascript" src="../../library/dynarch_calendar_setup.js"></script>
 244 <script type="text/javascript" src="<?php echo $GLOBALS['assets_static_relative']; ?>/jquery-min-1-2-2/index.js"></script>
 245
 246 <script language="JavaScript">
 247
 248 var mypcc = '<?php echo $GLOBALS['phone_country_code'] ?>';
 249
 250 function myRestoreSession() {
 251  if (top.restoreSession) top.restoreSession(); else opener.top.restoreSession();
 252  return true;
 253 }
 254
 255 // This capitalizes the first letter of each word in the passed input
 256 // element.  It also strips out extraneous spaces.
 257 // Copied from demographics_full.php.
 258 function capitalizeMe(elem) {
 259  var a = elem.value.split(' ');
 260  var s = '';
 261  for(var i = 0; i < a.length; ++i) {
 262   if (a[i].length > 0) {
 263    if (s.length > 0) s += ' ';
 264    s += a[i].charAt(0).toUpperCase() + a[i].substring(1);
 265   }
 266  }
 267  elem.value = s;
 268 }
 269
 270 function validate() {
 271  var f = document.forms[0];
 272  // TBD
 273  return true;
 274 }
 275
 276 </script>
 277 </head>
 278
 279 <body class="body_top">
 280 <center>
 281
 282 <form method='post' action='insurance_form.php' onsubmit='return validate()'>
 283
 284 <input type='hidden' name='ptid'   value='<?php echo attr($ptid);   ?>' />
 285 <input type='hidden' name='postid' value='<?php echo attr($postid); ?>' />
 286
 287 <table width='100%' cellpadding='1' cellspacing='2'>
 288  <tr class='head'>
 289   <th align='left'><?php echo xlt('Field'        ); ?></th>
 290   <th align='left'><?php echo xlt('Current Value'); ?></th>
 291   <th align='left'><?php echo xlt('New Value'    ); ?></th>
 292  </tr>
 293
 294 <?php
 295 $insrow = getInsuranceData($pid, $result['fields']['type']);
 296
 297 foreach ($insurance_layout as $lorow) {
 298   $data_type  = $lorow['data_type'];
 299   $field_id   = $lorow['field_id'];
 300
 301   $list_id = $lorow['list_id'];
 302   $field_title = $lorow['title'];
 303
 304   $currvalue  = '';
 305   if (isset($insrow[$field_id])) $currvalue = $insrow[$field_id];
 306
 307   $newvalue = '';
 308   if (isset($result['fields'][$field_id])) $newvalue = trim($result['fields'][$field_id]);
 309
 310   // Translate $newvalue for certain field types including lists.
 311   if ($newvalue !== '') {
 312     if ($list_id) {
 313       $tmp = sqlQuery("SELECT option_id FROM list_options WHERE " .
 314         "list_id = ? AND title = ? AND activity = 1 ORDER BY option_id LIMIT 1",
 315         array($list_id, $newvalue));
 316       if (isset($tmp['option_id'])) $newvalue = $tmp['option_id'];
 317     }
 318     // Some data types like insurance provider are pretty hopeless, so let the display
 319     // logic generate a "Fix me" message and the user can translate it.
 320   }
 321
 322   echo " <tr class='detail'>\n";
 323   echo "  <td class='bold'>" . text($field_title) . "</td>\n";
 324   echo "  <td>";
 325   echo generate_display_field($lorow, $currvalue);
 326   echo "</td>\n";
 327   echo "  <td>";
 328   generate_form_field($lorow, $newvalue);
 329   echo "</td>\n";
 330   echo " </tr>\n";
 331 }
 332 ?>
 333
 334 </table>
 335
 336 <p>
 337 <input type='submit' name='bn_save' value='<?php echo xla('Save and Delete Request'); ?>' />
 338 &nbsp;
 339 <input type='button' value='<?php echo xla('Back'); ?>' onclick="window.history.back()" />
 340 <!-- Was: onclick="myRestoreSession();location='list_requests.php'" -->
 341 </p>
 342
 343 </form>
 344
 345 <script language="JavaScript">
 346
 347 // Fix inconsistently formatted phone numbers from the database.
 348 var f = document.forms[0];
 349 if (f.form_phone) phonekeyup(f.form_phone, mypcc);
 350
 351 // This is a by-product of generate_form_field().
 352 <?php echo $date_init; ?>
 353
 354 </script>
 355
 356 <!-- include support for the list-add selectbox feature -->
 357 <?php include $GLOBALS['fileroot'] . "/library/options_listadd.inc"; ?>
 358
 359 </center>
 360 </body>
 361 </html>
 362