interface/usergroup/facilities_add.php

   1 <?php
   2 require_once("../globals.php");
   3 require_once("../../library/acl.inc");
   4 require_once("$srcdir/sql.inc");
   5 require_once("$srcdir/formdata.inc.php");
   6 require_once("$srcdir/classes/POSRef.class.php");
   7
   8 $alertmsg = '';
   9 ?>
  10 <html>
  11 <head>
  12 <link rel="stylesheet" href="<?php echo $css_header;?>" type="text/css">
  13 <link rel="stylesheet" type="text/css" href="<?php echo $GLOBALS['webroot'] ?>/library/js/fancybox/jquery.fancybox-1.2.6.css" media="screen" />
  14 <script type="text/javascript" src="<?php echo $GLOBALS['webroot'] ?>/library/dialog.js"></script>
  15 <script type="text/javascript" src="<?php echo $GLOBALS['webroot'] ?>/library/js/jquery.1.3.2.js"></script>
  16 <script type="text/javascript" src="<?php echo $GLOBALS['webroot'] ?>/library/js/common.js"></script>
  17 <script type="text/javascript" src="<?php echo $GLOBALS['webroot'] ?>/library/js/fancybox/jquery.fancybox-1.2.6.js"></script>
  18 <script type="text/javascript" src="<?php echo $GLOBALS['webroot'] ?>/library/js/jquery-ui.js"></script>
  19 <?php
  20 // Old Browser comp trigger on js
  21
  22 if (isset($_POST["mode"]) && $_POST["mode"] == "facility") {
  23         echo '
  24 <script type="text/javascript">
  25 <!--
  26 parent.$.fn.fancybox.close();
  27 //-->
  28 </script>
  29
  30         ';
  31 }
  32 ?>
  33 <script type="text/javascript">
  34 /// todo, move this to a common library
  35
  36 function submitform() {
  37     if (document.forms[0].facility.value.length>0) {
  38         top.restoreSession();
  39         document.forms[0].submit();
  40                 parent.$.fn.fancybox.close();
  41                 parent.location.reload();
  42     } else {
  43         document.forms[0].facility.style.backgroundColor="red";
  44         document.forms[0].facility.focus();
  45     }
  46 }
  47
  48 function toggle( target, div ) {
  49
  50     $mode = $(target).find(".indicator").text();
  51     if ( $mode == "collapse" ) {
  52         $(target).find(".indicator").text( "expand" );
  53         $(div).hide();
  54     } else {
  55         $(target).find(".indicator").text( "collapse" );
  56         $(div).show();
  57     }
  58
  59 }
  60
  61 $(document).ready(function(){
  62
  63     $("#dem_view").click( function() {
  64         toggle( $(this), "#DEM" );
  65     });
  66
  67     // fancy box
  68     enable_modals();
  69
  70     tabbify();
  71
  72     // special size for
  73         $(".large_modal").fancybox( {
  74                 'overlayOpacity' : 0.0,
  75                 'showCloseButton' : true,
  76                 'frameHeight' : 600,
  77                 'frameWidth' : 1000
  78         });
  79
  80     // special size for
  81         $(".medium_modal").fancybox( {
  82                 'overlayOpacity' : 0.0,
  83                 'showCloseButton' : true,
  84                 'frameHeight' : 260,
  85                 'frameWidth' : 510
  86         });
  87
  88 });
  89
  90 $(document).ready(function(){
  91     $("#cancel").click(function() {
  92                   parent.$.fn.fancybox.close();
  93          });
  94 });
  95
  96 </script>
  97 <link rel="stylesheet" href="<?php echo $css_header;?>" type="text/css">
  98
  99 </head>
 100 <body class="body_top">
 101 <table>
 102 <tr><td>
 103     <span class="title"><?php xl('Add Facility','e'); ?></span>&nbsp;&nbsp;&nbsp;</td>
 104     <td colspan=5 align=center style="padding-left:2px;">
 105         <a onclick="submitform();" class="css_button large_button" name='form_save' id='form_save' href='#'>
 106             <span class='css_button_span large_button_span'><?php xl('Save','e');?></span>
 107         </a>
 108         <a class="css_button large_button" id='cancel' href='#' >
 109             <span class='css_button_span large_button_span'><?php xl('Cancel','e');?></span>
 110         </a>
 111 </td></tr>
 112 </table>
 113
 114 <br>
 115
 116 <form name='facility' method='post' action="facilities.php" onsubmit='return top.restoreSession()'>
 117     <input type=hidden name=mode value="facility">
 118     <table border=0 cellpadding=0 cellspacing=0>
 119         <tr>
 120         <td><span class="text"><?php xl('Name','e'); ?>: </span></td><td><input type=entry name=facility size=20 value=""><span class="mandatory">&nbsp;*</span></td>
 121         <td width=20>&nbsp;</td>
 122         <td><span class="text"><?php xl('Phone','e'); ?>: </span></td><td><input type=entry name=phone size=20 value=""></td>
 123         </tr>
 124         <tr>
 125         <td><span class="text"><?php xl('Address','e'); ?>: </span></td><td><input type=entry size=20 name=street value=""></td>
 126         <td>&nbsp;</td>
 127         <td><span class="text"><?php xl('Fax','e'); ?>: </span></td><td><input type=entry name=fax size=20 value=""></td>
 128         </tr>
 129         <tr>
 130         <td><span class="text"><?php xl('City','e'); ?>: </span></td><td><input type=entry size=20 name=city value=""></td>
 131         <td>&nbsp;</td>
 132         <td><span class="text"><?php xl('Zip Code','e'); ?>: </span></td><td><input type=entry size=20 name=postal_code value=""></td>
 133         </tr>
 134         <tr>
 135         <td><span class="text"><?php xl('State','e'); ?>: </span></td><td><input type=entry size=20 name=state value=""></td>
 136         <td>&nbsp;</td>
 137         <td><span class="text"><?php xl('Tax ID','e'); ?>: </span></td><td><select name=tax_id_type><option value="EI"><?php xl('EIN','e'); ?></option><option value="SY"><?php xl('SSN','e'); ?></option></select><input type=entry size=11 name=federal_ein value=""></td>
 138         </tr>
 139         <tr>
 140         <td height="22"><span class="text"><?php xl('Country','e'); ?>: </span></td><td><input type=entry size=20 name=country_code value=""></td>
 141         <td>&nbsp;</td>
 142         <td><span class="text"><?php ($GLOBALS['simplified_demographics'] ? xl('Facility Code','e') : xl('Facility NPI','e')); ?>:
 143         </span></td><td><input type=entry size=20 name=facility_npi value=""></td>
 144         </tr>
 145
 146         <tr>
 147           <td><span class='text'><?php xl('Billing Location','e'); ?>: </span></td><td><input type='checkbox' name='billing_location' value = '1'></td>
 148           <td>&nbsp;</td>
 149           <td><span class='text'><?php xl('Accepts Assignment','e'); ?><br>(<?php xl('only if billing location','e'); ?>): </span></td> <td><input type='checkbox' name='accepts_assignment' value = '1'></td>
 150         </tr>
 151         <tr>
 152           <td><span class='text'><?php xl('Service Location','e'); ?>: </span></td> <td><input type='checkbox' name='service_location' value = '1'></td>
 153           <td>&nbsp;</td>
 154           <td>&nbsp;</td> <td>&nbsp;</td>
 155         </tr>
 156
 157         <tr>
 158             <td><span class=text><?php xl('POS Code','e'); ?>: </span></td>
 159             <td colspan="6">
 160                 <select name="pos_code">
 161                 <?php
 162                 $pc = new POSRef();
 163
 164                 foreach ($pc->get_pos_ref() as $pos) {
 165                     echo "<option value=\"" . $pos["code"] . "\" ";
 166                     echo ">" . $pos['code']  . ": ". $pos['title'];
 167                     echo "</option>\n";
 168                 }
 169
 170                 ?>
 171                 </select>
 172             </td>
 173         </tr>
 174         <tr>
 175             <td><span class="text"><?php xl('Billing Attn','e'); ?>:</span></td>
 176             <td colspan="4"><input type="text" name="attn" size="45"></td>
 177         </tr>
 178         <tr>
 179             <td><span class="text"><?php xl('CLIA Number','e'); ?>:</span></td>
 180             <td colspan="4"><input type="text" name="domain_identifier" size="45"></td>
 181         </tr>
 182
 183         <tr height="25" style="valign:bottom;">
 184         <td><font class="mandatory">*</font><span class="text"> <?php echo xl('Required','e'); ?></span></td><td>&nbsp;</td><td>&nbsp;</td>
 185         <td>&nbsp;</td><td>&nbsp;</td>
 186         </tr>
 187     </table>
 188 </form>
 189
 190 <script language="JavaScript">
 191 <?php
 192   if ($alertmsg = trim($alertmsg)) {
 193     echo "alert('$alertmsg');\n";
 194   }
 195 ?>
 196 </script>
 197
 198 </body>
 199 </html>