interface/patient_file/summary/demographics_full.php

   1 <?
   2 include_once("../../globals.php");
   3
   4 // Session pid must be right or bad things can happen when demographics are saved!
   5 //
   6 include_once("$srcdir/pid.inc");
   7 if ($_GET["set_pid"] && $_GET["set_pid"] != $_SESSION["pid"]) {
   8         setpid($_GET["set_pid"]);
   9 }
  10 else if ($_GET["pid"] && $_GET["pid"] != $_SESSION["pid"]) {
  11         setpid($_GET["pid"]);
  12 }
  13
  14 include_once("$srcdir/patient.inc");
  15
  16 $relats = array('','self','spouse','child','other');
  17 $statii = array('married','single','divorced','widowed','separated','domestic partner');
  18 //$langi = array('english','spanish','french','tagalog','vietnamese');
  19
  20 $langi = getLanguages();
  21 $ethnoraciali = getEthnoRacials();
  22 $provideri = getProviderInfo();
  23 $insurancei = getInsuranceProviders();
  24 ?>
  25
  26 <html>
  27 <head>
  28
  29
  30 <link rel=stylesheet href="<?echo $css_header;?>" type="text/css">
  31 <SCRIPT LANGUAGE="JavaScript"><!--
  32 function update_phone_biz() {
  33 document.demographics_form.phone_biz.value = '('+document.demographics_form.phone_biz_area.value+') '+document.demographics_form.phone_biz_first.value+'-'+document.demographics_form.phone_biz_last.value;
  34 if (document.demographics_form.phone_biz.value == "() -"){
  35         document.demographics_form.phone_biz.value = "";
  36 }
  37 }
  38
  39 function update_phone_cell() {
  40 document.demographics_form.phone_cell.value = '('+document.demographics_form.phone_cell_area.value+') '+document.demographics_form.phone_cell_first.value+'-'+document.demographics_form.phone_cell_last.value;
  41 if (document.demographics_form.phone_cell.value == "() -"){
  42         document.demographics_form.phone_cell.value = "";
  43 }
  44 }
  45
  46
  47
  48 //code used from http://tech.irt.org/articles/js037/
  49 function replace(string,text,by) {
  50   // Replaces text with by in string
  51       var strLength = string.length, txtLength = text.length;
  52       if ((strLength == 0) || (txtLength == 0)) return string;
  53
  54       var i = string.indexOf(text);
  55       if ((!i) && (text != string.substring(0,txtLength))) return string;
  56       if (i == -1) return string;
  57
  58       var newstr = string.substring(0,i) + by;
  59
  60       if (i+txtLength < strLength)
  61           newstr += replace(string.substring(i+txtLength,strLength),text,by);
  62
  63       return newstr;
  64   }
  65
  66   function upperFirst(string,text) {
  67       return replace(string,text,text.charAt(0).toUpperCase() + text.substring(1,text.length));
  68   }
  69
  70
  71 function update_phone_contact() {
  72 document.demographics_form.phone_contact.value = '('+document.demographics_form.phone_contact_area.value+') '+document.demographics_form.phone_contact_first.value+'-'+document.demographics_form.phone_contact_last.value;
  73 if (document.demographics_form.phone_contact.value == "() -"){
  74         document.demographics_form.phone_contact.value = "";
  75 }
  76 }
  77 function update_phone_home() {
  78 document.demographics_form.phone_home.value = '('+document.demographics_form.phone_home_area.value+') '+document.demographics_form.phone_home_first.value+'-'+document.demographics_form.phone_home_last.value;
  79 if (document.demographics_form.phone_home.value == "() -"){
  80         document.demographics_form.phone_home.value = "";
  81 }
  82 }
  83 <? for ($i=1;$i<=3;$i++) { ?>
  84 function auto_populate_employer_address<?=$i?>(){
  85 //alert(document.demographics_form.i<?=$i?>subscriber_relationship.options[document.demographics_form.i<?=$i?>subscriber_relationship.selectedIndex].value);
  86 if (document.demographics_form.i<?=$i?>subscriber_relationship.options[document.demographics_form.i<?=$i?>subscriber_relationship.selectedIndex].value == "self") {
  87 document.demographics_form.i<?=$i?>subscriber_fname.value=document.demographics_form.fname.value;
  88 document.demographics_form.i<?=$i?>subscriber_mname.value=document.demographics_form.mname.value;
  89 document.demographics_form.i<?=$i?>subscriber_lname.value=document.demographics_form.lname.value;
  90 document.demographics_form.i<?=$i?>subscriber_street.value=document.demographics_form.street.value;
  91 document.demographics_form.i<?=$i?>subscriber_city.value=document.demographics_form.city.value;
  92 document.demographics_form.i<?=$i?>subscriber_state.value=document.demographics_form.state.value;
  93 document.demographics_form.i<?=$i?>subscriber_postal_code.value=document.demographics_form.postal_code.value;
  94 document.demographics_form.i<?=$i?>subscriber_country.value=document.demographics_form.country_code.value;
  95 document.demographics_form.i<?=$i?>subscriber_phone.value=document.demographics_form.phone_home.value;
  96 document.demographics_form.i<?=$i?>subscriber_phone_area.value=document.demographics_form.phone_home_area.value;
  97 document.demographics_form.i<?=$i?>subscriber_phone_first.value=document.demographics_form.phone_home_first.value;
  98 document.demographics_form.i<?=$i?>subscriber_phone_last.value=document.demographics_form.phone_home_last.value;
  99 document.demographics_form.i<?=$i?>subscriber_DOB.value=document.demographics_form.dob.value;
 100 document.demographics_form.i<?=$i?>subscriber_ss.value=document.demographics_form.ss.value;
 101 document.demographics_form.i<?=$i?>subscriber_sex.selectedIndex = document.demographics_form.sex.selectedIndex;
 102 document.demographics_form.i<?=$i?>subscriber_employer.value=document.demographics_form.ename.value;
 103 document.demographics_form.i<?=$i?>subscriber_employer_street.value=document.demographics_form.estreet.value;
 104 document.demographics_form.i<?=$i?>subscriber_employer_city.value=document.demographics_form.ecity.value;
 105 document.demographics_form.i<?=$i?>subscriber_employer_state.value=document.demographics_form.estate.value;
 106 document.demographics_form.i<?=$i?>subscriber_employer_postal_code.value=document.demographics_form.epostal_code.value;
 107 document.demographics_form.i<?=$i?>subscriber_employer_country.value=document.demographics_form.ecountry.value;
 108
 109
 110 }
 111 }
 112 function update_i<?=$i?>subscriber_phone() {
 113 document.demographics_form.i<?=$i?>subscriber_phone.value = '('+document.demographics_form.i<?=$i?>subscriber_phone_area.value+') '+document.demographics_form.i<?=$i?>subscriber_phone_first.value+'-'+document.demographics_form.i<?=$i?>subscriber_phone_last.value;
 114 if (document.demographics_form.i<?=$i?>subscriber_phone.value == "() -"){
 115         document.demographics_form.i<?=$i?>subscriber_phone.value = "";
 116 }
 117 }
 118
 119 <?}?>
 120
 121
 122 function popUp(URL) {
 123 day = new Date();
 124 id = day.getTime();
 125 eval("page" + id + " = window.open(URL, '" + id + "', 'toolbar=0,scrollbars=1,location=0,statusbar=0,menubar=0,resizable=1,width=400,height=300,left = 440,top = 362');");
 126 }
 127
 128 function checkNum () {
 129 var re= new RegExp();
 130 re = /^\d*\.?\d*$/;
 131 str=document.demographics_form.monthly_income.value;
 132 if(re.exec(str))
 133 {
 134
 135 }else{
 136 alert("Please enter a dollar amount using only numbers and a decimal point.");
 137 }
 138 }
 139 //-->
 140 </script>
 141 </head>
 142 <body <?echo $top_bg_line;?> topmargin=0 rightmargin=0 leftmargin=2 bottommargin=0 marginwidth=2 marginheight=0>
 143 <?
 144 $result = getPatientData($pid);
 145 $result2 = getEmployerData($pid);
 146
 147 //extract formatting of phone number:
 148 $pmatch_contact=array();
 149 // preg_match("/^\((.*?)\)\s(.*?)\-(.*?)$/",$result{"phone_contact"},$pmatch_contact);
 150 preg_match("/\D*(\d\d\d)\D*(\d\d\d)\D*(\d\d\d\d)\D*$/",$result{"phone_contact"},$pmatch_contact);
 151
 152 //extract formatting of phone number:
 153 $pmatch_home=array();
 154 // preg_match("/^\((.*?)\)\s(.*?)\-(.*?)$/",$result{"phone_home"},$pmatch_home);
 155 preg_match("/\D*(\d\d\d)\D*(\d\d\d)\D*(\d\d\d\d)\D*$/",$result{"phone_home"},$pmatch_home);
 156
 157 //extract formatting of phone number:
 158 $pmatch_biz=array();
 159 // preg_match("/^\((.*?)\)\s(.*?)\-(.*?)$/",$result{"phone_biz"},$pmatch_biz);
 160 preg_match("/\D*(\d\d\d)\D*(\d\d\d)\D*(\d\d\d\d)\D*$/",$result{"phone_biz"},$pmatch_biz);
 161
 162 //extract formatting of phone number:
 163 $pmatch_cell=array();
 164 // preg_match("/^\((.*?)\)\s(.*?)\-(.*?)$/",$result{"phone_cell"},$pmatch_cell);
 165 preg_match("/\D*(\d\d\d)\D*(\d\d\d)\D*(\d\d\d\d)\D*$/",$result{"phone_cell"},$pmatch_cell);
 166
 167 ?>
 168
 169 <form action="demographics_save.php" name=demographics_form method=post>
 170 <input type=hidden name=mode value=save>
 171 <input type=hidden name=phone_contact value="<?echo $result{"phone_contact"}?>">
 172 <input type=hidden name=phone_biz value="<?echo $result{"phone_biz"}?>">
 173 <input type=hidden name=phone_cell value="<?echo $result{"phone_cell"}?>">
 174
 175 <a href="patient_summary.php" target=Main><font class=title>Demographics</font><font class=back><?echo $tback;?></font></a>
 176
 177 <table border="0" cellpadding="0">
 178 <tr><td valign="top">
 179 <span class=required>Name: </span></td>
 180 <td colspan="6">
 181 <select name=title tabindex="1">
 182         <option value="<?echo $result{"title"}?>"><?echo $result{"title"}?></option>
 183         <option value="Mr.">Mr.</option>
 184         <option value="Mrs.">Mrs.</option>
 185         <option value="Ms.">Ms.</option>
 186         <option value="Dr.">Dr.</option>
 187 </select>
 188 <input tabindex="2" type=entry size=15 name=fname value="<?echo $result{"fname"}?>"> <input tabindex="3" type=entry size=3 name=mname value="<?echo $result{"mname"}?>"> <input tabindex="4" type=entry size=15 name=lname value="<?echo $result{"lname"}?>">
 189 </td>
 190
 191 </tr>
 192 <tr>
 193 <td valign=top>
 194 <span class=required>DOB: </span>
 195 <td><input tabindex="5" type=entry size=11 name=dob value="
 196 <?
 197         if (!empty($result['DOB_TS'])) {
 198           echo $result['DOB_TS'];
 199         }
 200         else {
 201           echo "MM/DD/YYYY";
 202         }
 203 ?>
 204 "></td><td rowspan="12">&nbsp;</td>
 205 <td><span class=bold>Patient Number: </span></td><td rowspan="12">&nbsp;</td><td><input type=entry size=10 name=pubpid value="<?echo $result{"pubpid"}?>"></td>
 206 </tr>
 207 <tr>
 208 <td>
 209 <span class=required>Sex: </span></td><td>
 210 <select name=sex tabindex="6">
 211 <option value="Male" <?if ($result{"sex"} == "Male") {echo "selected";};?>>Male</option>
 212 <option value="Female" <?if ($result{"sex"} == "Female") {echo "selected";};?>>Female</option>
 213 </select>
 214 </td>
 215 <td><span class=bold>Emergency Contact: </span></td><td><input type=entry size=10 name=contact_relationship value="<?echo $result{"contact_relationship"}?>"></td>
 216
 217 </tr>
 218 <tr>
 219         <td><span class=bold>S.S.: </span></td><td><input tabindex="7" type=entry size=11 name=ss value="<?echo $result{"ss"}?>"></td>
 220         <td><span class=bold>Emergency Phone:</span></td><td>(<input type=entry size=3 name=phone_contact_area onblur="javascript:update_phone_contact();" value="<?echo $pmatch_contact[1]?>">) <input type=entry size=3 name=phone_contact_first onblur="javascript:update_phone_contact();" value="<?echo $pmatch_contact[2]?>">-<input type=entry size=4 name=phone_contact_last onblur="javascript:update_phone_contact();" value="<?echo $pmatch_contact[3]?>"></td>
 221 </tr>
 222 <tr>
 223         <td><span class=required>Address: </span></td><td><input tabindex="8" type=entry size=25 name=street value="<?echo $result{"street"}?>"></td>
 224         <td><span class=bold>Home Phone: <input type=hidden name=phone_home value="<?echo $result{"phone_home"}?>"></span></td><td>(<input type=entry size=3 name=phone_home_area onblur="javascript:update_phone_home();" value="<?echo $pmatch_home[1]?>">) <input type=entry size=3 name=phone_home_first onblur="javascript:update_phone_home();" value="<?echo $pmatch_home[2]?>">-<input type=entry size=4 name=phone_home_last onblur="javascript:update_phone_home();" value="<?echo $pmatch_home[3]?>"></td>
 225 </tr>
 226 <tr>
 227         <td><span class=required>City: </span></td><td><input tabindex="9" type=entry size=15 name=city value="<?echo $result{"city"}?>"></td>
 228         <td><span class=bold>Work Phone:</span></td><td>(<input type=entry size=3 name=phone_biz_area onblur="javascript:update_phone_biz();" value="<?echo $pmatch_biz[1]?>">) <input type=entry size=3 name=phone_biz_first onblur="javascript:update_phone_biz();" value="<?echo $pmatch_biz[2]?>">-<input type=entry size=4 name=phone_biz_last onblur="javascript:update_phone_biz();" value="<?echo $pmatch_biz[3]?>"></td>
 229 </tr>
 230 <tr>
 231         <td><span class=required>State: </span></td><td><input tabindex="10" type=entry size=15 name=state value="<?echo $result{"state"}?>"></td>
 232         <td><span class=bold>Mobile Phone: </span></td><td>(<input type=entry size=3 name=phone_cell_area onblur="javascript:update_phone_cell();" value="<?echo $pmatch_cell[1]?>">) <input type=entry size=3 name=phone_cell_first onblur="javascript:update_phone_cell();" value="<?echo $pmatch_cell[2]?>">-<input type=entry size=4 name=phone_cell_last onblur="javascript:update_phone_cell();" value="<?echo $pmatch_cell[3]?>"></td>
 233 </tr>
 234 <tr>
 235         <td><span class=required>Zip Code: </span></td><td><input tabindex="11" type=entry size=6 name=postal_code value="<?echo $result{"postal_code"}?>"></td>
 236         <td><span class=bold>Contact Email: </span></td><td><input type=entry size=30 name=email value="<?echo $result{"email"}?>"></td>
 237 </tr>
 238 <tr>
 239         <td><span class=required>Country: </span></td><td><input tabindex="12" type=entry size=10 name=country_code value="<?echo $result{"country_code"}?>"></td>
 240         <td><span class=bold>User Defined Fields</span></td>
 241 </tr>
 242 <tr>
 243         <td><span class=required>Marital Status: </span></td>
 244         <td>
 245
 246                 <select name=status tabindex="13">
 247 <?php
 248                 print "<!-- ".$result["status"]." -->\n";
 249                 foreach ($statii as $s) {
 250                         if ($s == "unassigned") {
 251                                 echo "<option value=''";
 252                         } else {
 253                 echo "<option value='".$s."'";
 254             }
 255
 256             if ($s == $result["status"])
 257                                 echo " selected";
 258
 259                 echo ">".ucwords($s)."</option>\n";
 260                 }
 261 ?>
 262                 </select>
 263                 </td>
 264                 <td><input name="genericname1" size=20 value="<?echo $result{"genericname1"};?>" /></td><td><input name="genericval1" size=20 value="<?echo $result{"genericval1"};?>" /></td>
 265         </tr>
 266 <tr>
 267         <td><span class=required>Provider: </span></td>
 268 <td>
 269         <select tabindex="14" name="providerID" onchange="javascript:document.demographics_form.referrer.value=upperFirst(this.options[this.selectedIndex].text,this.options[this.selectedIndex].text);">
 270         <option value=''>Unassigned</option>
 271         <?php
 272
 273         foreach ($provideri as $s) {
 274         //echo "defined provider is: " .trim($s['fname']." ".$s['lname']). " compared to : " .$result["referrer"] . "<br />";
 275
 276                 echo "<option value='".$s['id']."'";
 277
 278                 if ($s['id'] == $result["providerID"])
 279                         echo " selected";
 280                 echo ">".ucwords($s['fname']." ".$s['lname'])."</option>\n";
 281         }
 282
 283 ?>
 284
 285         </select>
 286         </td>
 287         <td><input name="genericname2" size=20 value="<?echo $result{"genericname2"};?>" /></td><td><input name="genericval2" size=20 value="<?echo $result{"genericval2"};?>" /></td>
 288 </tr>
 289 <tr>
 290         <td colspan=6>
 291                 <a href="javascript:document.demographics_form.submit();" target=Main class=link_submit>[Save Patient Demographics]</a>
 292                 <hr>
 293         </td>
 294 </tr>
 295 </table>
 296
 297 <table class=bold>
 298 <th>HIPAA Choices:</th>
 299 <tr>
 300         <td>Allow Mail:</td>
 301         <td>
 302         <select name="hipaa_mail">
 303                 <?
 304                 echo ('<option>NO</option>');
 305                 $result{"hipaa_mail"}=='YES' ? $opt_out='<option selected>YES</option>' : $opt_out='<option>YES</option>' ;
 306                 echo $opt_out;
 307                 ?>
 308         </select>
 309         <td>Allow Voice Msg:</td>
 310         <td>
 311         <select name="hipaa_voice">
 312                 <?
 313                 echo ('<option>NO</option>');
 314                 $result{"hipaa_voice"}=='YES' ? $opt_out='<option selected>YES</option>' : $opt_out='<option>YES</option>' ;
 315                 echo $opt_out;
 316                 ?>
 317         </select>
 318         </td>
 319         <td></td>
 320         <td></td>
 321 </tr>
 322 </table>
 323
 324
 325 <table><tr>
 326 <td colspan=4>
 327 <a href="javascript:document.demographics_form.submit();" target=Main class=link_submit>[Save Patient Demographics]</a><hr></td>
 328 </tr>
 329
 330
 331 <tr>
 332 <td valign=top>
 333 <input type=hidden size=30 name=referrer value="<?echo ucfirst($result{"referrer"});?>">
 334 <input type=hidden size=20 name=referrerID value="<?echo $result{"referrerID"}?>">
 335 <input type=hidden size=20 name=db_id value="<?echo $result{"id"}?>">
 336 <table>
 337   <tr>
 338   <td><span class=bold>Occupation: </span></td>
 339   <td><input type=entry size=20 name=occupation value="<?echo $result{"occupation"}?>"></td>
 340   </tr>
 341   <tr>
 342   <td><span class=bold>Employer: <br>(enter Student, PT Student, or leave blank for unemployed)</span></td><td><input type=entry size=20 name=ename value="<?echo $result2{"name"}?>"></td>
 343   </tr>
 344 </table>
 345 </td>
 346 <td valign=top>
 347 <table>
 348   <tr>
 349     <td><span class=bold>Employer Address</span></td><td><span class=bold></span><input type=entry size=25 name=estreet value="<?echo $result2{"street"}?>"></td>
 350   </tr>
 351   <tr>
 352     <td><span class=bold>City: </span></td><td><input type=entry size=15 name=ecity value="<?echo $result2{"city"}?>"></td>
 353   </tr>
 354   <tr>
 355     <td><span class=bold>State: </span></td><td><input type=entry size=15 name=estate value="<?echo $result2{"state"}?>"></td>
 356   </tr>
 357   <tr>
 358     <td><span class=bold>Zip Code: </span></td><td><input type=entry size=10 name=epostal_code value="<?echo $result2{"postal_code"}?>"></td>
 359   </tr>
 360   <tr>
 361     <td><span class=bold>Country: </span></td><td><input type=entry size=10 name=ecountry value="<?echo $result2{"country"}?>"></td>
 362   </tr>
 363 </table>
 364 </td>
 365 <td valign=top></td>
 366 </tr>
 367
 368 <tr>
 369 <td colspan=4>
 370 <a href="javascript:document.demographics_form.submit();" target=Main class=link_submit>[Save Patient Demographics]</a><hr></td>
 371 </tr>
 372
 373
 374 <tr>
 375 <td valign=top>
 376 <span class=bold>Language: </span><br>
 377 <select onchange="javascript:document.demographics_form.language.value=upperFirst(this.options[this.selectedIndex].value,this.options[this.selectedIndex].value);">
 378 <?php
 379 foreach ($langi as $s) {
 380                 if ($s == "unassigned") {
 381                 echo "<option value=''";
 382                 } else {
 383                 echo "<option value='".$s."'";
 384         }
 385         if ($s == strtolower($result["language"]))
 386                 echo " selected";
 387         echo ">".ucwords($s)."</option>\n";
 388 }
 389 ?>
 390 </select><br>
 391 <input type=entry size=30 name=language value="<?echo ucfirst($result{"language"});?>"><br><br />
 392
 393
 394 <span class=bold>Race/Ethnicity: </span><br>
 395 <select onchange="javascript:document.demographics_form.ethnoracial.value=upperFirst(this.options[this.selectedIndex].value,this.options[this.selectedIndex].value);">
 396 <?php
 397 foreach ($ethnoraciali as $s) {
 398                 if ($s == "unassigned") {
 399                 echo "<option value=''";
 400                 } else {
 401                 echo "<option value='".$s."'";
 402         }
 403         if ($s == strtolower($result["ethnoracial"]))
 404                 echo " selected";
 405         echo ">".ucwords($s)."</option>\n";
 406 }
 407 ?>
 408 </select>
 409 <br>
 410 <input type=entry size=30 name=ethnoracial value="<?echo ucfirst($result{"ethnoracial"});?>"><br>
 411
 412 </td>
 413 <td valign=top>
 414 <table>
 415   <tr>
 416     <td><span class=bold>Financial Review Date: </span></td><td><input type=entry size=11 name=financial_review value="<?if ($result{"financial_review"} != "0000-00-00 00:00:00") {echo date("m/d/Y",strtotime($result{"financial_review"}));} else {echo "MM/DD/YYYY";}?>"></td>
 417   </tr>
 418   <tr>
 419     <td><span class=bold>Family Size: </span></td><td><input type=entry size=20 name=family_size value="<?echo $result{"family_size"}?>"></td>
 420   </tr>
 421   <tr>
 422     <td><span class=bold>Monthly Income: </span></td><td><input type=entry size=20 name=monthly_income onblur="javascript:checkNum();" value="<?echo $result{"monthly_income"}?>"><span class=small>(Numbers only)</span></td>
 423   </tr>
 424   <tr>
 425     <td><span class=bold>Homeless, etc.: </span></td><td><input type=entry size=20 name=homeless value="<?echo $result{"homeless"}?>"></td>
 426   </tr>
 427   <tr>
 428     <td><span class=bold>Interpretter: </span></td><td><input type=entry size=20 name=interpretter value="<?echo $result{"interpretter"}?>"></td>
 429   </tr>
 430   <tr>
 431     <td><span class=bold>Migrant/Seasonal: </span></td><td><input type=entry size=20 name=migrantseasonal value="<?echo $result{"migrantseasonal"}?>"></td>
 432   </tr>
 433 </table>
 434
 435
 436
 437
 438
 439
 440
 441 </td>
 442 <td valign=top></td>
 443 </tr>
 444
 445 <tr>
 446 <td colspan=4>
 447 <a href="javascript:document.demographics_form.submit();" target=Main class=link_submit>[Save Patient Demographics]</a>
 448 <hr></td>
 449 </tr>
 450
 451 <?
 452 $insurance_headings = array("Primary Insurance Provider:", "Secondary Insurance Provider", "Tertiary Insurance provider");
 453 $insurance_info = array();
 454 $insurance_info[1] = getInsuranceData($pid,"primary");
 455 $insurance_info[2] = getInsuranceData($pid,"secondary");
 456 $insurance_info[3] = getInsuranceData($pid,"tertiary");
 457 for($i=1;$i<=3;$i++) {
 458         $result3 = $insurance_info[$i];
 459         ?>
 460 <table border="0">
 461 <tr>
 462 <td valign=top>
 463 <table border="0">
 464 <tr>
 465 <td colspan="5"><span class=required><?=$insurance_headings[$i -1]?></span></td>
 466 <tr></tr>
 467 <td colspan="5"><select name="i<?=$i?>provider">
 468 <option value="">Unassigned</option>
 469 <?php
 470
 471 foreach ($insurancei as $iid => $iname) {
 472                 echo "<option value='".$iid."'";
 473         if (strtolower($iid) == strtolower($result3{"provider"}))
 474                 echo " selected";
 475         echo ">".$iname."</option>\n";
 476 }
 477 ?>
 478 </select>&nbsp;<a href="<? echo  $GLOBALS['webroot'] ?>/controller.php?practice_settings&insurance_company&action=edit">Add New Insurer</a>
 479 </td>
 480 </tr>
 481 <tr>
 482         <td><span class=required>Plan Name: </span></td><td><input type=entry size=20 name=i<?=$i?>plan_name value="<?echo $result3{"plan_name"}?>"></td>
 483 </tr>
 484 <tr>
 485         <td><span class=required>Policy Number: </span></td><td><input type=entry size=16 name=i<?=$i?>policy_number value="<?echo $result3{"policy_number"}?>"></td>
 486 </tr>
 487 <tr>
 488         <td><span class=required>Group Number: </span></td><td><input type=entry size=16 name=i<?=$i?>group_number value="<?echo $result3{"group_number"}?>"></td>
 489 </tr>
 490 <tr>
 491         <td><span class=required>Subscriber Employer (SE) <br>(enter Student, PT Student, or leave blank for unemployed): </span></td><td><input type=entry size=25 name=i<?=$i?>subscriber_employer value="<?echo $result3{"subscriber_employer"}?>"></td>
 492 </tr>
 493 <tr>
 494         <td><span class=required>SE Address: </span></td><td><input type=entry size=25 name=i<?=$i?>subscriber_employer_street value="<?echo $result3{"subscriber_employer_street"}?>"></td>
 495 </tr>
 496 <tr>
 497         <td colspan="2">
 498         <table>
 499           <tr>
 500             <td><span class=required>SE City: </span></td>
 501                 <td><input type=entry size=15 name=i<?=$i?>subscriber_employer_city value="<?echo $result3{"subscriber_employer_city"}?>"></td>
 502             <td><span class=required>SE State: </span></td>
 503                 <td><input type=entry size=15 name=i<?=$i?>subscriber_employer_state value="<?echo $result3{"subscriber_employer_state"}?>"></td>
 504           </tr>
 505           <tr>
 506             <td><span class=required>SE Zip Code: </span></td>
 507                 <td><input type=entry size=10 name=i<?=$i?>subscriber_employer_postal_code value="<?echo $result3{"subscriber_employer_postal_code"}?>"></td>
 508             <td><span class=required>SE Country: </span></td>
 509                 <td><input type=entry size=25 name=i<?=$i?>subscriber_employer_country value="<?echo $result3{"subscriber_employer_country"}?>"></td>
 510           </tr>
 511         </table>
 512         </td>
 513 </tr>
 514 </table>
 515 </td>
 516
 517 <td valign=top>
 518 <span class=required>Subscriber: </span><input type=entry size=10 name=i<?=$i?>subscriber_fname value="<?echo $result3{"subscriber_fname"}?>"><input type=entry size=3 name=i<?=$i?>subscriber_mname value="<?echo $result3{"subscriber_mname"}?>"><input type=entry size=10 name=i<?=$i?>subscriber_lname value="<?echo $result3{"subscriber_lname"}?>">
 519
 520 <br>
 521
 522 <span class=required>Relationship: </span>
 523 <select name=i<?=$i?>subscriber_relationship onchange="javascript:auto_populate_employer_address<?=$i?>();">
 524
 525 <?php
 526 foreach ($relats as $s) {
 527                 if ($s == "unassigned") {
 528                         echo "<option value=''";
 529                 } else {
 530                 echo "<option value='".$s."'";
 531             }
 532         if ($s == $result3{"subscriber_relationship"})
 533                 echo " selected";
 534         echo ">".ucfirst($s)."</option>\n";
 535 }
 536 ?>
 537
 538 </select>
 539 <a href="javascript:popUp('browse.php?browsenum=<?=$i?>')" class=text>(Browse)</a><br />
 540 <span class=bold>D.O.B.: </span><input type=entry size=11 name=i<?=$i?>subscriber_DOB value="
 541 <?
 542         if (!empty($result3['subscriber_DOB'])) {
 543           echo $result3['subscriber_DOB'];
 544         }
 545         else {
 546           echo "MM/DD/YYYY";
 547         }
 548 ?>">
 549 <span class=bold>S.S.: </span><input type=entry size=11 name=i<?=$i?>subscriber_ss value="<?echo $result3{"subscriber_ss"}?> ">&nbsp;
 550 <span class=bold>Sex: </span>
 551 <select name=i<?=$i?>subscriber_sex>
 552 <option value="Male" <? if (strtolower($result3{"subscriber_sex"}) == "male") echo "selected"?>>Male</option>
 553 <option value="Female" <? if (strtolower($result3{"subscriber_sex"}) == "female") echo "selected"?>>Female</option>
 554 </select>
 555 <br>
 556 <span class=required>Subscriber Address: </span><input type=entry size=25 name=i<?=$i?>subscriber_street value="<?echo $result3{"subscriber_street"}?>"><br>
 557 <span class=required>City: </span><input type=entry size=15 name=i<?=$i?>subscriber_city value="<?echo $result3{"subscriber_city"}?>">
 558 <span class=required>State: </span><input type=entry size=15 name=i<?=$i?>subscriber_state value="<?echo $result3{"subscriber_state"}?>"><br>
 559 <span class=required>Zip Code: </span><input type=entry size=10 name=i<?=$i?>subscriber_postal_code value="<?echo $result3{"subscriber_postal_code"}?>">
 560 <span class=required>Country: </span><input type=entry size=10 name=i<?=$i?>subscriber_country value="<?echo $result3{"subscriber_country"}?>"><br>
 561
 562
 563 <span class=bold>Subscriber Phone: <input type=hidden name=i<?=$i?>subscriber_phone value="<?echo $result3{"subscriber_phone"}?>">
 564
 565 <?
 566 //extract formatting of phone number:
 567 $pmatch=array();
 568 preg_match("/^\((.*?)\)\s(.*?)\-(.*?)$/",$result3{"subscriber_phone"},$pmatch);
 569 ?>
 570 (<input type=entry size=3 name=i<?=$i?>subscriber_phone_area onblur="javascript:update_i<?=$i?>subscriber_phone();" value="<?echo $pmatch[1]?>">) <input type=entry size=3 name=i<?=$i?>subscriber_phone_first onblur="javascript:update_i<?=$i?>subscriber_phone();" value="<?echo $pmatch[2]?>">-<input type=entry size=4 name=i<?=$i?>subscriber_phone_last onblur="javascript:update_i<?=$i?>subscriber_phone();" value="<?echo $pmatch[3]?>">
 571 </span><br />
 572 <span class=bold>CoPay: <input type=text size="6" name=i<?=$i?>copay value="<?echo $result3{"copay"}?>">
 573 </td>
 574
 575 </tr>
 576 </table>
 577 <a href="javascript:document.demographics_form.submit();" target=Main class=link_submit>[Save Patient Demographics]</a
 578 <hr>
 579 </td></tr>
 580 </table>
 581 <?} //end insurer for loop ?>
 582
 583 </td></tr>
 584 </table>
 585
 586 </form>
 587
 588 <br><br>
 589
 590 </body>
 591 </html>