interface/forms/misc_billing_options/new.php

   1 <?php
   2 /*
   3  * This program creates the misc_billing_form
   4  *
   5  * @package OpenEMR
   6  * @author Terry Hill <terry@lilysystems.com>
   7  * @author Brady Miller <brady.g.miller@gmail.com>
   8  * @author Stephen Waite <stephen.waite@cmsvt.com>
   9  * @copyright Copyright (C) 2007 Bo Huynh
  10  * @copyright Copyright (C) 2016 Terry Hill <terry@lillysystems.com>
  11  * @copyright Copyright (C) 2017 Brady Miller <brady.g.miller@gmail.com>
  12  * @copyright Copyright (C) 2017 Stephen Waite <stephen.waite@cmsvt.com>
  13  * @link http://www.open-emr.org
  14  * @license https://github.com/openemr/openemr/blob/master/LICENSE GNU General Public License 3
  15  */
  16
  17 require_once("../../globals.php");
  18 require_once("$srcdir/options.inc.php");
  19 require_once("$srcdir/api.inc");
  20 require_once("date_qualifier_options.php");
  21
  22 if (! $encounter) { // comes from globals.php
  23   die(xlt("Internal error: we do not seem to be in an encounter!"));
  24 }
  25
  26 //only one misc billing form so grab if exists
  27 $formid   = 0 + formData('id', 'G');
  28 if (empty($formid)) {
  29     $mboquery = sqlquery("SELECT `fmbo`.`id` FROM `form_misc_billing_options` AS `fmbo`
  30                           INNER JOIN `forms` ON (`fmbo`.`id` = `forms`.`form_id`) WHERE
  31                           `forms`.`deleted` = 0 AND
  32                           `forms`.`encounter` = ? ORDER BY `fmbo`.`id` DESC", array($encounter));
  33     if (!empty($mboquery['id'])) {
  34         $formid = 0 + $mboquery['id'];
  35     }
  36 }
  37
  38 $obj = $formid ? formFetch("form_misc_billing_options", $formid) : array();
  39
  40 ?>
  41 <html>
  42   <head>
  43     <title><?php echo xlt('Miscellaneous Billing Options for HCFA-1500'); ?></title>
  44     <?php html_header_show(); ?>
  45     <link rel="stylesheet" href="<?php echo $css_header;?>" type="text/css">
  46     <link rel="stylesheet" href="<?php echo $GLOBALS['assets_static_relative']; ?>/jquery-datetimepicker-2-5-4/build/jquery.datetimepicker.min.css">
  47     <script type="text/javascript" src="<?php echo $GLOBALS['assets_static_relative']; ?>/jquery-min-3-1-1/index.js">
  48     </script>
  49     <script type="text/javascript" src="<?php echo $GLOBALS['webroot'] ?>/library/textformat.js?v=<?php echo $v_js_includes; ?>">
  50     </script>
  51     <script type="text/javascript" src="<?php echo $GLOBALS['assets_static_relative']; ?>/jquery-datetimepicker-2-5-4/build/jquery.datetimepicker.full.min.js">
  52     </script>
  53     <script language="javascript">
  54       // jQuery stuff to make the page a little easier to use
  55       $(document).ready(function(){
  56         $(".save").click(function() { top.restoreSession(); document.my_form.submit(); });
  57         $(".dontsave").click(function() { location.href='<?php echo "$rootdir/patient_file/encounter/encounter_top.php";?>'; });
  58         $('.datepicker').datetimepicker({
  59           <?php $datetimepicker_timepicker = false; ?>
  60           <?php $datetimepicker_showseconds = false; ?>
  61           <?php $datetimepicker_formatInput = false; ?>
  62           <?php require($GLOBALS['srcdir'] . '/js/xl/jquery-datetimepicker-2-5-4.js.php'); ?>
  63           <?php // can add any additional javascript settings to datetimepicker here;
  64                 // need to prepend first setting with a comma ?>
  65         });
  66       });
  67     </script>
  68   </head>
  69   <body class="body_top">
  70     <form method="post" <?php echo "name='my_form' " . "action='$rootdir/forms/misc_billing_options/save.php?id=" . attr($formid) . "'>\n";?>
  71       <h4><?php echo xlt('Miscellaneous Billing Options for HCFA-1500'); ?></h4>
  72       <label for="box10a"><?php echo xlt('Box 10. a. Employment related:'); ?></label>
  73       <input type="checkbox" name="employment_related" id="box10a" value="1" <?php if ($obj['employment_related'] == "1") echo "checked"; ?> ><br><br>
  74       <label for="box10b"><?php echo xlt('Box 10. b. Auto Accident:'); ?></label>
  75       <input type="checkbox" name="auto_accident" id="box10b" value="1" <?php if ($obj['auto_accident'] == "1") echo "checked"; ?> >
  76       <label for="box10bstate"><?php echo xlt('State:'); ?></label>
  77       <input type="entry" name="accident_state" id="box10bstate" size="1" value="<?php echo attr($obj{"accident_state"}); ?>" /><br><br>
  78       <label for="box10c"><?php echo xlt('Box 10. c. Other Accident:'); ?></label>
  79       <input type="checkbox" name="other_accident" id="box10c" value="1" <?php if ($obj['other_accident'] == "1") echo "checked" ; ?> ><br><br>
  80       <label for="box10d"><?php echo xlt('Box 10. d. EPSDT Referral Code:'); ?></label>
  81       <input type="entry" size="2" name="medicaid_referral_code" id="box10d" value="<?php echo attr($obj{"medicaid_referral_code"}); ?>" >
  82       <label for="box10depsdt"><?php echo xlt('EPSDT:'); ?></label>
  83       <input type="checkbox" name="epsdt_flag" id="box10depsdt" value="1" <?php if ($obj['epsdt_flag'] == "1") echo "checked"; ?> ><br><br>
  84       <label for="onset_date"><?php echo xlt('Box 14. Onset Date:'); $onset_date = $obj{"onset_date"}; ?></label>
  85       <input type="text" size="10" class='datepicker' name='onset_date' id='onset_date' value='<?php echo attr($onset_date); ?>' title='<?php echo xla('yyyy-mm-dd'); ?>' >
  86       <label for="box_14_date_qual_box"><?php echo generateDateQualifierSelect("box_14_date_qual",$box_14_qualifier_options,$obj); ?><br><br>
  87       <label for="date_initial_treament"><?php echo xlt('Box 15. Other Date:'); $date_initial_treatment = $obj{"date_initial_treatment"}; ?></label>
  88       <input type="text" size="10" class='datepicker' name='date_initial_treatment' id='date_initial_treatment' value='<?php echo attr($date_initial_treatment); ?>' title='<?php echo xla('yyyy-mm-dd'); ?>' >
  89       <label for="box_15_date_qual"><?php generateDateQualifierSelect("box_15_date_qual",$box_15_qualifier_options,$obj); ?><br><br>
  90       <label for="off_work_from"><?php echo xlt('Box 16. Date unable to work from:'); $off_work_from = $obj{"off_work_from"}; ?></label>
  91       <input type="text" size="10" class='datepicker' name='off_work_from' id='off_work_from' value='<?php echo attr($off_work_from); ?>' title='<?php echo xla('yyyy-mm-dd'); ?>' >
  92       <label for="off_work_to"><?php echo xlt('Box 16. Date unable to work to:'); $off_work_to = $obj{"off_work_to"}; ?></label>
  93       <input type="text" size="10" class='datepicker' name='off_work_to' id='off_work_to' value='<?php echo attr($off_work_to); ?>' title='<?php echo xla('yyyy-mm-dd'); ?>' ><br><br>
  94       <label for="provider_id"><?php echo xlt('Box 17. Provider:'); ?></label>
  95       <?php  genProviderSelect('provider_id', '-- ' . xl("Please Select") . ' --', $obj{"provider_id"}); ?>
  96       <label for="provider_qualifier_code"><?php echo xlt('Box 17. Provider Qualifier:'); ?></label>
  97       <?php  echo generate_select_list('provider_qualifier_code', 'provider_qualifier_code', $obj{"provider_qualifier_code"}, 'Provider Qualifier Code'); ?><br><br>
  98       <label for="hospitalization_date_from"><?php echo xlt('Box 18. Hospitalization date from:'); $hospitalization_date_from = $obj{"hospitalization_date_from"}; ?></label>
  99       <input type="text" size="10" class='datepicker' name='hospitalization_date_from' id='hospitalization_date_from' value='<?php echo attr($hospitalization_date_from); ?>' title='<?php echo xla('yyyy-mm-dd'); ?>' >
 100       <label for="hospitalization_date_to"><?php echo xlt('Box 18. Hospitalization date to:'); $hospitalization_date_to = $obj{"hospitalization_date_to"}; ?></label>
 101       <input type="text" size="10" class='datepicker' name='hospitalization_date_to' id='hospitalization_date_to' value='<?php echo attr($hospitalization_date_to); ?>' title='<?php echo xla('yyyy-mm-dd'); ?>' ><br><br>
 102       <label for="outside_lab"><?php echo xlt('Box 20. Is Outside Lab used?'); ?></label>
 103       <input type="checkbox" name="outside_lab" id="outside_labe" value="1" <?php if ($obj['outside_lab'] == "1") echo "checked";?> >
 104       <label for="lab_amount"><?php echo xlt('Amount Charges:'); ?></label>
 105       <input type="entry" size="7" align='right' name="lab_amount" id="lab_amount" value="<?php echo attr($obj{"lab_amount"});?>" ><br><br>
 106       <label for="medicaid_resubmission_code"><?php echo xlt('Box 22. Medicaid Resubmission Code (ICD-9) ');?></label>
 107       <input type="entry" size="9" name="medicaid_resubmission_code" id="medicaid_resubmission_code" value="<?php echo attr($obj{"medicaid_resubmission_code"}); ?>" >
 108       <label for="medicaid_original_reference"><?php echo xlt(' Medicaid Original Reference No. '); ?></label>
 109       <input type="entry" size="15" name="medicaid_original_reference" id="medicaid_original_reference" value="<?php echo attr($obj{"medicaid_original_reference"}); ?>" ><br><br>
 110       <label for="prior_auth_number"><?php echo xlt('Box 23. Prior Authorization No. ');?></label>
 111       <input type="entry" size="15" name="prior_auth_number" id="prior_auth_number" value="<?php echo attr($obj{"prior_auth_number"}); ?>" ><br><br>
 112       <label for="replacement_claim"><?php echo xlt('X12 only replacement claim:'); ?></label>
 113       <input type="checkbox" name="replacement_claim" id="replacement_claim" value="1" <?php if ($obj['replacement_claim'] == "1") echo "checked"; ?> ><br><br>
 114       <label for="icn_resubmission_number"><?php echo xlt('X12 only ICN resubmission No.'); ?></label>
 115       <input type="entry" size="35" name="icn_resubmission_number" id="icn_resubmission_number" value="<?php echo attr($obj{"icn_resubmission_number"}); ?>" ><br><br>
 116       <label for="addl_notes"><?php echo xlt('Additional Notes:'); ?>
 117       <textarea cols="40" rows="8" wrap="virtual" name="comments" id="addl_notes"><?php echo text($obj{"comments"}); ?></textarea ><br><br>
 118       <div>
 119       <!-- Save/Cancel buttons -->
 120       <input type="button" class="save" value="<?php echo xla('Save'); ?>" >
 121       <input type="button" class="dontsave" value="<?php echo xla('Don\'t Save Changes'); ?>" >
 122       </div>
 123     </form>
 124   </body>
 125 </html>