templates/insurance_numbers/general_edit.html

   1 {if $ERROR}
   2  {$ERROR}
   3 {else}
   4 <form name="provider" method="post" action="{$FORM_ACTION}">
   5 <!-- it is important that the hidden form_id field be listed first, when it is called it populates any old information attached with the id, this allows for partial edits
   6                 if it were called last, the settings from the form would be overwritten with the old information-->
   7 <input type="hidden" name="form_id" value="{$ins->id}" />
   8
   9 <table class="showborder" CELLSPACING="0" CELLPADDING="3">
  10
  11 <tr><td colspan="5" style="border-style:none;" class="bold">
  12    {$provider->get_name_display()}
  13 </td></tr>
  14
  15 <tr  class="showborder_head">
  16     <th class="small">{xl t='Provider'} Number</th>
  17     <th class="small">{xl t='Rendering Provider'} #</th>
  18     <th class="small">{xl t='Group'} #</th>
  19 </tr>
  20 {foreach name=inums item=num_set from=$provider->get_insurance_numbers()}
  21 <tr>
  22     <td valign="middle">
  23         <a href="{$CURRENT_ACTION}action=edit&id={$num_set->get_id()}&showform=true" onclick="top.restoreSession()">{$num_set->get_insurance_company_name()}&nbsp;</a>
  24     </td>
  25     <td>{$num_set->get_provider_number()}&nbsp;</td>
  26     <td>{$num_set->get_rendering_provider_number()}&nbsp;</td>
  27     <td>{$num_set->get_group_number()}&nbsp;</td>
  28 </tr>
  29 {foreachelse}
  30 <tr>
  31    <td colspan="5">{xl t='No entries found, use the form below to add an entry.'}</td>
  32 </tr>
  33 {/foreach}
  34
  35 <tr> <td style="border-style:none;" colspan="5">
  36     <a href="{$CURRENT_ACTION}action=edit&id=&provider_id={$provider->get_id()}&showform=true"
  37        class="css_button_small" style='margin-top:2px'
  38        onclick="top.restoreSession()">
  39             <span>{xl t='Add New'}</span>
  40     </a>
  41 </td> </tr>
  42
  43 {php} if ( $_GET['showform'] == 'true' ) { {/php}
  44 <tr> <td style="border-style:none;" colspan="5">
  45 <br>
  46 <b><span>{if $ins->get_id() eq ""}{xl t='Add Provider Number'}{else}{xl t='Update Provider Number'}{/if}</span></b><br>
  47         <table width="100%"><tr>
  48         <td style="border-style:none;" width="200px" VALIGN="MIDDLE" >{xl t='Insurance Company'}</td>
  49         <td style="border-style:none;" VALIGN="MIDDLE" >
  50                 {if $ins->get_id() eq ""}
  51                         {html_options name="insurance_company_id" options=$ic_array values=$ic_array selected=$ins->get_insurance_company_id()}
  52                 {else}
  53                  {$ins->get_insurance_company_name()}
  54                 {/if}
  55         </td>
  56 </tr>
  57 <tr>
  58         <td style="border-style:none;" VALIGN="MIDDLE" >{xl t='Provider Number'}</td>
  59         <td style="border-style:none;" VALIGN="MIDDLE" >
  60            <input type="text" size="20" name="provider_number" value="{$ins->get_provider_number()}"/>
  61         </td>
  62 </tr>
  63 <tr>
  64         <td style="border-style:none;" VALIGN="MIDDLE" >Provider Number({xl t='Type'})</td>
  65         <td style="border-style:none;" VALIGN="MIDDLE" >
  66            {html_options name="provider_number_type" options=$ic_type_options_array values=$ins->provider_number_type_array selected=$ins->get_provider_number_type()}
  67         </td>
  68 </tr>
  69 <tr>
  70         <td style="border-style:none;" VALIGN="MIDDLE" >{xl t='Rendering Provider Number'}</td>
  71         <td style="border-style:none;" VALIGN="MIDDLE" >
  72                 <input type="text" size="20" name="rendering_provider_number" value="{$ins->get_rendering_provider_number()}"/>
  73                 </td>
  74 </tr>
  75 <tr>
  76         <td style="border-style:none;" VALIGN="MIDDLE" >{xl t='Rendering Provider Number'} ({xl t='Type'})</td>
  77         <td style="border-style:none;" VALIGN="MIDDLE" >
  78             {html_options name="rendering_provider_number_type" options=$ic_rendering_type_options_array values=$ins->rendering_provider_number_type_array selected=$ins->get_rendering_provider_number_type()}
  79         </td>
  80 </tr>
  81 <tr>
  82         <td style="border-style:none;" VALIGN="MIDDLE" >{xl t='Group Number'}</td>
  83         <td style="border-style:none;" VALIGN="MIDDLE" >
  84                 <input type="text" size="20" name="group_number" value="{$ins->get_group_number()}"/>
  85         </td>
  86 </tr>
  87 <tr><td style="border-style:none;"></td></tr>
  88 <tr>
  89         <td style="border-style:none;" colspan="2">
  90                 {if $ins->get_id() eq ""}
  91                         <a href="javascript:submit_insurancenumbers_add();" class="css_button"><span>{xl t='Save'}</span></a>
  92                 {else}
  93                         <a href="javascript:submit_insurancenumbers_update();" class="css_button"><span>{xl t='Save'}</span></a>
  94                 {/if}
  95
  96                 <a href="controller.php?practice_settings&insurance_numbers&action=list"  {php} if (!$GLOBALS['concurrent_layout']) echo "target='Main'"; {/php} class="css_button" onclick="top.restoreSession()">
  97 <span>{xl t='Cancel'}</span></a>
  98 </td> </tr>
  99 {php} } else { {/php}
 100 <input type="hidden" name="provider_number" value="{$ins->get_provider_number()}" />
 101 <input type="hidden" name="provider_number_type" value="{$ins->get_provider_number_type()}" />
 102 <input type="hidden" name="rendering_provider_number" value="{$ins->get_rendering_provider_number()}" />
 103 <input type="hidden" name="rendering_provider_number_type" value="{$ins->get_rendering_provider_number_type()}" />
 104 <input type="hidden" name="group_number" value="{$ins->get_group_number()}" />
 105
 106 {php} } {/php}
 107
 108     </table>
 109 </td></tr>
 110 </table>
 111 <input type="hidden" name="id" value="{$ins->id}" />
 112 <input type="hidden" name="provider_id" value="{$ins->get_provider_id()}" />
 113 <input type="hidden" name="process" value="{$PROCESS}" />
 114 </form>
 115 {/if}
 116 {literal}
 117 <script language="javascript">
 118 function submit_insurancenumbers_update() {
 119     top.restoreSession();
 120     document.provider.submit();
 121 }
 122 function submit_insurancenumbers_add() {
 123     top.restoreSession();
 124     document.provider.submit();
 125     Waittoredirect(500);
 126     document.location.href="{/literal}{$WEB_ROOT}{literal}/controller.php?practice_settings&insurance_numbers&action=list";
 127 }
 128
 129 function Waittoredirect(delaymsec) {
 130  var st = new Date();
 131  var et = null;
 132  do {
 133  et = new Date();
 134  } while ((et - st) < delaymsec);
 135
 136  }
 137 </script>
 138 <style type="text/css">
 139 text,select {font-size:9pt;}
 140 </style>
 141 {/literal}