templates/x12_partners/general_edit.html

   1 {**
   2  * Pharmacy edit
   3  *
   4  * @package   OpenEMR
   5  * @link      http://www.open-emr.org
   6  * @author    Brady Miller <brady.g.miller@gmail.com>
   7  * @copyright Copyright (c) 2017 Brady Miller <brady.g.miller@gmail.com>
   8  * @license   https://github.com/openemr/openemr/blob/master/LICENSE GNU General Public License 3
   9  *}
  10 <form name="x12_partner" method="post" action="{$FORM_ACTION}" class='form-horizontal' onsubmit="return top.restoreSession()">
  11     <div class="form-group">
  12         <label for="name" class="control-label col-sm-2">{xl t='Partner Name'|escape:'html'}</label>
  13         <div class="col-sm-8">
  14             <input type="text" id="name" name="name" class="form-control" value="{$partner->get_name()|escape:'html'}" onKeyDown="PreventIt(event)">
  15         </div>
  16     </div>
  17     <div class="form-group">
  18         <label for="id_number" class="control-label col-sm-2">{xl t='ID Number (ETIN)'|escape:'html'}</label>
  19         <div class="col-sm-8">
  20             <input type="text" id="id_number" name="id_number" class="form-control" value="{$partner->get_id_number()|escape:'html'}" onKeyDown="PreventIt(event)">
  21         </div>
  22     </div>
  23     <div class="form-group">
  24         <label for="x12_isa01" class="control-label col-sm-2">{xl t='User logon Required Indicator (ISA01~ use 00 or 03)'|escape:'html'}</label>
  25         <div class="col-sm-8">
  26             <input type="text" id="x12_isa01" name="x12_isa01" class="form-control" value="{$partner->get_x12_isa01()|escape:'html'}" onKeyDown="PreventIt(event)">
  27         </div>
  28     </div>
  29     <div class="form-group">
  30         <label for="x12_isa02" class="control-label col-sm-2">{xl t='User Logon (If 03 above, else leave spaces) (ISA02)'|escape:'html'}</label>
  31         <div class="col-sm-8">
  32             <input type="text" id="x12_isa02" name="x12_isa02" class="form-control" value="{$partner->get_x12_isa02()|escape:'html'}" onKeyDown="PreventIt(event)">
  33         </div>
  34     </div>
  35     <div class="form-group">
  36         <label for="x12_isa03" class="control-label col-sm-2">{xl t='User password required Indicator (ISA03~ use 00 or 01)'|escape:'html'}</label>
  37         <div class="col-sm-8">
  38             <input type="text" id="x12_isa03" name="x12_isa03" class="form-control" value="{$partner->get_x12_isa03()|escape:'html'}" onKeyDown="PreventIt(event)">
  39         </div>
  40     </div>
  41     <div class="form-group">
  42         <label for="x12_isa04" class="control-label col-sm-2">{xl t='User Password (ISA04~ if 01 above, else leave spaces)'|escape:'html'}</label>
  43         <div class="col-sm-8">
  44             <input type="text" id="x12_isa04" name="x12_isa04" class="form-control" value="{$partner->get_x12_isa04()|escape:'html'}" onKeyDown="PreventIt(event)">
  45         </div>
  46     </div>
  47     <div class="form-group">
  48         <label for="x12_isa05" class="control-label col-sm-2">{xl t='Sender ID Qualifier (ISA05)'|escape:'html'}</label>
  49         <div class="col-sm-8">
  50             <select id="x12_isa05" name="x12_isa05" class="form-control">
  51                 {html_options options=$partner->get_idqual_array() selected=$partner->get_x12_isa05()}
  52             </select>
  53         </div>
  54     </div>
  55     <div class="form-group">
  56         <label for="x12_sender_id" class="control-label col-sm-2">{xl t='Sender ID (ISA06)'|escape:'html'}</label>
  57         <div class="col-sm-8">
  58             <input type="text" id="x12_sender_id" name="x12_sender_id" class="form-control"  value="{$partner->get_x12_sender_id()|escape:'html'}" onKeyDown="PreventIt(event)">
  59         </div>
  60     </div>
  61     <div class="form-group">
  62         <label for="x12_isa07" class="control-label col-sm-2">{xl t='Receiver ID Qualifier (ISA07)'|escape:'html'}</label>
  63         <div class="col-sm-8">
  64             <select id="x12_isa07" name="x12_isa07" class="form-control">
  65                 {html_options options=$partner->get_idqual_array() selected=$partner->get_x12_isa07()}
  66             </select>
  67         </div>
  68     </div>
  69     <div class="form-group">
  70         <label for="x12_receiver_id" class="control-label col-sm-2">{xl t='Receiver ID (ISA08)'|escape:'html'}</label>
  71         <div class="col-sm-8">
  72             <input type="text" id="x12_receiver_id" name="x12_receiver_id" class="form-control" value="{$partner->get_x12_receiver_id()}" onKeyDown="PreventIt(event)">
  73         </div>
  74     </div>
  75     <div class="form-group">
  76         <label for="x12_isa14" class="control-label col-sm-2">{xl t='Acknowledgment Requested (ISA14)'|escape:'html'}</label>
  77         <div class="col-sm-8">
  78             <select id="x12_isa14" name="x12_isa14" class="form-control">
  79                 {html_options options=$partner->get_x12_isa14_array() selected=$partner->get_x12_isa14()}
  80             </select>
  81         </div>
  82     </div>
  83     <div class="form-group">
  84         <label for="x12_isa15" class="control-label col-sm-2">{xl t='Usage Indicator (ISA15)'|escape:'html'}</label>
  85         <div class="col-sm-8">
  86             <select id="x12_isa15" name="x12_isa15" class="form-control">
  87                 {html_options options=$partner->get_x12_isa15_array() selected=$partner->get_x12_isa15()}
  88             </select>
  89         </div>
  90     </div>
  91     <div class="form-group">
  92         <label for="x12_gs02" class="control-label col-sm-2">{xl t='Application Sender Code (GS02)'|escape:'html'}</label>
  93         <div class="col-sm-8">
  94             <input type="text" id="x12_gs02" name="x12_gs02" class="form-control" value="{$partner->get_x12_gs02()|escape:'html'}" onKeyDown="PreventIt(event)">
  95         </div>
  96     </div>
  97     <div class="form-group">
  98         <label for="12_per06" class="control-label col-sm-2">{xl t='Submitter EDI Access Number (PER06)'|escape:'html'}</label>
  99         <div class="col-sm-8">
 100             <input type="text" id="12_per06" name="x12_per06" class="form-control" value="{$partner->get_x12_per06()|escape:'html'}" onKeyDown="PreventIt(event)">
 101         </div>
 102     </div>
 103     <div class="form-group">
 104         <label for="x12_version" class="control-label col-sm-2">{xl t='Version'|escape:'html'}</label>
 105         <div class="col-sm-8">
 106             <select id="x12_version" name="x12_version" class="form-control">
 107                 {html_options options=$partner->get_x12_version_array() selected=$partner->get_x12_version()}
 108             </select>
 109         </div>
 110     </div>
 111     <div class="form-group">
 112         <label for="processing_format" class="control-label col-sm-2">{xl t='Processing format'|escape:'html'}</label>
 113         <div class="col-sm-8">
 114             <select id="x12_isa07" id="processing_format" name="processing_format" class="form-control">
 115                 {html_options options=$partner->get_processing_format_array() selected=$partner->get_processing_format()}
 116             </select>
 117         </div>
 118     </div>
 119     <div class="form-group">
 120         <label for="x12_gs03" class="control-label col-sm-2">{xl t='Application Receiver Code (GS03 - If blank ISA08 will be used)'|escape:'html'}</label>
 121         <div class="col-sm-8">
 122             <input type="text" maxlength="15" id="x12_gs03" name="x12_gs03" class="form-control" value="{$partner->get_x12_gs03()|escape:'html'}" onKeyDown="PreventIt(event)">
 123         </div>
 124     </div>
 125     <div class="btn-group col-sm-offset-2">
 126         <a href="javascript:add_x12();" class="btn btn-default btn-save" onclick="top.restoreSession()">
 127             {xl t='Save'|escape:'html'}
 128         </a>
 129         <a href="controller.php?practice_settings&x12_partner&action=list"  class="btn btn-link btn-cancel" onclick="top.restoreSession()">
 130             {xl t='Cancel'|escape:'html'}
 131         </a>
 132     </div>
 133     <input type="hidden" name="id" value="{$partner->id|escape:'html'}" />
 134     <input type="hidden" name="process" value="{$PROCESS|escape:'html'}" />
 135     <input type="hidden" name="sub" value="no" />
 136 </form>
 137
 138 {literal}
 139 <script language="javascript">
 140 function add_x12()
 141 {
 142 if (document.x12_partner.name.value.length>0)
 143 {
 144 top.restoreSession();
 145 document.x12_partner.submit();
 146 }
 147 else
 148 {
 149 document.x12_partner.name.style.backgroundColor="red";
 150 document.x12_partner.name.focus();
 151 }
 152 }
 153
 154  function Waittoredirect(delaymsec) {
 155  var st = new Date();
 156  var et = null;
 157  do {
 158  et = new Date();
 159  } while ((et - st) < delaymsec);
 160
 161    }
 162 </script>
 163 {/literal}