Fixed hardcoded webroot.
[openemr.git] / templates / x12_partners / general_edit.html
blob4e01859e9e94f900025207dc29c871c6a4ef9480
1 <form name="x12_partner" method="post" action="{$FORM_ACTION}" onsubmit="return top.restoreSession()">
2 <table CELLSPACING="0" CELLPADDING="3" border="0">
3 <tr>
4 <td colspan="2">{xl t='X12 Partner'}</td>
5 </tr>
6 <tr>
7 <td COLSPAN="1" ALIGN="LEFT" VALIGN="MIDDLE" >{xl t='Partner'}&nbsp;{xl t='Name'}</td>
8 <td COLSPAN="2" ALIGN="LEFT" VALIGN="MIDDLE" ><input type="text" size="20" name="name" value="{$partner->get_name()}"/></td>
9 </tr>
10 <tr>
11 <td COLSPAN="1" ALIGN="LEFT" VALIGN="MIDDLE" >{xl t='ID'}&nbsp;{xl t='Number'}&nbsp;({xl t='ETIN'})</td>
12 <td COLSPAN="2" ALIGN="LEFT" VALIGN="MIDDLE" ><input type="text" size="20" name="id_number" value="{$partner->get_id_number()}"/></td>
13 </tr>
14 <tr>
15 <td COLSPAN="1" ALIGN="LEFT" VALIGN="MIDDLE" >{xl t='Receiver'}&nbsp;{xl t='ID'}</td>
16 <td COLSPAN="2" ALIGN="LEFT" VALIGN="MIDDLE" ><input type="text" size="20" name="x12_receiver_id" value="{$partner->get_x12_receiver_id()}"/></td>
17 </tr>
18 <tr>
19 <td COLSPAN="1" ALIGN="LEFT" VALIGN="MIDDLE" >{xl t='Sender'}&nbsp;{xl t='ID'}</td>
20 <td COLSPAN="2" ALIGN="LEFT" VALIGN="MIDDLE" ><input type="text" size="20" name="x12_sender_id" value="{$partner->get_x12_sender_id()}"/></td>
21 </tr>
22 <tr>
23 <td COLSPAN="1" ALIGN="LEFT" VALIGN="MIDDLE" >{xl t='Version'}</td>
24 <td COLSPAN="2" ALIGN="LEFT" VALIGN="MIDDLE" ><input type="text" size="20" name="x12_version" value="{$partner->get_x12_version()}"/></td>
25 </tr>
26 <tr>
27 <td COLSPAN="1" ALIGN="LEFT" VALIGN="MIDDLE" >{xl t='Processing'}&nbsp;{xl t='Format'}</td>
28 <td COLSPAN="2" ALIGN="LEFT" VALIGN="MIDDLE" >{html_options name="processing_format" options=$partner->get_processing_format_array() selected=$partner->get_processing_format()}</td>
29 </tr>
32 <tr>
33 <td>
34 {if $partner->get_id() eq ""}
35 <input type="submit" value="{xl t='Add'}" />
36 {else}
37 <input type="submit" value="{xl t='Update'}" />
38 {/if}
39 </td>
40 </tr>
41 </table>
42 <input type="hidden" name="id" value="{$partner->id}" />
43 <input type="hidden" name="process" value="{$PROCESS}" />
44 </form>