Made to work with or without magic quotes on.
[openemr.git] / templates / insurance_numbers / general_edit.html
blob26c8dd2b2291bce799f25a9cafe209e47e93f6c5
1 {if $ERROR}
2 {$ERROR}
3 {else}
4 <form name="provider" method="post" action="{$FORM_ACTION}" onsubmit="return top.restoreSession()">
5 <!-- it is important that the hidden form_id field be listed first, when it is called it populates any old information attached with the id, this allows for partial edits
6 if it were called last, the settings from the form would be overwritten with the old information-->
7 <input type="hidden" name="form_id" value="{$ins->id}" />
8 <table CELLSPACING="0" CELLPADDING="3" border="0">
9 <tr>
10 <td COLSPAN="1" ALIGN="LEFT" VALIGN="MIDDLE">{xl t='Provider'}</td>
11 <td COLSPAN="2" ALIGN="LEFT" VALIGN="MIDDLE">
12 {$provider->get_name_display()}
13 </td>
14 <td></td>
15 </tr>
16 {foreach name=inums item=num_set from=$provider->get_insurance_numbers()}
17 <tr>
18 <td ALIGN="LEFT" VALIGN="MIDDLE"></td>
19 <td ALIGN="LEFT" VALIGN="MIDDLE">
20 <a href="{$CURRENT_ACTION}action=edit&id={$num_set->get_id()}" class="small" onclick="top.restoreSession()">{$num_set->get_insurance_company_name()}</a>
21 </td>
22 <td class="small">{xl t='Provider'} #</td>
23 <td class="small">{$num_set->get_provider_number()}</td>
24 </tr>
25 <tr>
26 <td></td>
27 <td></td>
28 <td class="small">{xl t='Rendering Provider'} #</td>
29 <td class="small">{$num_set->get_rendering_provider_number()}</td>
30 </tr>
31 <tr>
32 <td></td>
33 <td></td>
34 <td class="small">{xl t='Group'} #</td>
35 <td class="small">{$num_set->get_group_number()}</td>
36 </tr>
37 {if $smarty.foreach.inums.last}
38 <tr>
39 <td></td>
40 <td><a class="small" href="{$CURRENT_ACTION}action=edit&id=&provider_id={$provider->get_id()}" onclick="top.restoreSession()">{xl t='Add New'}...</a></td>
41 <td></td>
42 <td></td>
43 </tr>
44 {/if}
45 {foreachelse}
46 <tr>
47 <td></td>
48 <td class="small">{xl t='No entries found, use the form below to add an entry.'}</td>
49 <td></td>
50 <td></td>
51 </tr>
52 {/foreach}
55 <tr>
56 <td colspan="4"><br /><br /><br /></td>
57 </tr>
58 <tr>
59 <td COLSPAN="1" ALIGN="LEFT" VALIGN="MIDDLE" >{xl t='Insurance Company'}</td>
60 <td COLSPAN="2" ALIGN="LEFT" VALIGN="MIDDLE" >
61 {if $ins->get_id() eq ""}
62 {html_options name="insurance_company_id" options=$ic_array values=$ic_array selected=$ins->get_insurance_company_id()}
63 {else}
64 {$ins->get_insurance_company_name()}
65 {/if}
66 </td>
67 </tr>
68 <tr>
69 <td COLSPAN="1" ALIGN="LEFT" VALIGN="MIDDLE" >{xl t='Provider Number'}</td>
70 <td COLSPAN="3" ALIGN="LEFT" VALIGN="MIDDLE" >
71 <input type="text" size="20" name="provider_number" value="{$ins->get_provider_number()}"/>
72 &nbsp;Type:&nbsp;
73 {html_options name="provider_number_type" options=$ic_type_options_array values=$ins->provider_number_type_array selected=$ins->get_provider_number_type()}
74 </td>
75 </tr>
76 <tr>
77 <td COLSPAN="1" ALIGN="LEFT" VALIGN="MIDDLE" >{xl t='Rendering Provider Number'}</td>
78 <td COLSPAN="3" ALIGN="LEFT" VALIGN="MIDDLE" >
79 <input type="text" size="20" name="rendering_provider_number" value="{$ins->get_rendering_provider_number()}"/>
80 &nbsp;Type:&nbsp;
81 {html_options name="rendering_provider_number_type" options=$ic_rendering_type_options_array values=$ins->rendering_provider_number_type_array selected=$ins->get_rendering_provider_number_type()}
82 </td>
83 </tr>
84 <tr>
85 <td COLSPAN="1" ALIGN="LEFT" VALIGN="MIDDLE" >{xl t='Group Number'}</td>
86 <td COLSPAN="2" ALIGN="LEFT" VALIGN="MIDDLE" >
87 <input type="text" size="20" name="group_number" value="{$ins->get_group_number()}"/>
88 </td>
89 </tr>
90 <tr>
91 <td><br />
93 {if $ins->get_id() eq ""}
94 <input type="submit" value="{xl t='Add'}" />
95 {else}
96 <input type="submit" value="{xl t='Update'}" />
97 {/if}
99 </td>
100 </tr>
101 </table>
102 <input type="hidden" name="id" value="{$ins->id}" />
103 <input type="hidden" name="provider_id" value="{$ins->get_provider_id()}" />
104 <input type="hidden" name="process" value="{$PROCESS}" />
105 </form>
106 {/if}