2 require_once("../globals.php");
3 require_once("../../library/acl.inc");
4 require_once("$srcdir/sql.inc");
5 require_once("$srcdir/formdata.inc.php");
6 require_once("$srcdir/classes/POSRef.class.php");
12 <link rel
="stylesheet" href
="<?php echo $css_header;?>" type
="text/css">
13 <link rel
="stylesheet" type
="text/css" href
="<?php echo $GLOBALS['webroot'] ?>/library/js/fancybox/jquery.fancybox-1.2.6.css" media
="screen" />
14 <script type
="text/javascript" src
="<?php echo $GLOBALS['webroot'] ?>/library/dialog.js"></script
>
15 <script type
="text/javascript" src
="<?php echo $GLOBALS['webroot'] ?>/library/js/jquery.1.3.2.js"></script
>
16 <script type
="text/javascript" src
="<?php echo $GLOBALS['webroot'] ?>/library/js/common.js"></script
>
17 <script type
="text/javascript" src
="<?php echo $GLOBALS['webroot'] ?>/library/js/fancybox/jquery.fancybox-1.2.6.js"></script
>
18 <script type
="text/javascript" src
="<?php echo $GLOBALS['webroot'] ?>/library/js/jquery-ui.js"></script
>
20 // Old Browser comp trigger on js
22 if (isset($_POST["mode"]) && $_POST["mode"] == "facility") {
24 <script type="text/javascript">
26 parent.$.fn.fancybox.close();
33 <script type
="text/javascript">
34 /// todo, move this to a common library
36 function submitform() {
37 if (document
.forms
[0].facility
.value
.length
>0) {
39 document
.forms
[0].submit();
40 parent
.$
.fn
.fancybox
.close();
41 parent
.location
.reload();
43 document
.forms
[0].facility
.style
.backgroundColor
="red";
44 document
.forms
[0].facility
.focus();
48 function toggle( target
, div
) {
50 $mode = $
(target
).find(".indicator").text();
51 if ( $mode == "collapse" ) {
52 $
(target
).find(".indicator").text( "expand" );
55 $
(target
).find(".indicator").text( "collapse" );
61 $
(document
).ready(function(){
63 $
("#dem_view").click( function() {
64 toggle( $
(this
), "#DEM" );
73 $
(".large_modal").fancybox( {
74 'overlayOpacity' : 0.0,
75 'showCloseButton' : true,
81 $
(".medium_modal").fancybox( {
82 'overlayOpacity' : 0.0,
83 'showCloseButton' : true,
90 $
(document
).ready(function(){
91 $
("#cancel").click(function() {
92 parent
.$
.fn
.fancybox
.close();
97 <link rel
="stylesheet" href
="<?php echo $css_header;?>" type
="text/css">
100 <body
class="body_top">
103 <span
class="title"><?php
xl('Add Facility','e'); ?
></span
> 
; 
; 
;</td
>
104 <td colspan
=5 align
=center style
="padding-left:2px;">
105 <a onclick
="submitform();" class="css_button large_button" name
='form_save' id
='form_save' href
='#'>
106 <span
class='css_button_span large_button_span'><?php
xl('Save','e');?
></span
>
108 <a
class="css_button large_button" id
='cancel' href
='#' >
109 <span
class='css_button_span large_button_span'><?php
xl('Cancel','e');?
></span
>
116 <form name
='facility' method
='post' action
="facilities.php" onsubmit
='return top.restoreSession()'>
117 <input type
=hidden name
=mode value
="facility">
118 <table border
=0 cellpadding
=0 cellspacing
=0>
120 <td
><span
class="text"><?php
xl('Name','e'); ?
>: </span
></td
><td
><input type
=entry name
=facility size
=20 value
=""><span
class="mandatory"> 
;*</span
></td
>
121 <td width
=20> 
;</td
>
122 <td
><span
class="text"><?php
xl('Phone','e'); ?
>: </span
></td
><td
><input type
=entry name
=phone size
=20 value
=""></td
>
125 <td
><span
class="text"><?php
xl('Address','e'); ?
>: </span
></td
><td
><input type
=entry size
=20 name
=street value
=""></td
>
127 <td
><span
class="text"><?php
xl('Fax','e'); ?
>: </span
></td
><td
><input type
=entry name
=fax size
=20 value
=""></td
>
130 <td
><span
class="text"><?php
xl('City','e'); ?
>: </span
></td
><td
><input type
=entry size
=20 name
=city value
=""></td
>
132 <td
><span
class="text"><?php
xl('Zip Code','e'); ?
>: </span
></td
><td
><input type
=entry size
=20 name
=postal_code value
=""></td
>
135 <td
><span
class="text"><?php
xl('State','e'); ?
>: </span
></td
><td
><input type
=entry size
=20 name
=state value
=""></td
>
137 <td
><span
class="text"><?php
xl('Tax ID','e'); ?
>: </span
></td
><td
><select name
=tax_id_type
><option value
="EI"><?php
xl('EIN','e'); ?
></option
><option value
="SY"><?php
xl('SSN','e'); ?
></option
></select
><input type
=entry size
=11 name
=federal_ein value
=""></td
>
140 <td height
="22"><span
class="text"><?php
xl('Country','e'); ?
>: </span
></td
><td
><input type
=entry size
=20 name
=country_code value
=""></td
>
142 <td
><span
class="text"><?
php ($GLOBALS['simplified_demographics'] ?
xl('Facility Code','e') : xl('Facility NPI','e')); ?
>:
143 </span
></td
><td
><input type
=entry size
=20 name
=facility_npi value
=""></td
>
147 <td
><span
class='text'><?php
xl('Billing Location','e'); ?
>: </span
></td
><td
><input type
='checkbox' name
='billing_location' value
= '1'></td
>
149 <td
><span
class='text'><?php
xl('Accepts Assignment','e'); ?
><br
>(<?php
xl('only if billing location','e'); ?
>): </span
></td
> <td
><input type
='checkbox' name
='accepts_assignment' value
= '1'></td
>
152 <td
><span
class='text'><?php
xl('Service Location','e'); ?
>: </span
></td
> <td
><input type
='checkbox' name
='service_location' value
= '1'></td
>
154 <td
> 
;</td
> <td
> 
;</td
>
158 <td
><span
class=text
><?php
xl('POS Code','e'); ?
>: </span
></td
>
160 <select name
="pos_code">
164 foreach ($pc->get_pos_ref() as $pos) {
165 echo "<option value=\"" . $pos["code"] . "\" ";
166 echo ">" . $pos['code'] . ": ". $pos['title'];
175 <td
><span
class="text"><?php
xl('Billing Attn','e'); ?
>:</span
></td
>
176 <td colspan
="4"><input type
="text" name
="attn" size
="45"></td
>
179 <td
><span
class="text"><?php
xl('CLIA Number','e'); ?
>:</span
></td
>
180 <td colspan
="4"><input type
="text" name
="domain_identifier" size
="45"></td
>
183 <tr height
="25" style
="valign:bottom;">
184 <td
><font
class="mandatory">*</font
><span
class="text"> <?php
echo xl('Required','e'); ?
></span
></td
><td
> 
;</td
><td
> 
;</td
>
185 <td
> 
;</td
><td
> 
;</td
>
190 <script language
="JavaScript">
192 if ($alertmsg = trim($alertmsg)) {
193 echo "alert('$alertmsg');\n";