interface/usergroup/facility_admin.php

   1 <?
   2 include_once("../globals.php");
   3 include_once("$srcdir/md5.js");
   4 include_once("$srcdir/sql.inc");
   5 require_once("$srcdir/classes/POSRef.class.php");
   6
   7 if ($_POST["mode"] == "facility")
   8 {
   9         sqlStatement("update facility set
  10                 name='{$_POST['facility']}',
  11                 phone='{$_POST['phone']}',
  12                 fax='{$_POST['fax']}',
  13                 street='{$_POST['street']}',
  14                 city='{$_POST['city']}',
  15                 state='{$_POST['state']}',
  16                 postal_code='{$_POST['postal_code']}',
  17                 country_code='{$_POST['country_code']}',
  18                 federal_ein='{$_POST['federal_ein']}',
  19                 service_location='{$_POST['service_location']}',
  20                 billing_location='{$_POST['billing_location']}',
  21                 accepts_assignment='{$_POST['accepts_assignment']}',
  22                 pos_code='{$_POST['pos_code']}',
  23                 domain_identifier='{$_POST['domain_identifier']}',
  24                 facility_npi='{$_POST['facility_npi']}',
  25                 attn='{$_POST['attn']}'
  26         where id='{$_POST['fid']}'");
  27 }
  28
  29 if (isset($_GET["fid"])) {
  30         $my_fid = $_GET["fid"];
  31 }
  32
  33 if (isset($_POST["fid"])) {
  34         $my_fid = $_POST["fid"];
  35 }
  36
  37 ?>
  38 <html>
  39 <head>
  40
  41 <link rel=stylesheet href="<?echo $css_header;?>" type="text/css">
  42
  43 </head>
  44 <body <?echo $top_bg_line;?> topmargin=0 rightmargin=0 leftmargin=2 bottommargin=0 marginwidth=2 marginheight=0>
  45
  46 <span class="title"><? xl('Edit Facility Information','e'); ?></span>
  47
  48 <form name='facility' method='post' action="facility_admin.php">
  49 <input type=hidden name=mode value="facility">
  50 <input type=hidden name=fid value="<?echo $my_fid;?>">
  51 <span class=bold><? xl('Facility Information','e'); ?>: </span>
  52 </td><td>
  53 <?php $facility = sqlQuery("select * from facility where id='$my_fid'"); ?>
  54 <br><br>
  55 <table border=0 cellpadding=0 cellspacing=0>
  56 <tr>
  57         <td width="24"><span class=text><? xl('Name','e'); ?>: </span></td><td width="120"><input type=entry name=facility size=20 value="<?=$facility['name']?>"></td><td rowspan="10" width="15"></d>
  58         <td width="145"><span class=text><? xl('Phone','e'); ?> <? xl('as','e'); ?> (000) 000-0000:</span></td><td width="210"><input type=entry name=phone size=20 value="<?=$facility['phone']?>"></td>
  59 </tr>
  60 <tr>
  61         <td>&nbsp;</td><td>&nbsp;</td>
  62         <td><span class=text><? xl('Fax','e'); ?> <? xl('as','e'); ?> (000) 000-0000:</span></td><td><input type=entry name=f
  63 ax size=20 value="<?=$facility['fax']?>"></td>
  64 </tr>
  65 <tr>
  66         <td><span class=text><? xl('Address','e'); ?>: </span></td><td><input type=entry size=20 name=street value="<?=$facility["street"]?>"></td>
  67         <td><span class=text><? xl('City','e'); ?>: </span></td><td><input type=entry size=20 name=city value="<?echo $facility{"city"}?>"></td>
  68 </tr>
  69 <tr>
  70         <td><span class=text><? xl('State','e'); ?>: </span></td><td><input type=entry size=20 name=state value="<?echo $facility{"state"}?>"></td>
  71         <td><span class=text><? xl('Zip Code','e'); ?>: </span></td><td><input type=entry size=20 name=postal_code value="<?echo $facility{"postal_code"}?>"></td>
  72 </tr>
  73 <tr>
  74         <td><span class=text><? xl('Country','e'); ?>: </span></td><td><input type=entry size=20 name=country_code value="<?echo $facility{"country_code"}?>"></td>
  75         <td><span class=text><? xl('Federal EIN','e'); ?>: </span></td><td><input type=entry size=20 name=federal_ein value="<?echo $facility{"federal_ein"}?>"></td>
  76 </tr>
  77 <tr>
  78          <td>&nbsp;</td><td>&nbsp;</td>
  79         <td width="21"><span class=text><? xl('Facility NPI','e'); ?>: </span></td><td><input type=entry size=20 name=facility_npi value="<?echo $facility{"facility_npi"}?>"></td>
  80
  81 </tr>
  82 <tr>
  83   <td><span class='text'><?php xl('Billing Location','e'); ?>: </span></td>
  84   <td><input type='checkbox' name="billing_location" value="1" <?php if ($facility['billing_location'] == 1) echo "checked"?>"></td>
  85   <td rowspan='2'><span class='text'><?php xl('Accepts Assignment','e'); ?><br>(<?php xl('only if billing location','e'); ?>): </span></td>
  86   <td><input type='checkbox' name="accepts_assignment" value="1" <?php if ($facility['accepts_assignment'] == 1) echo "checked"?>"></td>
  87 </tr>
  88
  89 <tr>
  90   <td><span class='text'><?php xl('Service Location','e'); ?>: </span></td>
  91   <td><input type='checkbox' name="service_location" value="1" <?php if ($facility['service_location']) echo "checked"?>"></td>
  92   <td>&nbsp;</td>
  93 </tr>
  94
  95 <tr>
  96         <td><span class=text><? xl('POS Code','e'); ?>: </span></td>
  97         <td colspan="6">
  98                 <select name="pos_code">
  99                 <?php
 100                 $pc = new POSRef();
 101
 102                 foreach ($pc->get_pos_ref() as $pos) {
 103                         echo "<option value=\"" . $pos["code"] . "\" ";
 104                         if ($facility['pos_code'] == $pos['code']) {
 105                                 echo "selected";
 106                         }
 107                         echo ">" . $pos['code']  . ": ". $pos['title'];
 108                         echo "</option>\n";
 109                 }
 110
 111                 ?>
 112                 </select>
 113         </td>
 114 </tr>
 115 <tr>
 116         <td><span class="text"><? xl('Billing Attn','e'); ?>:</span></td>
 117         <td colspan="4"><input type="text" name="attn" size="45" value="<?=$facility['attn']?>"></td>
 118 </tr>
 119 <tr>
 120         <td><span class="text"><? xl('CLIA Number','e'); ?>:</span></td>
 121         <td colspan="4"><input type="text" name="domain_identifier" size="45" value="<?=$facility['domain_identifier']?>"></td>
 122 </tr>
 123 <tr>
 124         <td>&nbsp;</td><td>&nbsp;</td>
 125         <td>&nbsp;</td><td><br><br><input type="submit" value=<? xl('Update Info','e'); ?>>&nbsp;&nbsp;&nbsp;<a href="usergroup_admin.php" class=link_submit>[<? xl('Back','e'); ?>]</font></a></td>
 126 </tr>
 127 </table>
 128 </form>
 129
 130 </body>
 131 </html>