templates/x12_partners/general_edit.html

   1 {**
   2  * X12 Partner 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  * Modified by Daniel Pflieger at GrowlingFlea Software to handle submitters
  10  *}
  11 <form name="x12_partner" method="post" action="{$FORM_ACTION}" class='form-horizontal' onsubmit="return top.restoreSession()">
  12     <div class="form-row my-sm-2">
  13         <label for="name" class="col-form-label col-sm-2">{xlt t='Partner Name'}</label>
  14         <div class="col-sm-8">
  15             <input type="text" id="name" name="name" class="form-control" value="{$partner->get_name()|attr}" onKeyDown="PreventIt(event)">
  16         </div>
  17     </div>
  18     <div class="form-row my-sm-2">
  19         <label for="name" class="col-form-label col-sm-2">{xlt t='Submitter Name (3rd Party Submitter Only)'}</label>
  20         <div class="col-sm-8">
  21             <input type="text" id="x12_submitter_name" name="x12_submitter_name" class="form-control" value="{$partner->get_x12_submitter_name()|attr}" onKeyDown="PreventIt(event)">
  22         </div>
  23     </div>
  24     <div class="form-row my-sm-2">
  25         <label for="id_number" class="col-form-label col-sm-2">{xlt t='ID Number (ETIN)'}</label>
  26         <div class="col-sm-8">
  27             <input type="text" id="id_number" name="id_number" class="form-control" value="{$partner->get_id_number()|attr}" onKeyDown="PreventIt(event)">
  28         </div>
  29     </div>
  30     <div class="form-row my-sm-2">
  31         <label for="x12_isa01" class="col-form-label col-sm-2">{xlt t='User logon Required Indicator (ISA01~ use 00 or 03)'}</label>
  32         <div class="col-sm-8">
  33             <input type="text" id="x12_isa01" name="x12_isa01" class="form-control" value="{$partner->get_x12_isa01()|attr}" onKeyDown="PreventIt(event)">
  34         </div>
  35     </div>
  36     <div class="form-row my-sm-2">
  37         <label for="x12_isa02" class="col-form-label col-sm-2">{xlt t='User Logon (If 03 above, else leave spaces) (ISA02)'}</label>
  38         <div class="col-sm-8">
  39             <input type="text" id="x12_isa02" name="x12_isa02" class="form-control" value="{$partner->get_x12_isa02()|attr}" onKeyDown="PreventIt(event)" maxlength="10">
  40         </div>
  41     </div>
  42     <div class="form-row my-sm-2">
  43         <label for="x12_isa03" class="col-form-label col-sm-2">{xlt t='User password required Indicator (ISA03~ use 00 or 01)'}</label>
  44         <div class="col-sm-8">
  45             <input type="text" id="x12_isa03" name="x12_isa03" class="form-control" value="{$partner->get_x12_isa03()|attr}" onKeyDown="PreventIt(event)">
  46         </div>
  47     </div>
  48     <div class="form-row my-sm-2">
  49         <label for="x12_isa04" class="col-form-label col-sm-2">{xlt t='User Password (ISA04~ if 01 above, else leave spaces)'}</label>
  50         <div class="col-sm-8">
  51             <input type="text" id="x12_isa04" name="x12_isa04" class="form-control" value="{$partner->get_x12_isa04()|attr}" onKeyDown="PreventIt(event)" maxlength="10">
  52         </div>
  53     </div>
  54     <div class="form-row my-sm-2">
  55         <label for="x12_isa05" class="col-form-label col-sm-2">{xlt t='Sender ID Qualifier (ISA05)'}</label>
  56         <div class="col-sm-8">
  57             <select id="x12_isa05" name="x12_isa05" class="form-control">
  58                 {html_options options=$partner->get_idqual_array() selected=$partner->get_x12_isa05()}
  59             </select>
  60         </div>
  61     </div>
  62     <div class="form-row my-sm-2">
  63         <label for="x12_sender_id" class="col-form-label col-sm-2">{xlt t='Sender ID (ISA06)'}</label>
  64         <div class="col-sm-8">
  65             <input type="text" id="x12_sender_id" name="x12_sender_id" class="form-control"  value="{$partner->get_x12_sender_id()|attr}" onKeyDown="PreventIt(event)">
  66         </div>
  67     </div>
  68     <div class="form-row my-sm-2">
  69         <label for="x12_isa07" class="col-form-label col-sm-2">{xlt t='Receiver ID Qualifier (ISA07)'}</label>
  70         <div class="col-sm-8">
  71             <select id="x12_isa07" name="x12_isa07" class="form-control">
  72                 {html_options options=$partner->get_idqual_array() selected=$partner->get_x12_isa07()}
  73             </select>
  74         </div>
  75     </div>
  76     <div class="form-row my-sm-2">
  77         <label for="x12_receiver_id" class="col-form-label col-sm-2">{xlt t='Receiver ID (ISA08)'}</label>
  78         <div class="col-sm-8">
  79             <input type="text" id="x12_receiver_id" name="x12_receiver_id" class="form-control" value="{$partner->get_x12_receiver_id()|attr}" onKeyDown="PreventIt(event)">
  80         </div>
  81     </div>
  82     <div class="form-row my-sm-2">
  83         <label for="x12_isa14" class="col-form-label col-sm-2">{xlt t='Acknowledgment Requested (ISA14)'}</label>
  84         <div class="col-sm-8">
  85             <select id="x12_isa14" name="x12_isa14" class="form-control">
  86                 {html_options options=$partner->get_x12_isa14_array() selected=$partner->get_x12_isa14()}
  87             </select>
  88         </div>
  89     </div>
  90     <div class="form-row my-sm-2">
  91         <label for="x12_isa15" class="col-form-label col-sm-2">{xlt t='Usage Indicator (ISA15)'}</label>
  92         <div class="col-sm-8">
  93             <select id="x12_isa15" name="x12_isa15" class="form-control">
  94                 {html_options options=$partner->get_x12_isa15_array() selected=$partner->get_x12_isa15()}
  95             </select>
  96         </div>
  97     </div>
  98     <div class="form-row my-sm-2">
  99         <label for="x12_gs02" class="col-form-label col-sm-2">{xlt t='Application Sender Code (GS02)'}</label>
 100         <div class="col-sm-8">
 101             <input type="text" id="x12_gs02" name="x12_gs02" class="form-control" value="{$partner->get_x12_gs02()|attr}" onKeyDown="PreventIt(event)">
 102         </div>
 103     </div>
 104     <div class="form-row my-sm-2">
 105         <label for="x12_dtp03" class="col-form-label col-sm-2">{xlt t='Eligibility Service Date (270 DTP03)'}</label>
 106         <div class="col-sm-8">
 107             <select id="x12_dtp03" name="x12_dtp03" class="form-control">
 108                 {html_options options=$partner->get_x12_dtp03_type_array() selected=$partner->get_x12_dtp03()}
 109             </select>
 110         </div>
 111     </div>
 112     <div class="form-row my-sm-2">
 113         <label for="12_per06" class="col-form-label col-sm-2">{xlt t='Submitter EDI Access Number (PER06)'}</label>
 114         <div class="col-sm-8">
 115             <input type="text" id="12_per06" name="x12_per06" class="form-control" value="{$partner->get_x12_per06()|attr}" onKeyDown="PreventIt(event)">
 116         </div>
 117     </div>
 118     <div class="form-row my-sm-2">
 119         <label for="x12_version" class="col-form-label col-sm-2">{xlt t='Version'}</label>
 120         <div class="col-sm-8">
 121             <select id="x12_version" name="x12_version" class="form-control">
 122                 {html_options options=$partner->get_x12_version_array() selected=$partner->get_x12_version()}
 123             </select>
 124         </div>
 125     </div>
 126     <div class="form-row my-sm-2">
 127         <label for="processing_format" class="col-form-label col-sm-2">{xlt t='Processing format'}</label>
 128         <div class="col-sm-8">
 129             <select id="processing_format" name="processing_format" class="form-control">
 130                 {html_options options=$partner->get_processing_format_array() selected=$partner->get_processing_format()}
 131             </select>
 132         </div>
 133     </div>
 134     <div class="form-row my-sm-2">
 135         <label for="x12_gs03" class="col-form-label col-sm-2">{xlt t='Application Receiver Code (GS03 - If blank ISA08 will be used)'}</label>
 136         <div class="col-sm-8">
 137             <input type="text" maxlength="15" id="x12_gs03" name="x12_gs03" class="form-control" value="{$partner->get_x12_gs03()|attr}" onKeyDown="PreventIt(event)">
 138         </div>
 139     </div>
 140     <div class="form-row my-sm-2">
 141         <label for="x12_sftp_login" class="col-form-label col-sm-2">{xlt t='SFTP Login Credentials'}</label>
 142         <div class="col-sm-8">
 143             <input type="text" maxlength="45" id="x12_sftp_login" name="x12_sftp_login" class="form-control" value="{$partner->get_x12_sftp_login()|attr}" onKeyDown="PreventIt(event)">
 144         </div>
 145     </div>
 146     <div class="form-row my-sm-2">
 147         <label for="x12_sftp_pass" class="col-form-label col-sm-2">{xlt t='SFTP Pass Credentials'}</label>
 148         <div class="col-sm-8">
 149             <input type="password" maxlength="45" id="x12_sftp_pass" name="x12_sftp_pass" class="form-control" value="{$partner->get_x12_sftp_pass()|attr}" onKeyDown="PreventIt(event)">
 150         </div>
 151     </div>
 152     <div class="form-row my-sm-2">
 153         <label for="x12_sftp_host" class="col-form-label col-sm-2">{xlt t='SFTP Host'}</label>
 154         <div class="col-sm-8">
 155             <input type="text" maxlength="45" id="x12_sftp_host" name="x12_sftp_host" class="form-control" value="{$partner->get_x12_sftp_host()|attr}" onKeyDown="PreventIt(event)">
 156         </div>
 157     </div>
 158     <div class="form-row my-sm-2">
 159         <label for="x12_sftp_port" class="col-form-label col-sm-2">{xlt t='SFTP Port'}</label>
 160         <div class="col-sm-8">
 161             <input type="text" maxlength="5" id="x12_sftp_port" name="x12_sftp_port" class="form-control" value="{$partner->get_x12_sftp_port()|attr}" onKeyDown="PreventIt(event)">
 162         </div>
 163     </div>
 164     <div class="form-row my-sm-2">
 165         <label for="x12_sftp_local_dir" class="col-form-label col-sm-2">{xlt t='SFTP Local Directory'}</label>
 166         <div class="col-sm-8">
 167             <input type="text" maxlength="400" id="x12_sftp_local_dir" name="x12_sftp_local_dir" class="form-control" value="{$partner->get_x12_sftp_local_dir()|attr}" onKeyDown="PreventIt(event)">
 168         </div>
 169     </div>
 170     <div class="form-row my-sm-2">
 171         <label for="x12_sftp_remote_dir" class="col-form-label col-sm-2">{xlt t='SFTP Remote Directory'}</label>
 172         <div class="col-sm-8">
 173             <input type="text" maxlength="400" id="x12_sftp_remote_dir" name="x12_sftp_remote_dir" class="form-control" value="{$partner->get_x12_sftp_remote_dir()|attr}" onKeyDown="PreventIt(event)">
 174         </div>
 175     </div>
 176
 177     <div class="btn-group offset-sm-2">
 178         <a href="javascript:add_x12();" class="btn btn-secondary btn-save" onclick="top.restoreSession()">
 179             {xlt t='Save'}
 180         </a>
 181         <a href="controller.php?practice_settings&x12_partner&action=list"  class="btn btn-link btn-cancel" onclick="top.restoreSession()">
 182             {xlt t='Cancel'}
 183         </a>
 184     </div>
 185     <input type="hidden" name="id" value="{$partner->id|attr}" />
 186     <input type="hidden" name="process" value="{$PROCESS|attr}" />
 187     <input type="hidden" name="sub" value="no" />
 188 </form>
 189
 190
 191 <script>
 192 function add_x12()
 193 {
 194 if (document.x12_partner.name.value.length>0)
 195 {
 196 top.restoreSession();
 197 document.x12_partner.submit();
 198 }
 199 else
 200 {
 201 document.x12_partner.name.style.backgroundColor="red";
 202 document.x12_partner.name.focus();
 203 }
 204 }
 205
 206  function Waittoredirect(delaymsec) {
 207  var st = new Date();
 208  var et = null;
 209  do {
 210  et = new Date();
 211  } while ((et - st) < delaymsec);
 212
 213    }
 214 </script>
 215