templates/insurance_numbers/general_edit.html

   1 {**
   2  * Pharmacy 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  *}
  10 {if isset($ERROR)}
  11     <div class="alert alert-danger">{$ERROR|text}</div>
  12 {else}
  13     <form name="provider" method="post" action="{$FORM_ACTION}" class='form-horizontal' onsubmit="return top.restoreSession()">
  14         <!-- it is important that the hidden form_id field be listed first, when it is called it populates any old information attached with the id, this allows for partial edits
  15                     if it were called last, the settings from the form would be overwritten with the old information-->
  16         <input type="hidden" name="form_id" value="{$ins->id|attr}" />
  17
  18         <table class="table table-responsive table-striped">
  19
  20         <tr><td colspan="5" style="border-style:none;" class="bold">
  21             {$provider->get_name_display()|text}
  22         </td></tr>
  23
  24         <tr  class="showborder_head">
  25             <th class="small">{xlt t='Company Name'}</th>
  26             <th class="small">{xlt t='Provider Number'}</th>
  27             <th class="small">{xlt t='Rendering Provider Number'}</th>
  28             <th class="small">{xlt t='Group Number'}</th>
  29         </tr>
  30         {foreach name=inums item=num_set from=$provider->get_insurance_numbers()}
  31             <tr>
  32                 <td valign="middle">
  33                     <a href="{$CURRENT_ACTION}action=edit&id={$num_set->get_id()|attr_url}&showform=true" onclick="top.restoreSession()">
  34                         {$num_set->get_insurance_company_name()|text}&nbsp;
  35                     </a>
  36                 </td>
  37                 <td>{$num_set->get_provider_number()|text}&nbsp;</td>
  38                 <td>{$num_set->get_rendering_provider_number()|text}&nbsp;</td>
  39                 <td>{$num_set->get_group_number()|text}&nbsp;</td>
  40             </tr>
  41         {foreachelse}
  42         <tr>
  43             <td colspan="5">{xlt t='No entries found, use the form below to add an entry.'}</td>
  44         </tr>
  45         {/foreach}
  46
  47         <tr>
  48           <td style="border-style:none;" colspan="5">
  49             <a href="{$CURRENT_ACTION}action=edit&id=&provider_id={$provider->get_id()|attr_url}&showform=true" class="btn btn-secondary btn-add" onclick="top.restoreSession()">{xlt t='Add New'}</a>
  50         </td>
  51       </tr>
  52     </table>
  53
  54         {if $show_edit_gui}
  55             <div class="alert alert-info">
  56                 {if $ins->get_id() eq ""}
  57                     {xlt t='Add Provider Number'}
  58                 {else}
  59                     {xlt t='Update Provider Number'}
  60                 {/if}
  61             </div>
  62             <div class="form-row my-sm-2">
  63                 <label for="insurance_company_id" class="col-form-label col-sm-2">{xlt t='Insurance Company'}</label>
  64                 <div class="col-sm-8">
  65                     {if $ins->get_id() eq ""}
  66                         <select id="insurance_company_id" name="insurance_company_id" class="form-control">
  67                             {html_options options=$ic_array values=$ic_array selected=$ins->get_insurance_company_id()}
  68                         </select>
  69                     {else}
  70                         <span id="insurance_company_id" class="form-control-static">
  71                             {$ins->get_insurance_company_name()|text}
  72                         </span>
  73                     {/if}
  74                 </div>
  75             </div>
  76             <div class="form-row my-sm-2">
  77                 <label for="provider_number" class="col-form-label col-sm-2">{xlt t='Provider Number'}</label>
  78                 <div class="col-sm-8">
  79                     <input type="text" id="provider_number" name="provider_number" class="form-control" value="{$ins->get_provider_number()|attr}" onKeyDown="PreventIt(event)">
  80                 </div>
  81             </div>
  82             <div class="form-row my-sm-2">
  83                 <label for="provider_number_type" class="col-form-label col-sm-2">{xlt t='Provider Number (Type)'}</label>
  84                 <div class="col-sm-8">
  85                     <select id="provider_number_type" name="provider_number_type" class="form-control">
  86                         {html_options options=$ic_type_options_array values=$ins->provider_number_type_array selected=$ins->get_provider_number_type()}
  87                     </select>
  88                 </div>
  89             </div>
  90             <div class="form-row my-sm-2">
  91                 <label for="rendering_provider_number" class="col-form-label col-sm-2">{xlt t='Rendering Provider Number'}</label>
  92                 <div class="col-sm-8">
  93                     <input type="text" id="rendering_provider_number" name="rendering_provider_number" class="form-control" value="{$ins->get_rendering_provider_number()|attr}" onKeyDown="PreventIt(event)">
  94                 </div>
  95             </div>
  96             <div class="form-row my-sm-2">
  97                 <label for="rendering_provider_number_type" class="col-form-label col-sm-2">{xlt t='Rendering Provider Number (Type)'}</label>
  98                 <div class="col-sm-8">
  99                     <select id="rendering_provider_number_type" name="rendering_provider_number_type" class="form-control">
 100                         {html_options options=$ic_rendering_type_options_array values=$ins->rendering_provider_number_type_array selected=$ins->get_rendering_provider_number_type()}
 101                     </select>
 102                 </div>
 103             </div>
 104             <div class="form-row my-sm-2">
 105                 <label for="group_number" class="col-form-label col-sm-2">{xlt t='Group Number'}</label>
 106                 <div class="col-sm-8">
 107                     <input type="text" id="group_number" name="group_number" value="{$ins->get_group_number()|attr}" onKeyDown="PreventIt(event)" />
 108                 </div>
 109             </div>
 110             <div class="btn-group offset-sm-2">
 111                 {if $ins->get_id() eq ""}
 112                     <a href="javascript:submit_insurancenumbers_add();" class="btn btn-secondary btn-save" onclick="top.restoreSession()">
 113                         {xlt t='Save'}
 114                     </a>
 115                 {else}
 116                     <a href="javascript:submit_insurancenumbers_update();" class="btn btn-secondary btn-save" onclick="top.restoreSession()">
 117                         {xlt t='Save'}
 118                     </a>
 119                 {/if}
 120                 <a href="controller.php?practice_settings&insurance_numbers&action=list" class="btn btn-link btn-cancel" onclick="top.restoreSession()">
 121                     {xlt t='Cancel'}
 122                 </a>
 123             </div>
 124
 125         {else}
 126             <input type="hidden" name="provider_number" value="{$ins->get_provider_number()|attr}" />
 127             <input type="hidden" name="provider_number_type" value="{$ins->get_provider_number_type()|attr}" />
 128             <input type="hidden" name="rendering_provider_number" value="{$ins->get_rendering_provider_number()|attr}" />
 129             <input type="hidden" name="rendering_provider_number_type" value="{$ins->get_rendering_provider_number_type()|attr}" />
 130             <input type="hidden" name="group_number" value="{$ins->get_group_number()|attr}" />
 131         {/if}
 132
 133         <input type="hidden" name="id" value="{$ins->id|attr}" />
 134         <input type="hidden" name="provider_id" value="{$ins->get_provider_id()|attr}" />
 135         <input type="hidden" name="process" value="{$PROCESS|attr}" />
 136     </form>
 137 {/if}
 138
 139 <script>
 140 function submit_insurancenumbers_update() {
 141     top.restoreSession();
 142     document.provider.submit();
 143 }
 144 function submit_insurancenumbers_add() {
 145     top.restoreSession();
 146     document.provider.submit();
 147     //Z&H Removed redirection
 148 }
 149
 150 function Waittoredirect(delaymsec) {
 151  var st = new Date();
 152  var et = null;
 153  do {
 154  et = new Date();
 155  } while ((et - st) < delaymsec);
 156
 157  }
 158 </script>
 159
 160 <style>
 161
 162 text,select {
 163
 164     font-size:9pt;
 165
 166 }
 167
 168 </style>