4 <form name=
"provider" method=
"post" action=
"{$FORM_ACTION}">
5 <!-- it is important that the hidden form_id field be listed first, when it is called it populates any old information attached with the id, this allows for partial edits
6 if it were called last, the settings from the form would be overwritten with the old information-->
7 <input type=
"hidden" name=
"form_id" value=
"{$ins->id}" />
8 <table CELLSPACING=
"0" CELLPADDING=
"3" border=
"0">
10 <td COLSPAN=
"1" ALIGN=
"LEFT" VALIGN=
"MIDDLE">Provider
</td>
11 <td COLSPAN=
"2" ALIGN=
"LEFT" VALIGN=
"MIDDLE">
12 {$provider-
>get_name_display()}
16 {foreach name=inums item=num_set from=$provider-
>get_insurance_numbers()}
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">{$num_set-
>get_insurance_company_name()}
</a>
22 <td class=
"small">Provider #
</td>
23 <td class=
"small">{$num_set-
>get_provider_number()}
</td>
28 <td class=
"small">Rendering Provider #
</td>
29 <td class=
"small">{$num_set-
>get_rendering_provider_number()}
</td>
34 <td class=
"small">Group #
</td>
35 <td class=
"small">{$num_set-
>get_group_number()}
</td>
37 {if $smarty.foreach.inums.last}
40 <td><a class=
"small" href=
"{$CURRENT_ACTION}action=edit&id=&provider_id={$provider->get_id()}">Add New...
</a></td>
48 <td class=
"small">No entries found, use the form below to add an entry.
</td>
56 <td colspan=
"4"><br /><br /><br /></td>
59 <td COLSPAN=
"1" ALIGN=
"LEFT" VALIGN=
"MIDDLE" >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()}
64 {$ins-
>get_insurance_company_name()}
69 <td COLSPAN=
"1" ALIGN=
"LEFT" VALIGN=
"MIDDLE" >Provider Number
</td>
70 <td COLSPAN=
"3" ALIGN=
"LEFT" VALIGN=
"MIDDLE" >
71 <input type=
"text" size=
"20" name=
"provider_number" value=
"{$ins->get_provider_number()}"/>
73 {html_options
name=
"provider_number_type" options=$ic_type_options_array values=$ins-
>provider_number_type_array selected=$ins-
>get_provider_number_type()}
77 <td COLSPAN=
"1" ALIGN=
"LEFT" VALIGN=
"MIDDLE" >Rendering Provider Number
</td>
78 <td COLSPAN=
"3" ALIGN=
"LEFT" VALIGN=
"MIDDLE" >
79 <input type=
"text" size=
"20" name=
"rendering_provider_number" value=
"{$ins->get_rendering_provider_number()}"/>
81 {html_options
name=
"rendering_provider_number_type" options=$ic_rendering_type_options_array values=$ins-
>rendering_provider_number_type_array selected=$ins-
>get_rendering_provider_number_type()}
85 <td COLSPAN=
"1" ALIGN=
"LEFT" VALIGN=
"MIDDLE" >Group Number
</td>
86 <td COLSPAN=
"2" ALIGN=
"LEFT" VALIGN=
"MIDDLE" >
87 <input type=
"text" size=
"20" name=
"group_number" value=
"{$ins->get_group_number()}"/>
93 {if $ins-
>get_id() eq
""}
94 <input type=
"submit" value=
"Add" />
96 <input type=
"submit" value=
"Update" />
102 <input type=
"hidden" name=
"id" value=
"{$ins->id}" />
103 <input type=
"hidden" name=
"provider_id" value=
"{$ins->get_provider_id()}" />
104 <input type=
"hidden" name=
"process" value=
"{$PROCESS}" />