A couple of fixes for secondary X12 claims
[openemr.git] / templates / document_categories / general_upload.html
blob1377f005ab36b99202ace054ce83f2a5951fbdab
1 <html>
2 <head>
3 {php}html_header_show();{/php}
5 {literal}
6 <style type="text/css" title="mystyles" media="all">
7 <!--
8 td {
9 font-size:8pt;
10 font-family:helvetica;
12 a {
13 font-size:8pt;
14 font-family:helvetica;
17 -->
18 </style>
19 {/literal}
20 </head>
21 <body bgcolor="{$STYLE.BGCOLOR2}">
22 <form method=post enctype="multipart/form-data" action="{$FORM_ACTION}" onsubmit="return top.restoreSession()">
23 <input type="hidden" name="MAX_FILE_SIZE" value="64000000" />
24 <table>
25 <tr>
26 <td>{xl t="Upload Document"}</td>
27 </tr>
28 <tr>
29 <td><input type="file" name="file"></td>
30 </tr>
31 <tr>
32 <td><input type="submit" value="{xl t='Upload'}"></td>
33 </tr>
34 {if !empty($file)}
35 <tr>
36 <td><br><br></td>
37 </tr>
38 <tr>
39 <td>{xl t='Upload Report'}</td>
40 </tr>
41 <tr>
42 <td>{$error}</td>
43 </tr>
44 <tr>
45 <td><pre>{$file}</pre></td>
46 </tr>
47 {/if}
48 </table>
49 <input type="hidden" name="process" value="{$PROCESS}" />
50 </form>
51 </body>
52 </html>