2 include_once("../globals.php");
3 include_once("$srcdir/md5.js");
4 include_once("$srcdir/sql.inc");
5 require_once("$srcdir/classes/POSRef.class.php");
7 if ($_POST["mode"] == "facility")
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='{$_POST['fid']}'");
29 if (isset($_GET["fid"])) {
30 $my_fid = $_GET["fid"];
33 if (isset($_POST["fid"])) {
34 $my_fid = $_POST["fid"];
41 <link rel
="stylesheet" href
="<?php echo $css_header;?>" type
="text/css">
44 <body
class="body_top">
46 <span
class="title"><?php
xl('Edit Facility Information','e'); ?
></span
>
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
="<?php echo $my_fid;?>">
51 <?php
$facility = sqlQuery("select * from facility where id='$my_fid'"); ?
>
53 <table border
=0 cellpadding
=0 cellspacing
=0>
55 <td width
='24'><span
class='text'><?php
xl('Name','e'); ?
>: </span
></td
>
56 <td width
='120'><input type
='entry' name
='facility' size
='20' value
='<?php echo $facility['name
'] ?>'></td
>
57 <td rowspan
='10' width
='15'></td
>
58 <td
><span
class='text'><?php
xl('Phone','e'); ?
> <?php
xl('as','e'); ?
> (000) 000-0000:</span
></td
>
59 <td width
='210'><input type
='entry' name
='phone' size
='20' value
='<?php echo $facility['phone
'] ?>'></td
>
64 <td
><span
class='text'><?php
xl('Fax','e'); ?
> <?php
xl('as','e'); ?
> (000) 000-0000:</span
></td
>
65 <td width
='210'><input type
='entry' name
='fax' size
='20' value
='<?php echo $facility['fax
'] ?>'></td
>
68 <td
><span
class=text
><?php
xl('Address','e'); ?
>: </span
></td
><td
><input type
=entry size
=20 name
=street value
="<?php echo $facility["street
"] ?>"></td
>
69 <td
><span
class=text
><?php
xl('City','e'); ?
>: </span
></td
><td
><input type
=entry size
=20 name
=city value
="<?php echo $facility{"city
"} ?>"></td
>
72 <td
><span
class=text
><?php
xl('State','e'); ?
>: </span
></td
><td
><input type
=entry size
=20 name
=state value
="<?php echo $facility{"state
"} ?>"></td
>
73 <td
><span
class=text
><?php
xl('Zip Code','e'); ?
>: </span
></td
><td
><input type
=entry size
=20 name
=postal_code value
="<?php echo $facility{"postal_code
"} ?>"></td
>
76 <td
><span
class=text
><?php
xl('Country','e'); ?
>: </span
></td
><td
><input type
=entry size
=20 name
=country_code value
="<?php echo $facility{"country_code
"} ?>"></td
>
77 <td
><span
class=text
><?php
xl('Federal EIN','e'); ?
>: </span
></td
><td
><input type
=entry size
=20 name
=federal_ein value
="<?php echo $facility{"federal_ein
"} ?>"></td
>
80 <td
> 
;</td
><td
> 
;</td
>
81 <td width
="21"><span
class=text
><?php
xl('Facility NPI','e'); ?
>: </span
></td
><td
><input type
=entry size
=20 name
=facility_npi value
="<?php echo $facility{"facility_npi
"} ?>"></td
>
84 <td
><span
class='text'><?php
xl('Billing Location','e'); ?
>: </span
></td
>
85 <td
><input type
='checkbox' name
='billing_location' value
='1' <?php
if ($facility['billing_location'] == 1) echo 'checked'; ?
>></td
>
86 <td rowspan
='2'><span
class='text'><?php
xl('Accepts Assignment','e'); ?
><br
>(<?php
xl('only if billing location','e'); ?
>): </span
></td
>
87 <td
><input type
='checkbox' name
='accepts_assignment' value
='1' <?php
if ($facility['accepts_assignment'] == 1) echo 'checked'; ?
>></td
>
90 <td
><span
class='text'><?php
xl('Service Location','e'); ?
>: </span
></td
>
91 <td
><input type
='checkbox' name
='service_location' value
='1' <?php
if ($facility['service_location'] == 1) echo 'checked'; ?
>></td
>
95 <td
><span
class=text
><?php
xl('POS Code','e'); ?
>: </span
></td
>
97 <select name
="pos_code">
101 foreach ($pc->get_pos_ref() as $pos) {
102 echo "<option value=\"" . $pos["code"] . "\" ";
103 if ($facility['pos_code'] == $pos['code']) {
106 echo ">" . $pos['code'] . ": ". $pos['title'];
115 <td
><span
class="text"><?php
xl('Billing Attn','e'); ?
>:</span
></td
>
116 <td colspan
="4"><input type
="text" name
="attn" size
="45" value
="<?php echo $facility['attn'] ?>"></td
>
119 <td
><span
class="text"><?php
xl('CLIA Number','e'); ?
>:</span
></td
>
120 <td colspan
="4"><input type
="text" name
="domain_identifier" size
="45" value
="<?php echo $facility['domain_identifier'] ?>"></td
>
123 <td
> 
;</td
><td
> 
;</td
>
124 <td
> 
;</td
><td
><br
><br
><input type
="submit" value
=<?php
xl('Update Info','e'); ?
>> 
; 
; 
;<a href
="usergroup_admin.php" class=link_submit
>[<?php
xl('Back','e'); ?
>]</font
></a
></td
>