1 <form name=
"insurancecompany" method=
"post" action=
"{$FORM_ACTION}" onsubmit=
"return top.restoreSession()">
2 <!-- it is important that the hidden form_id field be listed first, when it is called it populates any old information attached with the id, this allows for partial edits
3 if it were called last, the settings from the form would be overwritten with the old information-->
4 <input type=
"hidden" name=
"form_id" value=
"{$insurancecompany->id|escape:'html'}" />
5 <table style=
"font-size:9pt;" width=
"500px" CELLSPACING=
"0" CELLPADDING=
"3">
7 <td width=
"220px" VALIGN=
"MIDDLE" >{xl t='Name'|escape:'html'}
</td>
9 <input type=
"text" size=
"40" name=
"name" value=
"{$insurancecompany->get_name()|escape:'html'}" onKeyDown=
"PreventIt(event)" /> ({xl t='Required'|escape:'html'})
13 <td VALIGN=
"MIDDLE" >{xl t='Attn'|escape:'html'}
</td>
15 <input type=
"text" size=
"40" name=
"attn" value=
"{$insurancecompany->get_attn()|escape:'html'}" onKeyDown=
"PreventIt(event)" />
20 <td VALIGN=
"MIDDLE" >{xl t='Address'|escape:'html'}
</td>
22 <input type=
"text" size=
"40" name=
"address_line1" value=
"{$insurancecompany->address->line1|escape:'html'}" onKeyDown=
"PreventIt(event)" />
26 <td VALIGN=
"MIDDLE" >{xl t='Address'|escape:'html'}
</td>
28 <input type=
"text" size=
"40" name=
"address_line2" value=
"{$insurancecompany->address->line2|escape:'html'}" onKeyDown=
"PreventIt(event)" />
32 <td VALIGN=
"MIDDLE" >{xl t='City, State Zip'|escape:'html'}
</td>
34 <input type=
"text" size=
"25" name=
"city" value=
"{$insurancecompany->address->city|escape:'html'}" onKeyDown=
"PreventIt(event)" /> ,
<input type=
"text" size=
"2" maxlength=
"2" name=
"state" value=
"{$insurancecompany->address->state|escape:'html'}" onKeyDown=
"PreventIt(event)" /> <input type=
"text" size=
"5" name=
"zip" value=
"{$insurancecompany->address->zip|escape:'html'}" onKeyDown=
"PreventIt(event)" />
38 <td VALIGN=
"MIDDLE" >{xl t='Phone'|escape:'html'}
</td>
40 <input TYPE=
"TEXT" NAME=
"phone" SIZE=
"12" VALUE=
"{$insurancecompany->get_phone()|escape:'html'}" onKeyDown=
"PreventIt(event)" />
44 <td VALIGN=
"MIDDLE" >{xl t='CMS ID'|escape:'html'}
</td>
46 <input type=
"text" size=
"15" name=
"cms_id" value=
"{$insurancecompany->get_cms_id()|escape:'html'}" onKeyDown=
"PreventIt(event)" />
49 {if $SUPPORT_ENCOUNTER_CLAIMS}
51 <td VALIGN=
"MIDDLE" >{xl t='CMS ID For Encounter Claims'}
</td>
53 <input type=
"text" size=
"15" name=
"alt_cms_id" value=
"{$insurancecompany->get_alt_cms_id()|escape:'html'}" onKeyDown=
"PreventIt(event)" />
58 <td VALIGN=
"MIDDLE">{xl t='Payer Type'|escape:'html'}
</td>
60 {html_options
name=
"ins_type_code" options=$insurancecompany-
>ins_type_code_array selected=$insurancecompany-
>get_ins_type_code()}
64 <td VALIGN=
"MIDDLE">{xl t='Default X12 Partner'|escape:'html'}
</td>
66 {html_options
name=
"x12_default_partner_id" options=$x12_partners selected=$insurancecompany-
>get_x12_default_partner_id()}
69 {if $insurancecompany-
>get_inactive() eq
1 }
71 <td VALIGN=
"MIDDLE" >{xl t='Reactivate'|escape:'html'}
</td>
73 <input type='checkbox' name='inactive'
value=
"0" />
78 {if $insurancecompany-
>get_inactive() eq
0 }
80 <td VALIGN=
"MIDDLE" >{xl t='Deactivate'|escape:'html'}
</td>
82 <input type='checkbox' name='inactive'
value=
"1" />
87 <tr height=
"25"><td colspan=
2> </td></tr>
90 <div class=
"btn-group">
91 <a href=
"javascript:submit_insurancecompany();" class=
"btn btn-default btn-save" onclick=
"top.restoreSession()">
92 {xl t='Save'|escape:'html'}
94 <a href=
"controller.php?practice_settings&insurance_company&action=list" class=
"btn btn-link btn-cancel" onclick=
"top.restoreSession()">
95 {xl t='Cancel'|escape:'html'}
101 <input type=
"hidden" name=
"id" value=
"{$insurancecompany->id|escape:'html'}" />
102 <input type=
"hidden" name=
"process" value=
"{$PROCESS|escape:'html'}" />
106 <script language=
"javascript">
107 function submit_insurancecompany() {
108 if(document
.insurancecompany
.name
.value
.length
>0) {
109 top
.restoreSession();
110 document
.insurancecompany
.submit();
111 //Z&H Removed redirection
113 document
.insurancecompany
.name
.style
.backgroundColor
="red";
114 document
.insurancecompany
.name
.focus();
118 function jsWaitForDelay(delay
) {
119 var startTime
= new Date();
122 endTime
= new Date();
123 } while ((endTime
- startTime
) < delay
);