templates/insurance_companies/general_edit.html

   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">
   6 <tr>
   7         <td width="220px" VALIGN="MIDDLE" >{xl t='Name'|escape:'html'}</td>
   8         <td VALIGN="MIDDLE" >
   9                 <input type="text" size="40" name="name" value="{$insurancecompany->get_name()|escape:'html'}" onKeyDown="PreventIt(event)" /> ({xl t='Required'|escape:'html'})
  10         </td>
  11 </tr>
  12 <tr>
  13         <td VALIGN="MIDDLE" >{xl t='Attn'|escape:'html'}</td>
  14         <td VALIGN="MIDDLE" >
  15                 <input type="text" size="40" name="attn" value="{$insurancecompany->get_attn()|escape:'html'}" onKeyDown="PreventIt(event)" />
  16         </td>
  17 </tr>
  18
  19 <tr>
  20         <td VALIGN="MIDDLE" >{xl t='Address'|escape:'html'}</td>
  21         <td VALIGN="MIDDLE" >
  22                 <input type="text" size="40" name="address_line1" value="{$insurancecompany->address->line1|escape:'html'}" onKeyDown="PreventIt(event)" />
  23         </td>
  24 </tr>
  25 <tr>
  26         <td VALIGN="MIDDLE" >{xl t='Address'|escape:'html'}</td>
  27         <td VALIGN="MIDDLE" >
  28                 <input type="text" size="40" name="address_line2" value="{$insurancecompany->address->line2|escape:'html'}" onKeyDown="PreventIt(event)" />
  29         </td>
  30 </tr>
  31 <tr>
  32         <td VALIGN="MIDDLE" >{xl t='City, State Zip'|escape:'html'}</td>
  33         <td VALIGN="MIDDLE" >
  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="{$insurancecompany->address->zip|escape:'html'}" onKeyDown="PreventIt(event)" />
  35         </td>
  36 </tr>
  37 <tr>
  38         <td VALIGN="MIDDLE" >{xl t='Phone'|escape:'html'}</td>
  39         <td VALIGN="MIDDLE" >
  40                 <input TYPE="TEXT" NAME="phone" SIZE="12" VALUE="{$insurancecompany->get_phone()|escape:'html'}" onKeyDown="PreventIt(event)" />
  41         </td>
  42 </tr>
  43 <tr>
  44         <td VALIGN="MIDDLE" >{xl t='CMS ID'|escape:'html'}</td>
  45         <td VALIGN="MIDDLE" >
  46                 <input type="text" size="15" name="cms_id" value="{$insurancecompany->get_cms_id()|escape:'html'}" onKeyDown="PreventIt(event)" />
  47         </td>
  48 </tr>
  49 {if $SUPPORT_ENCOUNTER_CLAIMS}
  50 <tr>
  51     <td VALIGN="MIDDLE" >{xl t='CMS ID For Encounter Claims'}</td>
  52     <td VALIGN="MIDDLE" >
  53                 <input type="text" size="15" name="alt_cms_id" value="{$insurancecompany->get_alt_cms_id()|escape:'html'}" onKeyDown="PreventIt(event)" />
  54     </td>
  55 </tr>
  56 {/if}
  57 <tr>
  58         <td VALIGN="MIDDLE">{xl t='Payer Type'|escape:'html'}</td>
  59         <td VALIGN="MIDDLE">
  60                 {html_options name="ins_type_code" options=$insurancecompany->ins_type_code_array selected=$insurancecompany->get_ins_type_code()}
  61         </td>
  62 </tr>
  63 <tr>
  64         <td VALIGN="MIDDLE">{xl t='Default X12 Partner'|escape:'html'}</td>
  65         <td VALIGN="MIDDLE">
  66                 {html_options name="x12_default_partner_id" options=$x12_partners selected=$insurancecompany->get_x12_default_partner_id()}
  67         </td>
  68 </tr>
  69 {if $insurancecompany->get_inactive() eq 1 }
  70 <tr>
  71      <td VALIGN="MIDDLE" >{xl t='Reactivate'|escape:'html'}</td>
  72      <td VALIGN="MIDDLE" >
  73  <input type='checkbox'  name='inactive' value="0"   />
  74
  75     </td>
  76 </tr>
  77 {/if}
  78 {if $insurancecompany->get_inactive() eq 0 }
  79 <tr>
  80      <td VALIGN="MIDDLE" >{xl t='Deactivate'|escape:'html'}</td>
  81      <td VALIGN="MIDDLE" >
  82  <input type='checkbox'  name='inactive' value="1"   />
  83
  84     </td>
  85 </tr>
  86 {/if}
  87 <tr height="25"><td colspan=2>&nbsp;</td></tr>
  88 <tr>
  89         <td colspan="2">
  90             <div class="btn-group">
  91                 <a href="javascript:submit_insurancecompany();" class="btn btn-default btn-save" onclick="top.restoreSession()">
  92                     {xl t='Save'|escape:'html'}
  93                 </a>
  94                 <a href="controller.php?practice_settings&insurance_company&action=list" class="btn btn-link btn-cancel" onclick="top.restoreSession()">
  95                 {xl t='Cancel'|escape:'html'}
  96             </a>
  97         </div>
  98     </td>
  99 </tr>
 100 </table>
 101 <input type="hidden" name="id" value="{$insurancecompany->id|escape:'html'}" />
 102 <input type="hidden" name="process" value="{$PROCESS|escape:'html'}" />
 103 </form>
 104
 105 {literal}
 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
 112     } else{
 113         document.insurancecompany.name.style.backgroundColor="red";
 114         document.insurancecompany.name.focus();
 115     }
 116 }
 117
 118 function jsWaitForDelay(delay) {
 119      var startTime = new Date();
 120      var endTime = null;
 121      do {
 122         endTime = new Date();
 123      } while ((endTime - startTime) < delay);
 124 }
 125 </script>
 126 {/literal}