templates/insurance_numbers/general_edit.html

   1 {if $ERROR}
   2  {$ERROR}
   3 {else}
   4 <form name="provider" method="post" action="{$FORM_ACTION}" onsubmit="return top.restoreSession()">
   5 <!-- it is important that the hidden form_id field be listed first, when it is called it populates any old information attached with the id, this allows for partial edits
   6                 if it were called last, the settings from the form would be overwritten with the old information-->
   7 <input type="hidden" name="form_id" value="{$ins->id}" />
   8 <table CELLSPACING="0" CELLPADDING="3" border="0">
   9 <tr>
  10         <td COLSPAN="1" ALIGN="LEFT" VALIGN="MIDDLE">{xl t='Provider'}</td>
  11         <td COLSPAN="2" ALIGN="LEFT" VALIGN="MIDDLE">
  12                 {$provider->get_name_display()}
  13         </td>
  14         <td></td>
  15 </tr>
  16 {foreach name=inums item=num_set from=$provider->get_insurance_numbers()}
  17 <tr>
  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" onclick="top.restoreSession()">{$num_set->get_insurance_company_name()}</a>
  21         </td>
  22         <td class="small">{xl t='Provider'} #</td>
  23         <td class="small">{$num_set->get_provider_number()}</td>
  24 </tr>
  25 <tr>
  26         <td></td>
  27         <td></td>
  28         <td class="small">{xl t='Rendering Provider'} #</td>
  29         <td class="small">{$num_set->get_rendering_provider_number()}</td>
  30 </tr>
  31 <tr>
  32         <td></td>
  33         <td></td>
  34         <td class="small">{xl t='Group'} #</td>
  35         <td class="small">{$num_set->get_group_number()}</td>
  36 </tr>
  37         {if $smarty.foreach.inums.last}
  38         <tr>
  39                 <td></td>
  40                 <td><a class="small" href="{$CURRENT_ACTION}action=edit&id=&provider_id={$provider->get_id()}" onclick="top.restoreSession()">{xl t='Add New'}...</a></td>
  41                 <td></td>
  42                 <td></td>
  43         </tr>
  44         {/if}
  45 {foreachelse}
  46         <tr>
  47                 <td></td>
  48                 <td class="small">{xl t='No entries found, use the form below to add an entry.'}</td>
  49                 <td></td>
  50                 <td></td>
  51         </tr>
  52 {/foreach}
  53
  54
  55 <tr>
  56         <td colspan="4"><br /><br /><br /></td>
  57 </tr>
  58 <tr>
  59         <td COLSPAN="1" ALIGN="LEFT" VALIGN="MIDDLE" >{xl t='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()}
  63                 {else}
  64                  {$ins->get_insurance_company_name()}
  65                 {/if}
  66         </td>
  67 </tr>
  68 <tr>
  69         <td COLSPAN="1" ALIGN="LEFT" VALIGN="MIDDLE" >{xl t='Provider Number'}</td>
  70         <td COLSPAN="3" ALIGN="LEFT" VALIGN="MIDDLE" >
  71                 <input type="text" size="20" name="provider_number" value="{$ins->get_provider_number()}"/>
  72                 &nbsp;Type:&nbsp;
  73                 {html_options name="provider_number_type" options=$ic_type_options_array values=$ins->provider_number_type_array selected=$ins->get_provider_number_type()}
  74         </td>
  75 </tr>
  76 <tr>
  77         <td COLSPAN="1" ALIGN="LEFT" VALIGN="MIDDLE" >{xl t='Rendering Provider Number'}</td>
  78         <td COLSPAN="3" ALIGN="LEFT" VALIGN="MIDDLE" >
  79                 <input type="text" size="20" name="rendering_provider_number" value="{$ins->get_rendering_provider_number()}"/>
  80                 &nbsp;Type:&nbsp;
  81                 {html_options name="rendering_provider_number_type" options=$ic_rendering_type_options_array values=$ins->rendering_provider_number_type_array selected=$ins->get_rendering_provider_number_type()}
  82         </td>
  83 </tr>
  84 <tr>
  85         <td COLSPAN="1" ALIGN="LEFT" VALIGN="MIDDLE" >{xl t='Group Number'}</td>
  86         <td COLSPAN="2" ALIGN="LEFT" VALIGN="MIDDLE" >
  87                 <input type="text" size="20" name="group_number" value="{$ins->get_group_number()}"/>
  88         </td>
  89 </tr>
  90 <tr>
  91         <td><br />
  92
  93                 {if $ins->get_id() eq ""}
  94                         <input type="submit" value="{xl t='Add'}" />
  95                 {else}
  96                         <input type="submit" value="{xl t='Update'}" />
  97                 {/if}
  98
  99         </td>
 100 </tr>
 101 </table>
 102 <input type="hidden" name="id" value="{$ins->id}" />
 103 <input type="hidden" name="provider_id" value="{$ins->get_provider_id()}" />
 104 <input type="hidden" name="process" value="{$PROCESS}" />
 105 </form>
 106 {/if}
 107