interface/usergroup/facility_admin.php

   1 <?php
   2 include_once("../globals.php");
   3 include_once("$srcdir/md5.js");
   4 include_once("$srcdir/sql.inc");
   5 require_once("$srcdir/classes/POSRef.class.php");
   6
   7 if ($_POST["mode"] == "facility")
   8 {
   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='{$_POST['fid']}'");
  27 }
  28
  29 if (isset($_GET["fid"])) {
  30         $my_fid = $_GET["fid"];
  31 }
  32
  33 if (isset($_POST["fid"])) {
  34         $my_fid = $_POST["fid"];
  35 }
  36
  37 ?>
  38 <html>
  39 <head>
  40
  41 <link rel="stylesheet" href="<?php echo $css_header;?>" type="text/css">
  42
  43 </head>
  44 <body class="body_top">
  45
  46 <span class="title"><?php xl('Edit Facility Information','e'); ?></span>
  47
  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'"); ?>
  52 <br><br>
  53 <table border=0 cellpadding=0 cellspacing=0>
  54  <tr>
  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>
  60  </tr>
  61  <tr>
  62   <td>&nbsp;</td>
  63   <td>&nbsp;</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>
  66  </tr>
  67 <tr>
  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>
  70 </tr>
  71 <tr>
  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>
  74 </tr>
  75 <tr>
  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 $facility{"federal_ein"} ?>"></td>
  78 </tr>
  79 <tr>
  80          <td>&nbsp;</td><td>&nbsp;</td>
  81         <td width="21"><span class=text><?php ($GLOBALS['simplified_demographics'] ? xl('Facility Code','e') : xl('Facility NPI','e')); ?>:
  82   </span></td><td><input type=entry size=20 name=facility_npi value="<?php echo $facility{"facility_npi"} ?>"></td>
  83 </tr>
  84  <tr>
  85   <td><span class='text'><?php xl('Billing Location','e'); ?>: </span></td>
  86   <td><input type='checkbox' name='billing_location' value='1' <?php if ($facility['billing_location'] == 1) echo 'checked'; ?>></td>
  87   <td rowspan='2'><span class='text'><?php xl('Accepts Assignment','e'); ?><br>(<?php xl('only if billing location','e'); ?>): </span></td>
  88   <td><input type='checkbox' name='accepts_assignment' value='1' <?php if ($facility['accepts_assignment'] == 1) echo 'checked'; ?>></td>
  89  </tr>
  90  <tr>
  91   <td><span class='text'><?php xl('Service Location','e'); ?>: </span></td>
  92   <td><input type='checkbox' name='service_location' value='1' <?php if ($facility['service_location'] == 1) echo 'checked'; ?>></td>
  93   <td>&nbsp;</td>
  94  </tr>
  95 <tr>
  96         <td><span class=text><?php xl('POS Code','e'); ?>: </span></td>
  97         <td colspan="6">
  98                 <select name="pos_code">
  99                 <?php
 100                 $pc = new POSRef();
 101
 102                 foreach ($pc->get_pos_ref() as $pos) {
 103                         echo "<option value=\"" . $pos["code"] . "\" ";
 104                         if ($facility['pos_code'] == $pos['code']) {
 105                                 echo "selected";
 106                         }
 107                         echo ">" . $pos['code']  . ": ". $pos['title'];
 108                         echo "</option>\n";
 109                 }
 110
 111                 ?>
 112                 </select>
 113         </td>
 114 </tr>
 115 <tr>
 116         <td><span class="text"><?php xl('Billing Attn','e'); ?>:</span></td>
 117         <td colspan="4"><input type="text" name="attn" size="45" value="<?php echo $facility['attn'] ?>"></td>
 118 </tr>
 119 <tr>
 120         <td><span class="text"><?php xl('CLIA Number','e'); ?>:</span></td>
 121         <td colspan="4"><input type="text" name="domain_identifier" size="45" value="<?php echo $facility['domain_identifier'] ?>"></td>
 122 </tr>
 123 <tr>
 124         <td>&nbsp;</td><td>&nbsp;</td>
 125         <td>&nbsp;</td><td><br><br><input type="submit" value=<?php xl('Update Info','e'); ?>>&nbsp;&nbsp;&nbsp;<a href="facilities.php" class=link_submit>[<?php xl('Back','e'); ?>]</font></a></td>
 126 </tr>
 127 </table>
 128 </form>
 129
 130 </body>
 131 </html>