A new general survey form's XML file
[openemr.git] / templates / insurance_numbers / general_edit.html
blob810da7909cee1e3b57616410c3807f7c2b4c5c7e
1 {if $ERROR}
2 {$ERROR}
3 {else}
4 <form name="provider" method="post" action="{$FORM_ACTION}">
5 <!-- it is important that the hidden form_id field be listed first, when it is called it populates any old information attached with the id, this allows for partial edits
6 if it were called last, the settings from the form would be overwritten with the old information-->
7 <input type="hidden" name="form_id" value="{$ins->id}" />
9 <table class="showborder" CELLSPACING="0" CELLPADDING="3">
11 <tr><td colspan="5" style="border-style:none;" class="bold">
12 {$provider->get_name_display()}
13 </td></tr>
15 <tr class="showborder_head">
16 <th class="small">{xl t='Company Name'}</th>
17 <th class="small">{xl t='Provider Number'}</th>
18 <th class="small">{xl t='Rendering Provider Number'}</th>
19 <th class="small">{xl t='Group Number'}</th>
20 </tr>
21 {foreach name=inums item=num_set from=$provider->get_insurance_numbers()}
22 <tr>
23 <td valign="middle">
24 <a href="{$CURRENT_ACTION}action=edit&id={$num_set->get_id()}&showform=true" onclick="top.restoreSession()">{$num_set->get_insurance_company_name()}&nbsp;</a>
25 </td>
26 <td>{$num_set->get_provider_number()}&nbsp;</td>
27 <td>{$num_set->get_rendering_provider_number()}&nbsp;</td>
28 <td>{$num_set->get_group_number()}&nbsp;</td>
29 </tr>
30 {foreachelse}
31 <tr>
32 <td colspan="5">{xl t='No entries found, use the form below to add an entry.'}</td>
33 </tr>
34 {/foreach}
36 <tr> <td style="border-style:none;" colspan="5">
37 <a href="{$CURRENT_ACTION}action=edit&id=&provider_id={$provider->get_id()}&showform=true"
38 class="css_button_small" style='margin-top:2px'
39 onclick="top.restoreSession()">
40 <span>{xl t='Add New'}</span>
41 </a>
42 </td> </tr>
44 {php} if ( $_GET['showform'] == 'true' ) { {/php}
45 <tr> <td style="border-style:none;" colspan="5">
46 <br>
47 <b><span>{if $ins->get_id() eq ""}{xl t='Add Provider Number'}{else}{xl t='Update Provider Number'}{/if}</span></b><br>
48 <table width="100%"><tr>
49 <td style="border-style:none;" width="200px" VALIGN="MIDDLE" >{xl t='Insurance Company'}</td>
50 <td style="border-style:none;" VALIGN="MIDDLE" >
51 {if $ins->get_id() eq ""}
52 {html_options name="insurance_company_id" options=$ic_array values=$ic_array selected=$ins->get_insurance_company_id()}
53 {else}
54 {$ins->get_insurance_company_name()}
55 {/if}
56 </td>
57 </tr>
58 <tr>
59 <td style="border-style:none;" VALIGN="MIDDLE" >{xl t='Provider Number'}</td>
60 <td style="border-style:none;" VALIGN="MIDDLE" >
61 <input type="text" size="20" name="provider_number" value="{$ins->get_provider_number()}" onKeyDown="PreventIt(event)" />
62 </td>
63 </tr>
64 <tr>
65 <td style="border-style:none;" VALIGN="MIDDLE" >{xl t='Provider Number'} ({xl t='Type'})</td>
66 <td style="border-style:none;" VALIGN="MIDDLE" >
67 {html_options name="provider_number_type" options=$ic_type_options_array values=$ins->provider_number_type_array selected=$ins->get_provider_number_type()}
68 </td>
69 </tr>
70 <tr>
71 <td style="border-style:none;" VALIGN="MIDDLE" >{xl t='Rendering Provider Number'}</td>
72 <td style="border-style:none;" VALIGN="MIDDLE" >
73 <input type="text" size="20" name="rendering_provider_number" value="{$ins->get_rendering_provider_number()}" onKeyDown="PreventIt(event)" />
74 </td>
75 </tr>
76 <tr>
77 <td style="border-style:none;" VALIGN="MIDDLE" >{xl t='Rendering Provider Number'} ({xl t='Type'})</td>
78 <td style="border-style:none;" VALIGN="MIDDLE" >
79 {html_options name="rendering_provider_number_type" options=$ic_rendering_type_options_array values=$ins->rendering_provider_number_type_array selected=$ins->get_rendering_provider_number_type()}
80 </td>
81 </tr>
82 <tr>
83 <td style="border-style:none;" VALIGN="MIDDLE" >{xl t='Group Number'}</td>
84 <td style="border-style:none;" VALIGN="MIDDLE" >
85 <input type="text" size="20" name="group_number" value="{$ins->get_group_number()}" onKeyDown="PreventIt(event)" />
86 </td>
87 </tr>
88 <tr><td style="border-style:none;"></td></tr>
89 <tr>
90 <td style="border-style:none;" colspan="2">
91 {if $ins->get_id() eq ""}
92 <a href="javascript:submit_insurancenumbers_add();" class="css_button"><span>{xl t='Save'}</span></a>
93 {else}
94 <a href="javascript:submit_insurancenumbers_update();" class="css_button"><span>{xl t='Save'}</span></a>
95 {/if}
97 <a href="controller.php?practice_settings&insurance_numbers&action=list" {php} if (!$GLOBALS['concurrent_layout']) echo "target='Main'"; {/php} class="css_button" onclick="top.restoreSession()">
98 <span>{xl t='Cancel'}</span></a>
99 </td> </tr>
100 {php} } else { {/php}
101 <input type="hidden" name="provider_number" value="{$ins->get_provider_number()}" />
102 <input type="hidden" name="provider_number_type" value="{$ins->get_provider_number_type()}" />
103 <input type="hidden" name="rendering_provider_number" value="{$ins->get_rendering_provider_number()}" />
104 <input type="hidden" name="rendering_provider_number_type" value="{$ins->get_rendering_provider_number_type()}" />
105 <input type="hidden" name="group_number" value="{$ins->get_group_number()}" />
107 {php} } {/php}
109 </table>
110 </td></tr>
111 </table>
112 <input type="hidden" name="id" value="{$ins->id}" />
113 <input type="hidden" name="provider_id" value="{$ins->get_provider_id()}" />
114 <input type="hidden" name="process" value="{$PROCESS}" />
115 </form>
116 {/if}
117 {literal}
118 <script language="javascript">
119 function submit_insurancenumbers_update() {
120 top.restoreSession();
121 document.provider.submit();
123 function submit_insurancenumbers_add() {
124 top.restoreSession();
125 document.provider.submit();
126 //Z&H Removed redirection
129 function Waittoredirect(delaymsec) {
130 var st = new Date();
131 var et = null;
132 do {
133 et = new Date();
134 } while ((et - st) < delaymsec);
137 </script>
138 <style type="text/css">
139 text,select {font-size:9pt;}
140 </style>
141 {/literal}