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 {$provider-
>get_name_display()}
15 <tr class=
"showborder_head">
16 <th class=
"small">{xl t='Provider'} Number
</th>
17 <th class=
"small">{xl t='Rendering Provider'} #
</th>
18 <th class=
"small">{xl t='Group'} #
</th>
20 {foreach name=inums item=num_set from=$provider-
>get_insurance_numbers()}
23 <a href=
"{$CURRENT_ACTION}action=edit&id={$num_set->get_id()}&showform=true" onclick=
"top.restoreSession()">{$num_set-
>get_insurance_company_name()}
</a>
25 <td>{$num_set-
>get_provider_number()}
</td>
26 <td>{$num_set-
>get_rendering_provider_number()}
</td>
27 <td>{$num_set-
>get_group_number()}
</td>
31 <td colspan=
"5">{xl t='No entries found, use the form below to add an entry.'}
</td>
35 <tr> <td style=
"border-style:none;" colspan=
"5">
36 <a href=
"{$CURRENT_ACTION}action=edit&id=&provider_id={$provider->get_id()}&showform=true"
37 class=
"css_button_small" style='margin-top:
2px'
38 onclick=
"top.restoreSession()">
39 <span>{xl t='Add New'}
</span>
43 {php} if ( $_GET['showform'] == 'true' ) { {/php}
44 <tr> <td style=
"border-style:none;" colspan=
"5">
46 <b><span>{if $ins-
>get_id() eq
""}{xl t='Add Provider Number'}{else}{xl t='Update Provider Number'}{/if}
</span></b><br>
47 <table width=
"100%"><tr>
48 <td style=
"border-style:none;" width=
"200px" VALIGN=
"MIDDLE" >{xl t='Insurance Company'}
</td>
49 <td style=
"border-style:none;" VALIGN=
"MIDDLE" >
50 {if $ins-
>get_id() eq
""}
51 {html_options
name=
"insurance_company_id" options=$ic_array values=$ic_array selected=$ins-
>get_insurance_company_id()}
53 {$ins-
>get_insurance_company_name()}
58 <td style=
"border-style:none;" VALIGN=
"MIDDLE" >{xl t='Provider Number'}
</td>
59 <td style=
"border-style:none;" VALIGN=
"MIDDLE" >
60 <input type=
"text" size=
"20" name=
"provider_number" value=
"{$ins->get_provider_number()}"/>
64 <td style=
"border-style:none;" VALIGN=
"MIDDLE" >Provider Number({xl t='Type'})
</td>
65 <td style=
"border-style:none;" VALIGN=
"MIDDLE" >
66 {html_options
name=
"provider_number_type" options=$ic_type_options_array values=$ins-
>provider_number_type_array selected=$ins-
>get_provider_number_type()}
70 <td style=
"border-style:none;" VALIGN=
"MIDDLE" >{xl t='Rendering Provider Number'}
</td>
71 <td style=
"border-style:none;" VALIGN=
"MIDDLE" >
72 <input type=
"text" size=
"20" name=
"rendering_provider_number" value=
"{$ins->get_rendering_provider_number()}"/>
76 <td style=
"border-style:none;" VALIGN=
"MIDDLE" >{xl t='Rendering Provider Number'} ({xl t='Type'})
</td>
77 <td style=
"border-style:none;" VALIGN=
"MIDDLE" >
78 {html_options
name=
"rendering_provider_number_type" options=$ic_rendering_type_options_array values=$ins-
>rendering_provider_number_type_array selected=$ins-
>get_rendering_provider_number_type()}
82 <td style=
"border-style:none;" VALIGN=
"MIDDLE" >{xl t='Group Number'}
</td>
83 <td style=
"border-style:none;" VALIGN=
"MIDDLE" >
84 <input type=
"text" size=
"20" name=
"group_number" value=
"{$ins->get_group_number()}"/>
87 <tr><td style=
"border-style:none;"></td></tr>
89 <td style=
"border-style:none;" colspan=
"2">
90 {if $ins-
>get_id() eq
""}
91 <a href=
"javascript:submit_insurancenumbers_add();" class=
"css_button"><span>{xl t='Save'}
</span></a>
93 <a href=
"javascript:submit_insurancenumbers_update();" class=
"css_button"><span>{xl t='Save'}
</span></a>
96 <a href=
"controller.php?practice_settings&insurance_numbers&action=list" {php} if (!$GLOBALS['concurrent_layout']) echo
"target='Main'"; {/php}
class=
"css_button" onclick=
"top.restoreSession()">
97 <span>{xl t='Cancel'}
</span></a>
100 <input type=
"hidden" name=
"provider_number" value=
"{$ins->get_provider_number()}" />
101 <input type=
"hidden" name=
"provider_number_type" value=
"{$ins->get_provider_number_type()}" />
102 <input type=
"hidden" name=
"rendering_provider_number" value=
"{$ins->get_rendering_provider_number()}" />
103 <input type=
"hidden" name=
"rendering_provider_number_type" value=
"{$ins->get_rendering_provider_number_type()}" />
104 <input type=
"hidden" name=
"group_number" value=
"{$ins->get_group_number()}" />
111 <input type=
"hidden" name=
"id" value=
"{$ins->id}" />
112 <input type=
"hidden" name=
"provider_id" value=
"{$ins->get_provider_id()}" />
113 <input type=
"hidden" name=
"process" value=
"{$PROCESS}" />
117 <script language=
"javascript">
118 function submit_insurancenumbers_update() {
119 top
.restoreSession();
120 document
.provider
.submit();
122 function submit_insurancenumbers_add() {
123 top
.restoreSession();
124 document
.provider
.submit();
126 document
.location
.href
="{/literal}{$WEB_ROOT}{literal}/controller.php?practice_settings&insurance_numbers&action=list";
129 function Waittoredirect(delaymsec
) {
134 } while ((et
- st
) < delaymsec
);
138 <style type=
"text/css">
139 text
,select
{font-size:9pt;}