templates/insurance_numbers/general_edit.html

   1 {**
   2  * Pharmacy edit
   3  *
   4  * @package   OpenEMR
   5  * @link      http://www.open-emr.org
   6  * @author    Brady Miller <brady.g.miller@gmail.com>
   7  * @copyright Copyright (c) 2017 Brady Miller <brady.g.miller@gmail.com>
   8  * @license   https://github.com/openemr/openemr/blob/master/LICENSE GNU General Public License 3
   9  *}
  10 {if $ERROR}
  11     <div class="alert alert-danger">{$ERROR|escape:'html'}</div>
  12 {else}
  13     <form name="provider" method="post" action="{$FORM_ACTION}" class='form-horizontal' onsubmit="return top.restoreSession()">
  14         <!-- it is important that the hidden form_id field be listed first, when it is called it populates any old information attached with the id, this allows for partial edits
  15                     if it were called last, the settings from the form would be overwritten with the old information-->
  16         <input type="hidden" name="form_id" value="{$ins->id|escape:'html'}" />
  17
  18         <table class="table table-responsive table-striped">
  19
  20         <tr><td colspan="5" style="border-style:none;" class="bold">
  21             {$provider->get_name_display()|escape:'html'}
  22         </td></tr>
  23
  24         <tr  class="showborder_head">
  25             <th class="small">{xl t='Company Name'|escape:'html'}</th>
  26             <th class="small">{xl t='Provider Number'|escape:'html'}</th>
  27             <th class="small">{xl t='Rendering Provider Number'|escape:'html'}</th>
  28             <th class="small">{xl t='Group Number'|escape:'html'}</th>
  29         </tr>
  30         {foreach name=inums item=num_set from=$provider->get_insurance_numbers()}
  31             <tr>
  32                 <td valign="middle">
  33                     <a href="{$CURRENT_ACTION}action=edit&id={$num_set->get_id()|escape:'html'}&showform=true" onclick="top.restoreSession()">
  34                         {$num_set->get_insurance_company_name()|escape:'html'}&nbsp;
  35                     </a>
  36                 </td>
  37                 <td>{$num_set->get_provider_number()|escape:'html'}&nbsp;</td>
  38                 <td>{$num_set->get_rendering_provider_number()|escape:'html'}&nbsp;</td>
  39                 <td>{$num_set->get_group_number()|escape:'html'}&nbsp;</td>
  40             </tr>
  41         {foreachelse}
  42         <tr>
  43             <td colspan="5">{xl t='No entries found, use the form below to add an entry.'|escape:'html'}</td>
  44         </tr>
  45         {/foreach}
  46
  47         <tr> <td style="border-style:none;" colspan="5">
  48             <a href="{$CURRENT_ACTION}action=edit&id=&provider_id={$provider->get_id()|escape:'html'}&showform=true"
  49                 class="btn btn-default btn-add" onclick="top.restoreSession()">
  50                 <span>{xl t='Add New'|escape:'html'}
  51             </a>
  52         </td> </tr>
  53         </table>
  54
  55         {if $show_edit_gui}
  56             <div class="alert alert-info">
  57                 {if $ins->get_id() eq ""}
  58                     {xl t='Add Provider Number'|escape:'html'}
  59                 {else}
  60                     {xl t='Update Provider Number'|escape:'html'}
  61                 {/if}
  62             </div>
  63             <div class="form-group">
  64                 <label for="insurance_company_id" class="control-label col-sm-2">{xl t='Insurance Company'|escape:'html'}</label>
  65                 <div class="col-sm-8">
  66                     {if $ins->get_id() eq ""}
  67                         <select id="insurance_company_id" name="insurance_company_id" class="form-control">
  68                             {html_options options=$ic_array values=$ic_array selected=$ins->get_insurance_company_id()}
  69                         </select>
  70                     {else}
  71                         <span id="insurance_company_id" class="form-control-static">
  72                             {$ins->get_insurance_company_name()|escape:'html'}
  73                         </span>
  74                     {/if}
  75                 </div>
  76             </div>
  77             <div class="form-group">
  78                 <label for="provider_number" class="control-label col-sm-2">{xl t='Provider Number'|escape:'html'}</label>
  79                 <div class="col-sm-8">
  80                     <input type="text" id="provider_number" name="provider_number" class="form-control" value="{$ins->get_provider_number()|escape:'html'}" onKeyDown="PreventIt(event)">
  81                 </div>
  82             </div>
  83             <div class="form-group">
  84                 <label for="provider_number_type" class="control-label col-sm-2">{xl t='Provider Number (Type)'}</label>
  85                 <div class="col-sm-8">
  86                     <select id="provider_number_type" name="provider_number_type" class="form-control">
  87                         {html_options options=$ic_type_options_array values=$ins->provider_number_type_array selected=$ins->get_provider_number_type()}
  88                     </select>
  89                 </div>
  90             </div>
  91             <div class="form-group">
  92                 <label for="rendering_provider_number" class="control-label col-sm-2">{xl t='Rendering Provider Number'|escape:'html'}</label>
  93                 <div class="col-sm-8">
  94                     <input type="text" id="rendering_provider_number" name="rendering_provider_number" class="form-control" value="{$ins->get_rendering_provider_number()|escape:'html'}" onKeyDown="PreventIt(event)">
  95                 </div>
  96             </div>
  97             <div class="form-group">
  98                 <label for="rendering_provider_number_type" class="control-label col-sm-2">{xl t='Rendering Provider Number (Type)'|escape:'html'}</label>
  99                 <div class="col-sm-8">
 100                     <select id="rendering_provider_number_type" name="rendering_provider_number_type" class="form-control">
 101                         {html_options options=$ic_rendering_type_options_array values=$ins->rendering_provider_number_type_array selected=$ins->get_rendering_provider_number_type()}
 102                     </select>
 103                 </div>
 104             </div>
 105             <div class="form-group">
 106                 <label for="group_number" class="control-label col-sm-2">{xl t='Group Number'|escape:'html'}</label>
 107                 <div class="col-sm-8">
 108                     <input type="text" id="group_number" name="group_number" value="{$ins->get_group_number()|escape:'html'}" onKeyDown="PreventIt(event)">
 109                 </div>
 110             </div>
 111             <div class="btn-group col-sm-offset-2">
 112                 {if $ins->get_id() eq ""}
 113                     <a href="javascript:submit_insurancenumbers_add();" class="btn btn-default btn-save" onclick="top.restoreSession()">
 114                         {xl t='Save'|escape:'html'}
 115                     </a>
 116                 {else}
 117                     <a href="javascript:submit_insurancenumbers_update();" class="btn btn-default btn-save" onclick="top.restoreSession()">
 118                         {xl t='Save'|escape:'html'}
 119                     </a>
 120                 {/if}
 121                 <a href="controller.php?practice_settings&insurance_numbers&action=list" class="btn btn-link btn-cancel" onclick="top.restoreSession()">
 122                     {xl t='Cancel'|escape:'html'}
 123                 </a>
 124             </div>
 125
 126         {else}
 127             <input type="hidden" name="provider_number" value="{$ins->get_provider_number()|escape:'html'}" />
 128             <input type="hidden" name="provider_number_type" value="{$ins->get_provider_number_type()|escape:'html'}" />
 129             <input type="hidden" name="rendering_provider_number" value="{$ins->get_rendering_provider_number()|escape:'html'}" />
 130             <input type="hidden" name="rendering_provider_number_type" value="{$ins->get_rendering_provider_number_type()|escape:'html'}" />
 131             <input type="hidden" name="group_number" value="{$ins->get_group_number()|escape:'html'}" />
 132         {/if}
 133
 134         <input type="hidden" name="id" value="{$ins->id|escape:'html'}" />
 135         <input type="hidden" name="provider_id" value="{$ins->get_provider_id()|escape:'html'}" />
 136         <input type="hidden" name="process" value="{$PROCESS|escape:'html'}" />
 137     </form>
 138 {/if}
 139
 140 {literal}
 141 <script language="javascript">
 142 function submit_insurancenumbers_update() {
 143     top.restoreSession();
 144     document.provider.submit();
 145 }
 146 function submit_insurancenumbers_add() {
 147     top.restoreSession();
 148     document.provider.submit();
 149     //Z&H Removed redirection
 150 }
 151
 152 function Waittoredirect(delaymsec) {
 153  var st = new Date();
 154  var et = null;
 155  do {
 156  et = new Date();
 157  } while ((et - st) < delaymsec);
 158
 159  }
 160 </script>
 161 <style type="text/css">
 162 text,select {font-size:9pt;}
 163 </style>
 164 {/literal}