{**
 * Insurance company edit
 *
 * @package   OpenEMR
 * @link      https://www.open-emr.org
 * @author    Brady Miller <brady.g.miller@gmail.com>
 * @copyright Copyright (c) 2017 Brady Miller <brady.g.miller@gmail.com>
 * @license   https://github.com/openemr/openemr/blob/master/LICENSE GNU General Public License 3
 *}

<form name="insurancecompany" method="post" action="{$FORM_ACTION}" class='form-horizontal' onsubmit="return top.restoreSession()">
    <!-- it is important that the hidden form_id field be listed first, when it is called it populates any old information attached with the id, this allows for partial edits
    if it were called last, the settings from the form would be overwritten with the old information-->
    <input type="hidden" name="form_id" value="{$insurancecompany->id|attr}">
    {if $insurancecompany->get_inactive() eq 1 }
    <div class="form-row my-sm-2">
        <label for="inactive" class="col-form-label col-sm-2">{xlt t='Reactivate'}</label>
        <div class="col-sm-8">
            <input type="checkbox" id="inactive" name="inactive" class="checkbox" value="0" />
        </div>
    </div>
    {/if}
    {if $insurancecompany->get_inactive() eq 0 }
    <div class="form-row my-sm-2">
        <label for="inactive" class="col-form-label col-sm-2">{xlt t='Deactivate'}</label>
        <div class="col-sm-8">
            <input type="checkbox" id="inactive" name="inactive" class="checkbox" value="1" />
        </div>
    </div>
    {/if}
    <div class="form-row my-sm-2">
        <label for="name" class="col-form-label col-sm-2">{xlt t='Name'}</label>
        <div class="col-sm-8">
            <input type="text" id="name" name="name" class="form-control" aria-describedby="nameHelpBox" value="{$insurancecompany->get_name()|attr}" onKeyDown="PreventIt(event)">
            <span id="nameHelpBox" class="help-block">({xlt t='Required'})</span>
        </div>
    </div>
    <div class="form-row my-sm-2">
        <label for="attn" class="col-form-label col-sm-2">{xlt t='Attn'}</label>
        <div class="col-sm-8">
            <input type="text" id="attn" name="attn" class="form-control" value="{$insurancecompany->get_attn()|attr}" onKeyDown="PreventIt(event)">
        </div>
    </div>
    <div class="form-row my-sm-2">
        <label for="address_line1" class="col-form-label col-sm-2">{xlt t='Address'}</label>
        <div class="col-sm-8">
            <input type="text" id="address_line1" name="address_line1" class="form-control" value="{$insurancecompany->address->line1|attr}" onKeyDown="PreventIt(event)">
        </div>
    </div>
    <div class="form-row my-sm-2">
        <label for="address_line2" class="col-form-label col-sm-2">{xlt t='Address'}</label>
        <div class="col-sm-8">
            <input type="text" id="address_line2" name="address_line2" class="form-control" value="{$insurancecompany->address->line2|attr}" onKeyDown="PreventIt(event)">
        </div>
    </div>
    <div class="form-row my-sm-2">
        <label for="city" class="col-form-label col-sm-2">{xlt t='City'}</label>
        <div class="col-sm-8">
            <input type="text" id="city" name="city" class="form-control" value="{$insurancecompany->address->city|attr}" onKeyDown="PreventIt(event)">
        </div>
    </div>
    <div class="form-row my-sm-2">
        <label for="state" class="col-form-label col-sm-2">{xlt t='State'}</label>
        <div class="col-sm-8">
            <input type="text" maxlength="2" id="state" name="state" class="form-control" value="{$insurancecompany->address->state|attr}" onKeyDown="PreventIt(event)">
        </div>
    </div>
    <div class="form-row my-sm-2">
        <label for="zip" class="col-form-label col-sm-2">{xlt t='Zip Code'}</label>
        <div class="col-sm-8">
            <input type="text" id="zip" name="zip" class="form-control" value="{$insurancecompany->address->zip|attr}" onKeyDown="PreventIt(event)">
        </div>
    </div>
    <div class="form-row my-sm-2">
        <label for="phone" class="col-form-label col-sm-2">{xlt t='Phone'}</label>
        <div class="col-sm-8">
            <input type="text" id="phone" name="phone" class="form-control" value="{$insurancecompany->get_phone()|attr}" onKeyDown="PreventIt(event)">
        </div>
    </div>
    <div class="form-row my-sm-2">
        <label for="fax" class="col-form-label col-sm-2">{xlt t='Fax'}</label>
        <div class="col-sm-8">
            <input type="text" id="fax" name="fax" class="form-control" value="{$insurancecompany->get_fax()|attr}" onKeyDown="PreventIt(event)">
        </div>
    </div>
    <div class="form-row my-sm-2">
        <label for="cms_id" class="col-form-label col-sm-2">{xlt t='Payer ID'}</label>
        <div class="col-sm-8">
            <input type="text" id="cms_id" name="cms_id" class="form-control" value="{$insurancecompany->get_cms_id()|attr}" onKeyDown="PreventIt(event)">
        </div>
    </div>
    {if $SUPPORT_ENCOUNTER_CLAIMS}
        <div class="form-row my-sm-2">
            <label for="alt_cms_id" class="col-form-label col-sm-2">{xlt t='Payer ID For Encounter Claims'}</label>
            <div class="col-sm-8">
                <input type="text" id="alt_cms_id" name="alt_cms_id" class="form-control" value="{$insurancecompany->get_alt_cms_id()|attr}" onKeyDown="PreventIt(event)">
            </div>
        </div>
    {/if}
    {if $SUPPORT_ELIGIBILITY_REQUESTS}
    <div class="form-row my-sm-2">
        <label for="eligibility_id" class="col-form-label col-sm-2">{xlt t='Payer Id For Eligibility'}</label>
        <div class="col-sm-8">
            <input type="text" id="eligibility_id" name="eligibility_id" class="form-control" value="{$insurancecompany->get_eligibility_id()|attr}" onKeyDown="PreventIt(event)">
        </div>
    </div>
    {/if}
    <div class="form-row my-sm-2">
        <label for="ins_type_code" class="col-form-label col-sm-2">{xlt t='Payer Type'}</label>
        <div class="col-sm-8">
            <select id="ins_type_code" name="ins_type_code" class="form-control">
                {html_options options=$insurancecompany->ins_type_code_array selected=$insurancecompany->get_ins_type_code()}
            </select>
        </div>
    </div>
    <div class="form-row my-sm-2">
        <label for="x12_default_partner_id" class="col-form-label col-sm-2">{xlt t='Default X12 Partner'}</label>
        <div class="col-sm-8">
            <select id="x12_default_partner_id" name="x12_default_partner_id" class="form-control">
                {html_options options=$x12_partners selected=$insurancecompany->get_x12_default_partner_id()}
            </select>
        </div>
    </div>
    <div class="form-row my-sm-2">
        <label for="cqm_sop" class="col-form-label col-sm-2">{xlt t='CQM Source of Payment'}</label>
        <div class="col-sm-8">
            <select id="cqm_sop" name="cqm_sop" class="form-control">
                {html_options options=$insurancecompany->cqm_sop_array selected=$insurancecompany->get_cqm_sop()}
            </select>
        </div>
    </div>
    {if $SUPPORT_ELIGIBILITY_REQUESTS}
    <div class="form-row my-sm-2">
        <label for="x12_default_eligibility_id" class="col-form-label col-sm-2">{xlt t='Default Eligibility X12 Partner'}</label>
        <div class="col-sm-8">
            <select id="x12_default_eligibility_id" name="x12_default_eligibility_id" class="form-control">
                {html_options options=$x12_partners selected=$insurancecompany->get_x12_default_eligibility_id()}
            </select>
        </div>
    </div>
    {/if}
    <div class="btn-group offset-sm-2">
        <a href="javascript:submit_insurancecompany();" class="btn btn-secondary btn-save" onclick="top.restoreSession()">
            {xlt t='Save'}
        </a>
        <a href="controller.php?practice_settings&insurance_company&action=list" class="btn btn-link btn-cancel" onclick="top.restoreSession()">
            {xlt t='Cancel'}
        </a>
    </div>
    <input type="hidden" name="id" value="{$insurancecompany->id|attr}" />
    <input type="hidden" name="process" value="{$PROCESS|attr}" />
</form>

{literal}
<script>
    function submit_insurancecompany() {
        if(document.insurancecompany.name.value.length>0) {
            top.restoreSession();
            document.insurancecompany.submit();
            //Z&H Removed redirection
        } else{
            document.insurancecompany.name.style.backgroundColor="red";
            document.insurancecompany.name.focus();
        }
    }

    function jsWaitForDelay(delay) {
        var startTime = new Date();
        var endTime = null;
        do {
            endTime = new Date();
        } while ((endTime - startTime) < delay);
    }
</script>
{/literal}