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153 lines
8.9 KiB
153 lines
8.9 KiB
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<form method='post' name='theform' id='theform' action='cqm.php?type={{ type_report|attr_url }}' onsubmit='return validateForm()'> |
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<input type="hidden" name="csrf_token_form" value="{{ csrf_token|attr }}" /> |
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{% if not show_plans %} |
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<input type='hidden' id='form_plan_filter' name='form_plan_filter' value=''> |
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{% endif %} |
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<div id="report_parameters"> |
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<table> |
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<tr> |
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<td scope="row" width='{{ widthDyn|attr }}'> |
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<div style='float:left'> |
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<table class='text'> |
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{% if is_amc_report %} |
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<tr> |
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<td class='col-form-label'> |
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{{ 'Begin Date'|xlt }}: |
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</td> |
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<td> |
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<input {{ dis_text }} type='text' name='form_begin_date' id="form_begin_date" size='20' value='{{ begin_date|attr }}' class='datepicker form-control'> |
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</td> |
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</tr> |
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{% endif %} |
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<tr> |
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<td class='col-form-label'> |
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{{ target_date_label|text }} |
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</td> |
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<td> |
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<input {{ dis_text }} type='text' name='form_target_date' id="form_target_date" size='20' value='{{ target_date|attr }}' |
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class='datepicker form-control'> |
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</td> |
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</tr> |
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<tr> |
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<td class='col-form-label'> |
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{{ 'Rule Set'|xlt }} |
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</td> |
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<td> |
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<select {{ dis_text }} id='form_rule_filter' name='form_rule_filter' class='form-control'> |
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{% for filter in rule_filters %} |
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<option value="{{ filter.value|attr }}" {% if filter.selected %}selected{% endif %}> |
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{{ filter.label|text }} |
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</option> |
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{% endfor %} |
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</select> |
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</td> |
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</tr> |
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{% if show_plans %} |
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<tr> |
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<td class='col-form-label'> |
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{{ 'Plan Set'|xlt }} |
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</td> |
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<td> |
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<select {{ dis_text }} id='form_plan_filter' name='form_plan_filter' class='form-control'> |
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{% for plan in plans %} |
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<option value="{{ plan.value|attr }}" {% if plan.selected %}selected{% endif %}> |
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{{ plan.label|text }} |
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</option> |
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{% endfor %} |
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</select> |
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</td> |
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</tr> |
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{% endif %} |
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<tr> |
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<td class='col-form-label'> |
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{{ 'Provider'|xlt }}: |
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</td> |
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<td> |
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<select {{ dis_text }} id='form_provider' name='form_provider' class='form-control'> |
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{% for provider in providerReportOptions %} |
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<option value="{{ provider.value|attr }}" {% if provider.selected %}selected{% endif %}> |
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{{ provider.label|text }} |
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</option> |
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{% endfor %} |
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</select> |
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</td> |
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</tr> |
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<tr> |
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<td class='col-form-label'> |
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{{ 'Provider Relationship'|xlt }}: |
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</td> |
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<td> |
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<select {{ dis_text }} id='form_pat_prov_rel' name='form_pat_prov_rel' class='form-control'> |
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{% for relationship in providerRelationship %} |
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<option value="{{ relationship.value|attr }}" {% if relationship.selected %}selected{% endif %}> |
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{{ relationship.label|text }} |
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</option> |
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{% endfor %} |
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</select> |
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</td> |
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</tr> |
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{% if show_manual_labs %} |
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<tr> |
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<td> |
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{{ 'Number labs'|xlt }}:<br /> |
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({{ 'Non-electronic'|xlt }}) |
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</td> |
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<td> |
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<input {{ dis_text|text }} type="text" id="labs_manual_entry" name="labs_manual_entry" class='form-control' value="{{ labs_manual|attr }}"> |
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</td> |
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</tr> |
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{% endif %} |
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</table> |
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</div> |
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</td> |
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<td class='h-100' align='left' valign='middle'> |
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<table class='w-100 h-100' style='border-left:1px solid;'> |
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<tr> |
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<td scope="row"> |
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<div class="text-center"> |
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<div class="btn-group" role="group"> |
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{% if display_submit %} |
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<a href='#' id='submit_button' class='btn btn-secondary btn-save' onclick='runReport();'>{{ 'Submit'|xlt }}</a> |
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<span id='status_span'></span> |
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<div id='processing' style='margin:10px; display:none;'><img src='../pic/ajax-loader.gif'/></div> |
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{% endif %} |
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{% if display_pqri_btns %} |
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<a href='#' id='xmla_button' class='btn btn-secondary btn-transmit' onclick='return GenXml("false")'>{{ 'Generate PQRI report (Method A) - 2011'|xlt }}</a> |
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<a href='#' id='xmlb_button' class='btn btn-secondary btn-transmit' onclick='return GenXml("true")'>{{ 'Generate PQRI report (Method E) - 2011'|xlt}}</a> |
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{% endif %} |
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{% if display_amc_details %} |
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<a class="btn btn-secondary" href="amc_full_report.php?report_id={{ report_id|attr_url }}">{{ 'AMC Detailed Report'|xlt }}</a> |
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{% endif %} |
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<a href='#' class='btn btn-secondary btn-print' id='printbutton'>{{ 'Print'|xlt }}</a> |
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{% if display_qrda_btns %} |
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<a href='#' id="genQRDA" class='btn btn-secondary btn-transmit' onclick='return downloadQRDA()'>{{ 'Generate QRDA I – 2014'|xlt }}</a> |
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<a href='#' id="xmlc_button" class='btn btn-secondary btn-transmit' onclick='return GenXml("QRDA")'>{{ 'Generate QRDA III - 2014'|xlt }}</a> |
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{% endif %} |
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{% if display_back_link %} |
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<a href='report_results.php' class='btn btn-secondary btn-transmit' onclick='top.restoreSession()'>{{ "Return To Report Results"|xlt }}</a> |
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{% endif %} |
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{% if display_new_report_btn %} |
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<a href='#' class='btn btn-secondary btn-transmit' onclick='top.restoreSession(); $("#theform").submit();'>{{ "Start Another Report"|xlt }}</a> |
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{% endif %} |
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</div> |
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</div> |
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</td> |
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</tr> |
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</table> |
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</td> |
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</tr> |
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</table> |
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</div> <!-- end of search parameters --> |
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<input type='hidden' name='form_new_report_id' id='form_new_report_id' value=''/> |
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</form> |