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175 lines
8.5 KiB
175 lines
8.5 KiB
{** |
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* Insurance company edit |
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* |
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* @package OpenEMR |
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* @link https://www.open-emr.org |
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* @author Brady Miller <brady.g.miller@gmail.com> |
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* @copyright Copyright (c) 2017 Brady Miller <brady.g.miller@gmail.com> |
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* @license https://github.com/openemr/openemr/blob/master/LICENSE GNU General Public License 3 |
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*} |
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<form name="insurancecompany" method="post" action="{$FORM_ACTION}" class='form-horizontal' onsubmit="return top.restoreSession()"> |
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<!-- it is important that the hidden form_id field be listed first, when it is called it populates any old information attached with the id, this allows for partial edits |
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if it were called last, the settings from the form would be overwritten with the old information--> |
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<input type="hidden" name="form_id" value="{$insurancecompany->id|attr}"> |
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{if $insurancecompany->get_inactive() eq 1 } |
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<div class="form-row my-sm-2"> |
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<label for="inactive" class="col-form-label col-sm-2">{xlt t='Reactivate'}</label> |
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<div class="col-sm-8"> |
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<input type="checkbox" id="inactive" name="inactive" class="checkbox" value="0" /> |
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</div> |
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</div> |
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{/if} |
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{if $insurancecompany->get_inactive() eq 0 } |
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<div class="form-row my-sm-2"> |
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<label for="inactive" class="col-form-label col-sm-2">{xlt t='Deactivate'}</label> |
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<div class="col-sm-8"> |
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<input type="checkbox" id="inactive" name="inactive" class="checkbox" value="1" /> |
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</div> |
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</div> |
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{/if} |
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<div class="form-row my-sm-2"> |
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<label for="name" class="col-form-label col-sm-2">{xlt t='Name'}</label> |
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<div class="col-sm-8"> |
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<input type="text" id="name" name="name" class="form-control" aria-describedby="nameHelpBox" value="{$insurancecompany->get_name()|attr}" onKeyDown="PreventIt(event)"> |
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<span id="nameHelpBox" class="help-block">({xlt t='Required'})</span> |
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</div> |
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</div> |
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<div class="form-row my-sm-2"> |
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<label for="attn" class="col-form-label col-sm-2">{xlt t='Attn'}</label> |
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<div class="col-sm-8"> |
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<input type="text" id="attn" name="attn" class="form-control" value="{$insurancecompany->get_attn()|attr}" onKeyDown="PreventIt(event)"> |
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</div> |
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</div> |
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<div class="form-row my-sm-2"> |
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<label for="address_line1" class="col-form-label col-sm-2">{xlt t='Address'}</label> |
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<div class="col-sm-8"> |
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<input type="text" id="address_line1" name="address_line1" class="form-control" value="{$insurancecompany->address->line1|attr}" onKeyDown="PreventIt(event)"> |
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</div> |
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</div> |
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<div class="form-row my-sm-2"> |
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<label for="address_line2" class="col-form-label col-sm-2">{xlt t='Address'}</label> |
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<div class="col-sm-8"> |
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<input type="text" id="address_line2" name="address_line2" class="form-control" value="{$insurancecompany->address->line2|attr}" onKeyDown="PreventIt(event)"> |
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</div> |
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</div> |
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<div class="form-row my-sm-2"> |
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<label for="city" class="col-form-label col-sm-2">{xlt t='City'}</label> |
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<div class="col-sm-8"> |
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<input type="text" id="city" name="city" class="form-control" value="{$insurancecompany->address->city|attr}" onKeyDown="PreventIt(event)"> |
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</div> |
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</div> |
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<div class="form-row my-sm-2"> |
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<label for="state" class="col-form-label col-sm-2">{xlt t='State'}</label> |
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<div class="col-sm-8"> |
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<input type="text" maxlength="2" id="state" name="state" class="form-control" value="{$insurancecompany->address->state|attr}" onKeyDown="PreventIt(event)"> |
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</div> |
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</div> |
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<div class="form-row my-sm-2"> |
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<label for="zip" class="col-form-label col-sm-2">{xlt t='Zip Code'}</label> |
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<div class="col-sm-8"> |
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<input type="text" id="zip" name="zip" class="form-control" value="{$insurancecompany->address->zip|attr}" onKeyDown="PreventIt(event)"> |
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</div> |
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</div> |
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<div class="form-row my-sm-2"> |
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<label for="phone" class="col-form-label col-sm-2">{xlt t='Phone'}</label> |
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<div class="col-sm-8"> |
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<input type="text" id="phone" name="phone" class="form-control" value="{$insurancecompany->get_phone()|attr}" onKeyDown="PreventIt(event)"> |
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</div> |
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</div> |
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<div class="form-row my-sm-2"> |
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<label for="fax" class="col-form-label col-sm-2">{xlt t='Fax'}</label> |
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<div class="col-sm-8"> |
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<input type="text" id="fax" name="fax" class="form-control" value="{$insurancecompany->get_fax()|attr}" onKeyDown="PreventIt(event)"> |
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</div> |
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</div> |
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<div class="form-row my-sm-2"> |
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<label for="cms_id" class="col-form-label col-sm-2">{xlt t='Payer ID'}</label> |
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<div class="col-sm-8"> |
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<input type="text" id="cms_id" name="cms_id" class="form-control" value="{$insurancecompany->get_cms_id()|attr}" onKeyDown="PreventIt(event)"> |
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</div> |
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</div> |
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{if $SUPPORT_ENCOUNTER_CLAIMS} |
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<div class="form-row my-sm-2"> |
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<label for="alt_cms_id" class="col-form-label col-sm-2">{xlt t='Payer ID For Encounter Claims'}</label> |
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<div class="col-sm-8"> |
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<input type="text" id="alt_cms_id" name="alt_cms_id" class="form-control" value="{$insurancecompany->get_alt_cms_id()|attr}" onKeyDown="PreventIt(event)"> |
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</div> |
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</div> |
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{/if} |
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{if $SUPPORT_ELIGIBILITY_REQUESTS} |
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<div class="form-row my-sm-2"> |
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<label for="eligibility_id" class="col-form-label col-sm-2">{xlt t='Payer Id For Eligibility'}</label> |
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<div class="col-sm-8"> |
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<input type="text" id="eligibility_id" name="eligibility_id" class="form-control" value="{$insurancecompany->get_eligibility_id()|attr}" onKeyDown="PreventIt(event)"> |
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</div> |
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</div> |
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{/if} |
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<div class="form-row my-sm-2"> |
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<label for="ins_type_code" class="col-form-label col-sm-2">{xlt t='Payer Type'}</label> |
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<div class="col-sm-8"> |
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<select id="ins_type_code" name="ins_type_code" class="form-control"> |
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{html_options options=$insurancecompany->ins_type_code_array selected=$insurancecompany->get_ins_type_code()} |
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</select> |
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</div> |
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</div> |
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<div class="form-row my-sm-2"> |
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<label for="x12_default_partner_id" class="col-form-label col-sm-2">{xlt t='Default X12 Partner'}</label> |
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<div class="col-sm-8"> |
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<select id="x12_default_partner_id" name="x12_default_partner_id" class="form-control"> |
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{html_options options=$x12_partners selected=$insurancecompany->get_x12_default_partner_id()} |
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</select> |
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</div> |
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</div> |
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<div class="form-row my-sm-2"> |
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<label for="cqm_sop" class="col-form-label col-sm-2">{xlt t='CQM Source of Payment'}</label> |
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<div class="col-sm-8"> |
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<select id="cqm_sop" name="cqm_sop" class="form-control"> |
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{html_options options=$insurancecompany->cqm_sop_array selected=$insurancecompany->get_cqm_sop()} |
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</select> |
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</div> |
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</div> |
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{if $SUPPORT_ELIGIBILITY_REQUESTS} |
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<div class="form-row my-sm-2"> |
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<label for="x12_default_eligibility_id" class="col-form-label col-sm-2">{xlt t='Default Eligibility X12 Partner'}</label> |
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<div class="col-sm-8"> |
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<select id="x12_default_eligibility_id" name="x12_default_eligibility_id" class="form-control"> |
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{html_options options=$x12_partners selected=$insurancecompany->get_x12_default_eligibility_id()} |
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</select> |
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</div> |
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</div> |
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{/if} |
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<div class="btn-group offset-sm-2"> |
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<a href="javascript:submit_insurancecompany();" class="btn btn-secondary btn-save" onclick="top.restoreSession()"> |
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{xlt t='Save'} |
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</a> |
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<a href="controller.php?practice_settings&insurance_company&action=list" class="btn btn-link btn-cancel" onclick="top.restoreSession()"> |
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{xlt t='Cancel'} |
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</a> |
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</div> |
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<input type="hidden" name="id" value="{$insurancecompany->id|attr}" /> |
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<input type="hidden" name="process" value="{$PROCESS|attr}" /> |
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</form> |
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{literal} |
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<script> |
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function submit_insurancecompany() { |
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if(document.insurancecompany.name.value.length>0) { |
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top.restoreSession(); |
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document.insurancecompany.submit(); |
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//Z&H Removed redirection |
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} else{ |
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document.insurancecompany.name.style.backgroundColor="red"; |
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document.insurancecompany.name.focus(); |
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} |
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} |
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function jsWaitForDelay(delay) { |
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var startTime = new Date(); |
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var endTime = null; |
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do { |
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endTime = new Date(); |
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} while ((endTime - startTime) < delay); |
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} |
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</script> |
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{/literal}
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