<div class="ml-4 d-inline-flex justify-content-center">
    <span class="mr-2">New w/ Manual:</span>
    <div moe relative large>
        <a href="" start show >+ MC</a>
        <form url="/api/clientPrimaryCoverage/createNewCoverageForMedicareWithManualDetermination" right class="mcp-theme-1">
            <input type="hidden" name="clientUid" value="{{$patient->uid}}" class="form-control input-sm" />
            <div class="form-group">
                <label for="" class="control-label">Subscriber Name First</label>
                <input type="text" name="subscriberNameFirst" class="form-control input-sm" value="{{$patient->name_first}}"/>
            </div>
            <div class="form-group">
                <label for="" class="control-label">Subscriber Name Last</label>
                <input type="text" name="subscriberNameLast" class="form-control input-sm" value="{{$patient->name_last}}"/>
            </div>
            <div class="form-group">
                <label for="" class="control-label">Subscriber Dob</label>
                <input type="date" name="subscriberDob" class="form-control input-sm" value="{{$patient->dob}}"/>
            </div>
            <div class="form-group">
                <label for="" class="control-label">Payer Member Identifier</label>
                <input type="text" name="payerMemberIdentifier" class="form-control input-sm"/>
            </div>
            <div class="form-group">
                <label for="" class="control-label">Date Of Service</label>
                <input type="date" name="dateOfService" class="form-control input-sm" value="{{date('Y-m-d')}}"/>
            </div>
            <div class="form-group">
                <label for="" class="control-label">Manual Determination Strategy</label>
                <select  name="manualDeterminationStrategy" class="form-control input-sm">
                    <option value="">--select--</option>
                    <option value="REVIEWED_ELECTRONIC">Reviewed electronic</option>
                    <option value="CALLED_PAYER">Called payer</option>
                </select>
            </div>
            <div class="form-group">
                <label for="" class="control-label">Manual Determination Category</label>
                <select  name="manualDeterminationCategory" class="form-control input-sm">
                    <option value="">--select--</option>
                    <option value="COVERED">Covered</option>
                    <option value="NOT_COVERED">Not Covered</option>
                    <option value="INVALID">Invalid</option>
                    <option value="UNKNOWN">Unknown</option>
                </select>
            </div>
            <div class="form-group">
                <label for="" class="control-label">Manual Determination Category Memo</label>
                <input type="text" name="manualDeterminationCategoryMemo" class="form-control input-sm"/>
            </div>
            <div class="form-group">
                <label for="" class="control-label">Manual Detail Json</label>
                <input type="text" name="manualDetailJson" class="form-control input-sm"/>
            </div>
            <div class="form-group">
                <label for="" class="control-label">Manual Medicare Is Part B Primary</label>
                <select  name="manualMedicareIsPartBPrimary" class="form-control input-sm">
                    <option value="">--select--</option>
                    <option value="YES">Yes</option>
                    <option value="NO">No</option>
                    <option value="UNKNOWN">Unknown</option>
                </select>
            </div>
            <div class="form-group">
                <label for="" class="control-label">Manual Medicare Is Part B Active</label>
                <select  name="manualMedicareIsPartBActive" class="form-control input-sm">
                    <option value="">--select--</option>
                    <option value="YES">Yes</option>
                    <option value="NO">No</option>
                    <option value="UNKNOWN">Unknown</option>
                </select>
            </div>
            <div class="form-group">
                <label for="" class="control-label">Manual Medicare Is Part C Active</label>
                <select  name="manualMedicareIsPartCActive" class="form-control input-sm">
                    <option value="">--select--</option>
                    <option value="YES">Yes</option>
                    <option value="NO">No</option>
                    <option value="UNKNOWN">Unknown</option>
                </select>
            </div>
            <div class="form-group">
                <label for="" class="control-label">Manual Medicare Is Inpatient</label>
                <select  name="manualMedicareIsInpatient" class="form-control input-sm">
                    <option value="">--select--</option>
                    <option value="YES">Yes</option>
                    <option value="NO">No</option>
                    <option value="UNKNOWN">Unknown</option>
                </select>
            </div>
            <div class="form-group">
                <label for="" class="control-label">Manual Medicare Is Hospice Or Home Health</label>
                <select  name="manualMedicareIsHospiceOrHomeHealth" class="form-control input-sm">
                    <option value="">--select--</option>
                    <option value="YES">Yes</option>
                    <option value="NO">No</option>
                    <option value="UNKNOWN">Unknown</option>
                </select>
            </div>
            <div class="form-group">
                <label for="" class="control-label">Manual Medicare Is Msp</label>
                <select  name="manualMedicareIsMsp" class="form-control input-sm">
                    <option value="">--select--</option>
                    <option value="YES">Yes</option>
                    <option value="NO">No</option>
                    <option value="UNKNOWN">Unknown</option>
                </select>
            </div>
            <div class="form-group">
                <label for="" class="control-label">Manual Medicare Msp Memo</label>
                <select  name="manualMedicareMspMemo" class="form-control input-sm">
                    <option value="">--select--</option>
                    <option value="YES">Yes</option>
                    <option value="NO">No</option>
                    <option value="UNKNOWN">Unknown</option>
                </select>
            </div>
            <div class="form-group">
                <label for="" class="control-label">Manual Medicare Mpb Start Date</label>
                <input type="date" name="manualMedicareMpbStartDate" class="form-control input-sm"/>
            </div>
            <div class="form-group">
                <label for="" class="control-label">Manual Medicare Mpb End Date</label>
                <input type="date" name="manualMedicareMpbEndDate" class="form-control input-sm"/>
            </div>
            <div class="form-group">
                <label for="" class="control-label">Manual Medicare Mpb Deductible</label>
                <input type="number" name="manualMedicareMpbDeductible" class="form-control input-sm"/>
            </div>
            <div class="form-group">
                <label for="" class="control-label">Manual Medicare Mpb Remaining</label>
                <input type="number" name="manualMedicareMpbRemaining" class="form-control input-sm"/>
            </div>
            <div class="form-group">
                <label for="" class="control-label">Manual Medicare Mpb Insurance Type</label>
                <input type="text" name="manualMedicareMpbInsuranceType" class="form-control input-sm"/>
            </div>
            <div class="form-group">
                <label for="" class="control-label">Manual Medicare Mpb Insurance Type Label</label>
                <input type="text" name="manualMedicareMpbInsuranceTypeLabel" class="form-control input-sm"/>
            </div>
            <div class="form-group">
                <label for="" class="control-label">Manual Medicare Mpb Coinsurance Percent</label>
                <input type="number" name="manualMedicareMpbCoinsurancePercent" class="form-control input-sm"/>
            </div>
            <div class="form-group">
                <label for="" class="control-label">Manual Medicare Mpb Info Valid Until</label>
                <input type="date" name="manualMedicareMpbInfoValidUntil" class="form-control input-sm"/>
            </div>
            <div class="form-group">
                <label for="" class="control-label">Manual Medicare Mpb Info Valid Till</label>
                <input type="date" name="manualMedicareMpbInfoValidTill" class="form-control input-sm"/>
            </div>
            <div class="form-group text-nowrap mb-0">
                <button class="btn btn-sm btn-primary" submit>Submt</button>
                <button class="btn btn-sm btn-default border" close>Close</button>
            </div>
        </form>
    </div>
    <span class="mx-2 text-secondary text-sm">|</span>
    <div moe relative large>
        <a href="" start show >+ Medicaid</a>
        <form url="/api/clientPrimaryCoverage/createNewCoverageForMedicaidWithManualDetermination" right class="mcp-theme-1">
            <input type="hidden" name="clientUid" value="{{$patient->uid}}" class="form-control input-sm" />
            <div class="form-group">
                <label for="" class="control-label">Manual Determination Strategy</label>
                <select  name="manualDeterminationStrategy" class="form-control input-sm">
                    <option value="">--select--</option>
                    <option value="REVIEWED_ELECTRONIC">Reviewed electronic</option>
                    <option value="CALLED_PAYER">Called payer</option>
                </select>
            </div>
            <div class="form-group">
                <label for="" class="control-label">Manual Determination Category</label>
                <select  name="manualDeterminationCategory" class="form-control input-sm">
                    <option value="">--select--</option>
                    <option value="COVERED">Covered</option>
                    <option value="NOT_COVERED">Not Covered</option>
                    <option value="INVALID">Invalid</option>
                    <option value="UNKNOWN">Unknown</option>
                </select>
            </div>
            <div class="form-group">
                <label for="" class="form-control-label">Manual Determination Category Memo</label>
                <input type="text" name="manualDeterminationCategoryMemo" class="form-control input-sm">
            </div>
            <div class="form-group">
                <label for="" class="control-label">Manual Detail Json</label>
                <input type="text" name="manualDetailJson" class="form-control input-sm">
            </div>
            <div class="form-group text-nowrap mb-0">
                <button class="btn btn-sm btn-primary" submit>Submt</button>
                <button class="btn btn-sm btn-default border" close>Close</button>
            </div>
        </form>
    </div>
    <span class="mx-2 text-secondary text-sm">|</span>
    <div moe relative large>
        <a href="" start show >+ Comm.</a>
        <form url="/api/clientPrimaryCoverage/createNewCoverageForCommercialWithManualDetermination" right class="mcp-theme-1">
            <input type="hidden" name="clientUid" value="{{$patient->uid}}" class="form-control input-sm" />
            <div class="form-group">
                <label class="control-label">Subscriber Name First</label>
                <input type="text" name="subscriberNameFirst" class="form-control input-sm" value="{{$patient->name_first}}">
            </div>
            <div class="form-group">
                <label class="control-label">Subscriber Name Last</label>
                <input type="text" name="subscriberNameLast" class="form-control input-sm" value="{{$patient->name_last}}">
            </div>
            <div class="form-group">
                <label class="control-label">Subscriber Dob</label>
                <input type="date" name="subscriberDob" class="form-control input-sm" value="{{$patient->dob}}">
            </div>
            <div class="form-group">
                <label for="" class="control-label">Subscriber Sex</label>
                <select  name="subscriberSex" class="form-control input-sm">
                    <option value="">--select--</option>
                    <option value="M" {{$patient->sex === 'M' ? 'selected' : ''}}>M</option>
                    <option value="F" {{$patient->sex === 'F' ? 'selected' : ''}}>F</option>
                </select>
            </div>
            <div class="form-group">
                <label for="" class="control-label">Payer Name</label>
                <input type="text" name="payerName" class="form-control input-sm"/>
            </div>
            <div class="form-group">
                <label class="control-label">Payer Member Identifier</label>
                <input type="text" name="payerMemberIdentifier" class="form-control input-sm">
            </div>
            <div class="form-group">
                <label class="control-label">Date Of Service</label>
                <input type="date" name="dateOfService" class="form-control input-sm" value="{{date('Y-m-d')}}">
            </div>

            <div class="form-group">
                <label for="" class="control-label">Manual Determination Strategy</label>
                <select  name="manualDeterminationStrategy" class="form-control input-sm">
                    <option value="">--select--</option>
                    <option value="REVIEWED_ELECTRONIC">Reviewed electronic</option>
                    <option value="CALLED_PAYER">Called payer</option>
                </select>
            </div>
            <div class="form-group">
                <label for="" class="control-label">Manual Determination Category</label>
                <select  name="manualDeterminationCategory" class="form-control input-sm">
                    <option value="">--select--</option>
                    <option value="COVERED">Covered</option>
                    <option value="NOT_COVERED">Not Covered</option>
                    <option value="INVALID">Invalid</option>
                    <option value="UNKNOWN">Unknown</option>
                </select>
            </div>
            <div class="form-group">
                <label for="" class="control-label">Manual Determination Category Memo</label>
                <textarea name="manualDeterminationCategoryMemo" class="form-control input-sm"></textarea>
            </div>
            <div class="form-group">
                <label for="" class="control-label">Manual Detail Json</label>
                <textarea name="manualDetailJson" class="form-control input-sm"></textarea>
            </div>
            <div class="form-group text-nowrap mb-0">
                <button class="btn btn-sm btn-primary" submit>Submt</button>
                <button class="btn btn-sm btn-default border" close>Close</button>
            </div>
        </form>
    </div>
    <span class="mx-2 text-secondary text-sm">|</span>
    <div moe relative large>
        <a href="" start show >+ Mcr Adv.</a>
        <form url="/api/clientPrimaryCoverage/createNewCoverageForMcrAdvWithManualDetermination" right class="mcp-theme-1">
            <input type="hidden" name="clientUid" value="{{$patient->uid}}" class="form-control input-sm" />
            <div class="form-group">
                <label class="control-label">Subscriber Name First</label>
                <input type="text" name="subscriberNameFirst" class="form-control input-sm" value="{{$patient->name_first}}">
            </div>
            <div class="form-group">
                <label class="control-label">Subscriber Name Last</label>
                <input type="text" name="subscriberNameLast" class="form-control input-sm" value="{{$patient->name_last}}">
            </div>
            <div class="form-group">
                <label class="control-label">Subscriber Dob</label>
                <input type="date" name="subscriberDob" class="form-control input-sm" value="{{$patient->dob}}">
            </div>
            <div class="form-group">
                <label for="" class="control-label">Subscriber Sex</label>
                <select  name="subscriberSex" class="form-control input-sm">
                    <option value="">--select--</option>
                    <option value="M" {{$patient->sex === 'M' ? 'selected' : ''}}>M</option>
                    <option value="F" {{$patient->sex === 'F' ? 'selected' : ''}}>F</option>
                </select>
            </div>
            <div class="form-group">
                <label class="control-label">Payer Member Identifier</label>
                <input type="text" name="payerMemberIdentifier" class="form-control input-sm">
            </div>
            <div class="form-group">
                <label class="control-label">Medicare Number</label>
                <input type="text" name="mcrNumber" class="form-control input-sm">
            </div>
            <div class="form-group">
                <label class="control-label">Date Of Service</label>
                <input type="date" name="dateOfService" class="form-control input-sm" value="{{date('Y-m-d')}}">
            </div>

            <div class="form-group">
                <label for="" class="control-label">Manual Determination Strategy</label>
                <select  name="manualDeterminationStrategy" class="form-control input-sm">
                    <option value="">--select--</option>
                    <option value="REVIEWED_ELECTRONIC">Reviewed electronic</option>
                    <option value="CALLED_PAYER">Called payer</option>
                </select>
            </div>
            <div class="form-group">
                <label for="" class="control-label">Manual Determination Category</label>
                <select  name="manualDeterminationCategory" class="form-control input-sm">
                    <option value="">--select--</option>
                    <option value="COVERED">Covered</option>
                    <option value="NOT_COVERED">Not Covered</option>
                    <option value="INVALID">Invalid</option>
                    <option value="UNKNOWN">Unknown</option>
                </select>
            </div>
            <div class="form-group">
                <label for="" class="control-label">Manual Determination Category Memo</label>
                <textarea name="manualDeterminationCategoryMemo" class="form-control input-sm"></textarea>
            </div>
            <div class="form-group">
                <label for="" class="control-label">Manual Detail Json</label>
                <textarea name="manualDetailJson" class="form-control input-sm"></textarea>
            </div>
            <div class="form-group">
                <label for="" class="control-label">Manual Is Payer Member Identifier Valid</label>
                <select  name="manualIsPayerMemberIdentifierValid" class="form-control input-sm">
                    <option value="">--select--</option>
                    <option value="YES">Yes</option>
                    <option value="NO">No</option>
                    <option value="UNKNOWN">Unknown</option>
                </select>
            </div>

            <div class="form-group">
                <label for="" class="control-label">Manual Is Mcr Number Valid</label>
                <select  name="manualIsMcrNumberValid" class="form-control input-sm">
                    <option value="">--select--</option>
                    <option value="YES">Yes</option>
                    <option value="NO">No</option>
                    <option value="UNKNOWN">Unknown</option>
                </select>
            </div>

            <div class="form-group">
                <label for="" class="control-label">Manual Is Mcr Part Bprimary</label>
                <select  name="manualIsMcrPartBPrimary" class="form-control input-sm">
                    <option value="">--select--</option>
                    <option value="YES">Yes</option>
                    <option value="NO">No</option>
                    <option value="UNKNOWN">Unknown</option>
                </select>
            </div>

            <div class="form-group">
                <label for="" class="control-label">Manual Is Mcr Part C Active</label>
                <select  name="manualIsMcrPartCActive" class="form-control input-sm">
                    <option value="">--select--</option>
                    <option value="YES">Yes</option>
                    <option value="NO">No</option>
                    <option value="UNKNOWN">Unknown</option>
                </select>
            </div>
            <div class="form-group text-nowrap mb-0">
                <button class="btn btn-sm btn-primary" submit>Submt</button>
                <button class="btn btn-sm btn-default border" close>Close</button>
            </div>
        </form>
    </div>

    <span class="mx-2 text-secondary text-sm">|</span>
    <div moe relative large>
        <a href="" start show >+ Mcd Mco.</a>
        <form url="/api/clientPrimaryCoverage/createNewCoverageForMcdMcoWithManualDetermination" right class="mcp-theme-1">
            <input type="hidden" name="clientUid" value="{{$patient->uid}}" class="form-control input-sm" />
            <div class="form-group">
                <label class="control-label">Subscriber Name First</label>
                <input type="text" name="subscriberNameFirst" class="form-control input-sm" value="{{$patient->name_first}}">
            </div>
            <div class="form-group">
                <label class="control-label">Subscriber Name Last</label>
                <input type="text" name="subscriberNameLast" class="form-control input-sm" value="{{$patient->name_last}}">
            </div>
            <div class="form-group">
                <label class="control-label">Subscriber Dob</label>
                <input type="date" name="subscriberDob" class="form-control input-sm" value="{{$patient->dob}}">
            </div>
            <div class="form-group">
                <label for="" class="control-label">Subscriber Sex</label>
                <select  name="subscriberSex" class="form-control input-sm">
                    <option value="">--select--</option>
                    <option value="M" {{$patient->sex === 'M' ? 'selected' : ''}}>M</option>
                    <option value="F" {{$patient->sex === 'F' ? 'selected' : ''}}>F</option>
                </select>
            </div>
            <div class="form-group">
                <label class="control-label">Payer Member Identifier</label>
                <input type="text" name="payerMemberIdentifier" class="form-control input-sm">
            </div>
            <div class="form-group">
                <label class="control-label">Medicaid Number</label>
                <input type="text" name="mcrNumber" class="form-control input-sm">
            </div>
            <div class="form-group">
                <label class="control-label">Medicaid State</label>
                <input type="text" name="mcdState" class="form-control input-sm">
            </div>
            <div class="form-group">
                <label class="control-label">Date Of Service</label>
                <input type="date" name="dateOfService" class="form-control input-sm" value="{{date('Y-m-d')}}">
            </div>

            <div class="form-group">
                <label for="" class="control-label">Manual Determination Strategy</label>
                <select  name="manualDeterminationStrategy" class="form-control input-sm">
                    <option value="">--select--</option>
                    <option value="REVIEWED_ELECTRONIC">Reviewed electronic</option>
                    <option value="CALLED_PAYER">Called payer</option>
                </select>
            </div>
            <div class="form-group">
                <label for="" class="control-label">Manual Determination Category</label>
                <select  name="manualDeterminationCategory" class="form-control input-sm">
                    <option value="">--select--</option>
                    <option value="COVERED">Covered</option>
                    <option value="NOT_COVERED">Not Covered</option>
                    <option value="INVALID">Invalid</option>
                    <option value="UNKNOWN">Unknown</option>
                </select>
            </div>
            <div class="form-group">
                <label for="" class="control-label">Manual Determination Category Memo</label>
                <textarea name="manualDeterminationCategoryMemo" class="form-control input-sm"></textarea>
            </div>
            <div class="form-group">
                <label for="" class="control-label">Manual Detail Json</label>
                <textarea name="manualDetailJson" class="form-control input-sm"></textarea>
            </div>
            <div class="form-group">
                <label for="" class="control-label">Manual Is Mcd Number Valid</label>
                <select  name="manualIsMcdNumberValid" class="form-control input-sm">
                    <option value="">--select--</option>
                    <option value="YES">Yes</option>
                    <option value="NO">No</option>
                    <option value="UNKNOWN">Unknown</option>
                </select>
            </div>

            <div class="form-group">
                <label for="" class="control-label">Manual Is Mcd Response Mco Active</label>
                <select  name="manualIsMcdResponseMcoActive" class="form-control input-sm">
                    <option value="">--select--</option>
                    <option value="YES">Yes</option>
                    <option value="NO">No</option>
                    <option value="UNKNOWN">Unknown</option>
                </select>
            </div>
            <div class="form-group text-nowrap mb-0">
                <button class="btn btn-sm btn-primary" submit>Submt</button>
                <button class="btn btn-sm btn-default border" close>Close</button>
            </div>
        </form>
    </div>
</div>
