<div moe relative wide>
	<a href="" start show>
		+ Medicare Part B (Primary)
	</a>
	<form url="/api/clientPrimaryCoverage/createNewCoverageForMedicare" right class="mcp-theme-1">
		<input type="hidden" name="clientUid" value="{{$patient->uid}}" class="form-control input-sm" />
		<div class="row">
			<div class="form-group col-md-6">
				<label class="control-label">Patient First Name</label>
				<input type="text" name="patientNameFirst" value="{{$patient->name_first}}" class="form-control input-sm">
			</div>
			<div class="form-group col-md-6">
				<label class="control-label">Patient Middle Name / MI</label>
				<input type="text" name="patientNameMiddle" value="{{$patient->name_middle}}" class="form-control input-sm">
			</div>
			<div class="form-group col-md-6">
				<label class="control-label">Patient Last Name</label>
				<input type="text" name="patientNameLast" value="{{$patient->name_last}}" class="form-control input-sm">
			</div>
			<div class="form-group col-md-6">
				<label class="control-label">Patient Suffix</label>
				<input type="text" name="patientNameSuffix" value="{{$patient->name_suffix}}" class="form-control input-sm">
			</div>
			<div class="form-group col-md-6">
				<label class="control-label">Patient Dob</label>
				<input type="date" name="patientDob" value="{{$patient->dob}}" class="form-control input-sm">
			</div>

			<div class="form-group col-md-6">
				<label class="control-label">Medicare Number</label>
				<input type="text" name="mcrNumber" class="form-control input-sm">
			</div>

			<div class="form-group col-md-6">
				<label class="control-label">Date Of Service</label>
				<input type="date" name="dateOfService" value="{{date('Y-m-d')}}" class="form-control input-sm">
			</div>
		</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" cancel>Close</button>
		</div>
	</form>
</div>
