<div moe>
	<a start show title="Cancel manual determination" class="text-danger">Cancel?</a>
	<form url="/api/clientPrimaryCoverage/cancel" class="mcp-theme-1">
		<input type="hidden" name="uid" value="{{ $cpc->uid }}">
		<div class="mb-2">
			<p>Cancel manual determination?</p>
		</div>
		<div class="mb-2">
			<label class="font-weight-bold mb-1">Reason Memo:</label>
			<input type="text" class="form-control form-control-sm" name="memo">
		</div>
		<div>
			<button submit class="btn btn-sm btn-primary mr-1">Submit</button>
			<button cancel class="btn btn-sm btn-default border">Cancel</button>
		</div>
	</form>
</div>