<div moe relative>
    <a start show class="btn btn-primary btn-sm text-white">Submit Chart Review Bill</a>
    <form url="/api/clientReviewRequest/submitGenericBill" class="mcp-theme-1" right>
        <input type="hidden" name="uid" value="{{ $record->uid }}">
        <div class="mb-2">
            <label class="mb-1">Amount</label>
            <input type="number" name="amount" class="form-control" value="30.00" />
        </div>
        <div class="mb-2">
            <label class="mb-1">Effective Date</label>
            <input type="date" name="effectiveDate" class="form-control" value="{{ date('Y-m-d') }}" />
        </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>