Client > coverages - field order update

resources/views/app/patient/client-primary-coverages.blade.php

@@ -84,14 +84,6 @@
                         <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="String" 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">Subscriber Sex</label>
                         <select  name="subscriberSex" class="form-control input-sm">
@@ -104,6 +96,14 @@
                         <label for="" class="control-label">Payer Name</label>
                         <input type="text" name="payerName" class="form-control input-sm">
                     </div>
+                    <div class="form-group">
+                        <label for="" class="control-label">Payer Member Identifier</label>
+                        <input type="String" 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 text-nowrap mb-0">
                         <button class="btn btn-sm btn-primary" submit>Submt</button>
@@ -128,14 +128,6 @@
                         <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 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">Subscriber Sex</label>
                         <select  name="subscriberSex" class="form-control input-sm">
@@ -148,6 +140,14 @@
                         <label 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 text-nowrap mb-0">
                         <button class="btn btn-sm btn-primary" submit>Submt</button>
@@ -367,14 +367,6 @@
                         <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 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">Subscriber Sex</label>
                         <select  name="subscriberSex" class="form-control input-sm">
@@ -387,6 +379,14 @@
                         <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>