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@@ -71,10 +71,42 @@
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<label class='control-label'>Email Address </label>
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<label class='control-label'>Email Address </label>
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<input class='form-control' type='email' name='emailAddress'>
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<input class='form-control' type='email' name='emailAddress'>
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</div>
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</div>
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+ <hr class="m-neg-4">
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<div class='form-group mb-3'>
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<div class='form-group mb-3'>
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- <label class='control-label'>Medicare Number *</label>
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- <input class='form-control' type='text' name='medicareNumber' required>
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+ <label class='control-label'>Insurance </label>
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+ <div class="d-flex align-items-center">
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+ <label class="mr-3 d-inline-flex align-items-center">
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+ <input class='insurance' type='radio' name='insurance' value="medicare">
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+ <span class="ml-1">Medicare</span>
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+ </label>
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+ <label class="mr-3 d-inline-flex align-items-center">
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+ <input class='insurance' type='radio' name='insurance' value="non-medicare">
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+ <span class="ml-1">Non-Medicare</span>
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+ </label>
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+ </div>
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</div>
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</div>
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+ <div data-insurance="medicare" class="d-none">
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+ <div class='form-group mb-3'>
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+ <label class='control-label'>Medicare Number</label>
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+ <input class='form-control' type='text' name='medicareNumber'>
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+ </div>
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+ </div>
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+ <div data-insurance="non-medicare" class="d-none">
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+ <div class='form-group mb-3'>
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+ <label class='control-label d-block'>Payer</label>
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+ <select name="mbPayerUid" class="form-control select2">
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+ <option value="">--select--</option>
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+ @foreach($mbPayers as $mbPayer)
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+ <option value="{{$mbPayer->uid}}">{{$mbPayer->name()}}</option>
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+ @endforeach
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+ </select>
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+ </div>
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+ <div class='form-group mb-3'>
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+ <label class='control-label'>Member ID</label>
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+ <input class='form-control' type='text' name='mbPayerMemberId' required>
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+ </div>
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+ </div>
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+ <hr class="m-neg-4">
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<div class='form-group mb-3'>
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<div class='form-group mb-3'>
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<label class='control-label'>Initiative</label>
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<label class='control-label'>Initiative</label>
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<select name="initiative" class="form-control">
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<select name="initiative" class="form-control">
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@@ -93,6 +125,8 @@
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</div>
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</div>
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</div>
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</div>
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+ <link href="/select2/select2.min.css" rel="stylesheet" />
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+ <script src="/select2/select2.min.js"></script>
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<script src="/inputmask-5.x/dist/inputmask.js"></script>
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<script src="/inputmask-5.x/dist/inputmask.js"></script>
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<script>
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<script>
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(function() {
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(function() {
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@@ -120,6 +154,17 @@
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$('[name="cellNumber"]').val(hpn);
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$('[name="cellNumber"]').val(hpn);
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return false;
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return false;
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});
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});
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+ $(document)
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+ .off('change.insurance', '.insurance')
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+ .on('change.insurance', '.insurance', function() {
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+ $('[data-insurance]').addClass('d-none');
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+ $('[data-insurance="' + $(this).val() + '"]').removeClass('d-none');
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+ $(this).closest('form').attr('url', '/api/client/' + ($(this).val() === 'medicare' ? 'create' : 'createNonMcn'))
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+ return false;
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+ });
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+ $('.select2').select2({
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+ width: '100%'
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+ });
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}
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}
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addMCInitializer('new-patient', init, '#newPatientContainer');
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addMCInitializer('new-patient', init, '#newPatientContainer');
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}).call(window);
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}).call(window);
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