|
|
@@ -30,23 +30,23 @@ $medicaidStates = Config::get('constants.medicaid_states');
|
|
|
</div>
|
|
|
<div class="form-group col-md-4">
|
|
|
<label class="control-label">First Name <span class="text-danger">*</span> </label>
|
|
|
- <input type="text" required name="patientNameFirst" value="" class="form-control input-sm">
|
|
|
+ <input autocomplete="_blank" type="text" required name="patientNameFirst" value="" class="form-control input-sm">
|
|
|
</div>
|
|
|
<div class="form-group col-md-4">
|
|
|
<label class="control-label">Middle Name / MI</label>
|
|
|
- <input type="text" name="patientNameMiddle" value="" class="form-control input-sm">
|
|
|
+ <input autocomplete="_blank" type="text" name="patientNameMiddle" value="" class="form-control input-sm">
|
|
|
</div>
|
|
|
<div class="form-group col-md-4">
|
|
|
<label class="control-label">Last Name <span class="text-danger">*</span></label>
|
|
|
- <input type="text" required name="patientNameLast" value="" class="form-control input-sm">
|
|
|
+ <input autocomplete="_blank" type="text" required name="patientNameLast" value="" class="form-control input-sm">
|
|
|
</div>
|
|
|
<div class="form-group col-md-4">
|
|
|
<label class="control-label">Prefix</label>
|
|
|
- <input type="text" name="patientNamePrefix" value="" class="form-control input-sm">
|
|
|
+ <input autocomplete="_blank" type="text" name="patientNamePrefix" value="" class="form-control input-sm">
|
|
|
</div>
|
|
|
<div class="form-group col-md-4">
|
|
|
<label class="control-label">Suffix</label>
|
|
|
- <input type="text" name="patientNameSuffix" value="" class="form-control input-sm">
|
|
|
+ <input autocomplete="_blank" type="text" name="patientNameSuffix" value="" class="form-control input-sm">
|
|
|
</div>
|
|
|
<div class="form-group col-md-4">
|
|
|
<label class="control-label">Sex</label>
|
|
|
@@ -134,7 +134,7 @@ $medicaidStates = Config::get('constants.medicaid_states');
|
|
|
<i class="fa fa-retweet"></i>
|
|
|
</a>
|
|
|
</label>
|
|
|
- <input class='form-control' stag-input-phone type='tel' name='homeNumber' v-model="form.homeNumber">
|
|
|
+ <input class='form-control' autocomplete="_blank" stag-input-phone type='tel' name='homeNumber' v-model="form.homeNumber">
|
|
|
</div>
|
|
|
</div>
|
|
|
<div class="col-md-4">
|
|
|
@@ -145,7 +145,7 @@ $medicaidStates = Config::get('constants.medicaid_states');
|
|
|
<i class="fa fa-arrow-left"></i>
|
|
|
</a>
|
|
|
</label>
|
|
|
- <input class='form-control' stag-input-phone type='tel' name='cellNumber' v-model="form.cellNumber">
|
|
|
+ <input class='form-control' autocomplete="_blank" stag-input-phone type='tel' name='cellNumber' v-model="form.cellNumber">
|
|
|
</div>
|
|
|
</div>
|
|
|
<div class="col-md-4">
|
|
|
@@ -164,7 +164,7 @@ $medicaidStates = Config::get('constants.medicaid_states');
|
|
|
|
|
|
<div class='form-group mb-3 checkbox'>
|
|
|
<label>
|
|
|
- <input type='checkbox' name='isTestRecord' />
|
|
|
+ <input type='checkbox' name='isTestRecord' />
|
|
|
This is a test record
|
|
|
</label>
|
|
|
</div>
|
|
|
@@ -194,7 +194,7 @@ $medicaidStates = Config::get('constants.medicaid_states');
|
|
|
<div class="row" v-show="planType == 'COMMERCIAL'">
|
|
|
<div class="form-group col-md-12">
|
|
|
<label for="" class="control-label">Commercial Payer</label>
|
|
|
- <input name="commercialPayerUidSuggest" class="form-control input-sm" value="" stag-suggest stag-suggest-ep="/search-payer/json" />
|
|
|
+ <input name="commercialPayerUidSuggest" class="form-control input-sm" value="" autocomplete="off" stag-suggest stag-suggest-ep="/search-payer/json" />
|
|
|
<input type="hidden" name="commercialPayerUid" />
|
|
|
</div>
|
|
|
<div class="form-group col-md-6">
|
Peter Muturi