updated new patient creation form

resources/views/app/patient/create-patient/demographics-form.blade.php

@@ -60,9 +60,9 @@
 <div class="row">
 	<div class="col-12">
 		<div class="row align-items-center form-group">
-			<label class="col-md-2 pr-0 font-weight-bold m-0">HCP Pro:</label>
+			<label class="col-md-2 pr-0 font-weight-bold m-0">HCP Pro: <span class="text-danger">*</span></label>
 			<div class="col-md-10">
-				<select name="hcpProUid" class="form-control input-sm" provider-search provider-type="hcp">
+				<select name="hcpProUid" class="form-control input-sm" required provider-search provider-type="hcp">
 					<option value="">--select--</option>
 				</select>
 			</div>

resources/views/app/patient/create-patient/insurance-coverage-form.blade.php

@@ -6,48 +6,58 @@
 		<div class="form-group col-md-12">
 			<p class="mb-1 font-weight-bold">Type of insurance card:</p>
 			<div class="form-check form-check-inline">
-				<label class="form-check-label"><input class="form-check-input" type="radio" v-model="planType" name="planType" value="MEDICARE">Medicare Part B (Primary)</label>
+				<label class="form-check-label"><input class="form-check-input" type="radio" v-model="planType" name="planType" value="">Skip</label>
 			</div>
 			<div class="form-check form-check-inline">
-				<label class="form-check-label"><input class="form-check-input" type="radio" v-model="planType" name="planType" value="MEDICAID">Medicaid (Primary)</label>
+				<label class="form-check-label"><input class="form-check-input" type="radio" v-model="planType" name="planType" value="MEDICARE">Medicare Part B</label>
 			</div>
 			<div class="form-check form-check-inline">
-				<label class="form-check-label"><input class="form-check-input" type="radio" v-model="planType" name="planType" value="COMMERCIAL">Commercial / Third Party (Primary)</label>
+				<label class="form-check-label"><input class="form-check-input" type="radio" v-model="planType" name="planType" value="MEDICAID">Medicaid</label>
+			</div>
+			<div class="form-check form-check-inline">
+				<label class="form-check-label"><input class="form-check-input" type="radio" v-model="planType" name="planType" value="COMMERCIAL">Other Provider</label>
+			</div>
+			<div class="form-check form-check-inline">
+				<label class="form-check-label"><input class="form-check-input" type="radio" v-model="planType" name="planType" value="SELF_PAY">Self Pay</label>
 			</div>
 		</div>
 	</div>
 	<div class="px-2">
 		<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="" autocomplete="off" stag-suggest stag-suggest-ep="/search-payer/json" />
-				<input type="hidden" name="commercialPayerUid" />
-			</div>
-			<div class="col-md-12">
-				<p class="mb-2 font-weight-bold">If payer not found above, please key in carrier name (and memo if any):</p>
-			</div>
-			<div class="form-group col-md-6">
-				<label class="control-label">Carrier Name</label>
-				<input type="text" name="carrierFreeText" class="form-control input-sm">
-			</div>
 			<div class="form-group col-md-6">
-				<label class="control-label">Carrier Memo</label>
-				<input type="text" name="carrierFreeTextMemo" class="form-control input-sm">
-			</div>
-			<div class="col-12">
-				<hr class="mt-0 mb-2">
+				<label class="control-label">Insurance</label>
+				<input type="text" name="carrierFreeText" list="insurance" class="form-control input-sm">
+				<datalist id="insurance">
+					<option value="Aetna">
+					<option value="Anthem Blue Cross Blue Shield">
+					<option value="Cigna">
+					<option value="Humana">
+					<option value="Kaiser Permanente">
+					<option value="UnitedHealthcare">
+					<option value="Blue Cross Blue Shield">
+					<option value="Health Net">
+					<option value="Molina Healthcare">
+					<option value="Oscar Health">
+					<option value="Ambetter">
+					<option value="CareSource">
+					<option value="Centene Corporation">
+					<option value="Highmark">
+					<option value="Independence Blue Cross">
+					<option value="WellCare">
+					<option value="Tricare">
+				</datalist>
 			</div>
 			<div class="form-group col-md-6">
-				<label class="control-label">Patient Member Identifier</label>
+				<label class="control-label">ID Number</label>
 				<input type="text" name="commercialMemberIdentifier" class="form-control input-sm">
 			</div>
 			<div class="form-group col-md-6">
-				<label class="control-label">Patient Group Number</label>
+				<label class="control-label">Group Number</label>
 				<input type="text" name="commercialGroupNumber" class="form-control input-sm">
 			</div>
 			<div class="form-group col-md-6">
-				<label class="control-label">Phone Number For Hcps</label>
-				<input type="text" name="primaryInsurancePhoneNumberForHcps" class="form-control input-sm">
+				<label class="control-label">Support Phone Number</label>
+				<input type="text" name="primaryInsurancePhoneNumberForHcps" class="form-control input-sm phone">
 			</div>
 		</div>