updated ui

public/css/style.css

@@ -228,6 +228,9 @@ body>nav.navbar {
 [moe][large] form, [moe][large] [url] {
     width: 450px;
 }
+[moe][wide] form, [moe][wide] [url] {
+    width: 550px;
+}
 [moe][bottom] form {
     bottom: 100%;
 }
@@ -2074,4 +2077,4 @@ body.in-iframe .main-row > .sidebar {
 }
 .mrv-badge>span {
     font-size: 10px !important;
-}
+}

resources/views/app/patient/primary-coverage-manual-determination-commercial.blade.php

@@ -1,112 +1,114 @@
 <?php
 	$mdc = 'UNKNOWN';
 ?>
-<div moe relative large>
+<div moe relative wide>
 	<a href="" start show class="">Manual Determination for Commercial</a>
 	<form url="/api/clientPrimaryCoverage/manualDeterminationForMedicare" class="mcp-theme-1">
 		<input type="hidden" name="clientPrimaryCoverageUid" value="{{$cpc->uid}}" class="form-control input-sm" />
-		<div class="form-group">
-			<label for="" class="control-label">Manual Determination Strategy</label>
-			<select name="manualDeterminationStrategy" class="form-control input-sm">
-				<option value="">--select--</option>
-				<option value="REVIEWED_ELECTRONIC">Reviewed electronic</option>
-				<option value="CALLED_PAYER">Called payer</option>
-			</select>
+		<div class="row">
+			<div class="form-group col-md-6">
+				<label for="" class="control-label">Manual Determination Strategy</label>
+				<select name="manualDeterminationStrategy" class="form-control input-sm">
+					<option value="">--select--</option>
+					<option value="REVIEWED_ELECTRONIC">Reviewed electronic</option>
+					<option value="CALLED_PAYER">Called payer</option>
+				</select>
+			</div>
+			<div class="form-group col-md-6">
+				<label for="" class="control-label">Manual Determination Category</label>
+				<select name="manualDeterminationCategory" class="form-control input-sm">
+					<option value="">--select--</option>
+					<option value="COVERED">Covered</option>
+					<option value="NOT_COVERED">Not Covered</option>
+					<option value="INVALID">Invalid</option>
+					<option value="UNKNOWN">Unknown</option>
+				</select>
+			</div>
+			<div class="form-group col-md-12">
+				<label for="" class="control-label">Manual Determination Category Memo</label>
+				<input type="text" name="manualDeterminationCategoryMemo" class="form-control input-sm" />
+			</div>
+			@if($cpc->mcr_number)
+			<div class="form-group col-md-6">
+				<label for="" class="control-label">Manual Medicare Is Matched</label>
+				<select name="manualMedicareIsMatched" class="form-control input-sm">
+					<option value="">--select--</option>
+					<option value="YES">Yes</option>
+					<option value="NO">No</option>
+					<option value="UNKNOWN">Unknown</option>
+				</select>
+			</div>
+			<div class="form-group col-md-6">
+				<label for="" class="control-label">Manual Medicare Is Part B Active</label>
+				<select name="manualMedicareIsPartBActive" class="form-control input-sm">
+					<option value="">--select--</option>
+					<option value="YES">Yes</option>
+					<option value="NO">No</option>
+					<option value="UNKNOWN">Unknown</option>
+				</select>
+			</div>
+			<div class="form-group col-md-6">
+				<label for="" class="control-label">Manual Medicare Is Part B Primary</label>
+				<select name="manualMedicareIsPartBPrimary" class="form-control input-sm">
+					<option value="">--select--</option>
+					<option value="YES">Yes</option>
+					<option value="NO">No</option>
+					<option value="UNKNOWN">Unknown</option>
+				</select>
+			</div>
+			<div class="form-group col-md-6">
+				<label for="" class="control-label">Manual Medicare Is Part C Active</label>
+				<select name="manualMedicareIsPartCActive" class="form-control input-sm">
+					<option value="">--select--</option>
+					<option value="YES">Yes</option>
+					<option value="NO">No</option>
+					<option value="UNKNOWN">Unknown</option>
+				</select>
+			</div>
+			<div class="form-group col-md-6">
+				<label for="" class="control-label">Manual Medicare Is Inpatient</label>
+				<select name="manualMedicareIsInpatient" class="form-control input-sm">
+					<option value="">--select--</option>
+					<option value="YES">Yes</option>
+					<option value="NO">No</option>
+					<option value="UNKNOWN">Unknown</option>
+				</select>
+			</div>
+			<div class="form-group col-md-12">
+				<label for="" class="control-label">Manual Medicare Is Hospice Or Home Health</label>
+				<select name="manualMedicareIsHospiceOrHomeHealth" class="form-control input-sm">
+					<option value="">--select--</option>
+					<option value="YES">Yes</option>
+					<option value="NO">No</option>
+					<option value="UNKNOWN">Unknown</option>
+				</select>
+			</div>
+			<div class="form-group col-md-12">
+				<label for="" class="control-label">Manual Medicare Is Msp</label>
+				<select name="manualMedicareIsMsp" class="form-control input-sm">
+					<option value="">--select--</option>
+					<option value="YES">Yes</option>
+					<option value="NO">No</option>
+					<option value="UNKNOWN">Unknown</option>
+				</select>
+			</div>
+			<div class="form-group col-md-12">
+				<label for="" class="control-label">Manual Medicare Msp Memo</label>
+				<textarea name="manualMedicareMspMemo" class="form-control"></textarea>
+			</div>
+			@endif
+			@if($cpc->mcd_number)
+			<div class="form-group col-md-6">
+				<label for="" class="control-label">Manual Medicaid Is Matched</label>
+				<select name="manualMedicaidIsMatched" class="form-control input-sm">
+					<option value="">--select--</option>
+					<option value="YES">Yes</option>
+					<option value="NO">No</option>
+					<option value="UNKNOWN">Unknown</option>
+				</select>
+			</div>
+			@endif
 		</div>
-		<div class="form-group">
-			<label for="" class="control-label">Manual Determination Category</label>
-			<select name="manualDeterminationCategory" class="form-control input-sm">
-				<option value="">--select--</option>
-				<option value="COVERED">Covered</option>
-				<option value="NOT_COVERED">Not Covered</option>
-				<option value="INVALID">Invalid</option>
-				<option value="UNKNOWN">Unknown</option>
-			</select>
-		</div>
-		<div class="form-group">
-			<label for="" class="control-label">Manual Determination Category Memo</label>
-			<input type="text" name="manualDeterminationCategoryMemo" class="form-control input-sm" />
-		</div>
-		@if($cpc->medicare_number)
-		<div class="form-group">
-			<label for="" class="control-label">Manual Medicare Is Matched</label>
-			<select name="manualMedicareIsMatched" class="form-control input-sm">
-				<option value="">--select--</option>
-				<option value="YES">Yes</option>
-				<option value="NO">No</option>
-				<option value="UNKNOWN">Unknown</option>
-			</select>
-		</div>
-		<div class="form-group">
-			<label for="" class="control-label">Manual Medicare Is Part B Active</label>
-			<select name="manualMedicareIsPartBActive" class="form-control input-sm">
-				<option value="">--select--</option>
-				<option value="YES">Yes</option>
-				<option value="NO">No</option>
-				<option value="UNKNOWN">Unknown</option>
-			</select>
-		</div>
-		<div class="form-group">
-			<label for="" class="control-label">Manual Medicare Is Part B Primary</label>
-			<select name="manualMedicareIsPartBPrimary" class="form-control input-sm">
-				<option value="">--select--</option>
-				<option value="YES">Yes</option>
-				<option value="NO">No</option>
-				<option value="UNKNOWN">Unknown</option>
-			</select>
-		</div>
-		<div class="form-group">
-			<label for="" class="control-label">Manual Medicare Is Part C Active</label>
-			<select name="manualMedicareIsPartCActive" class="form-control input-sm">
-				<option value="">--select--</option>
-				<option value="YES">Yes</option>
-				<option value="NO">No</option>
-				<option value="UNKNOWN">Unknown</option>
-			</select>
-		</div>
-		<div class="form-group">
-			<label for="" class="control-label">Manual Medicare Is Inpatient</label>
-			<select name="manualMedicareIsInpatient" class="form-control input-sm">
-				<option value="">--select--</option>
-				<option value="YES">Yes</option>
-				<option value="NO">No</option>
-				<option value="UNKNOWN">Unknown</option>
-			</select>
-		</div>
-		<div class="form-group">
-			<label for="" class="control-label">Manual Medicare Is Hospice Or Home Health</label>
-			<select name="manualMedicareIsHospiceOrHomeHealth" class="form-control input-sm">
-				<option value="">--select--</option>
-				<option value="YES">Yes</option>
-				<option value="NO">No</option>
-				<option value="UNKNOWN">Unknown</option>
-			</select>
-		</div>
-		<div class="form-group">
-			<label for="" class="control-label">Manual Medicare Is Msp</label>
-			<select name="manualMedicareIsMsp" class="form-control input-sm">
-				<option value="">--select--</option>
-				<option value="YES">Yes</option>
-				<option value="NO">No</option>
-				<option value="UNKNOWN">Unknown</option>
-			</select>
-		</div>
-		<div class="form-group">
-			<label for="" class="control-label">Manual Medicare Msp Memo</label>
-			<textarea name="manualMedicareMspMemo" class="form-control"></textarea>
-		</div>
-		@endif
-		@if($cpc->mcd_number)
-		<div class="form-group">
-			<label for="" class="control-label">Manual Medicaid Is Matched</label>
-			<select name="manualMedicaidIsMatched" class="form-control input-sm">
-				<option value="">--select--</option>
-				<option value="YES">Yes</option>
-				<option value="NO">No</option>
-				<option value="UNKNOWN">Unknown</option>
-			</select>
-		</div>
-		@endif
 
 		<div class="form-group text-nowrap mb-0">
 			<button class="btn btn-sm btn-primary" submit>Submt</button>

resources/views/app/patient/primary-coverage-manual-determination-medicaid.blade.php

@@ -1,31 +1,33 @@
 <?php
 	$mdc = 'UNKNOWN';
 ?>
-<div moe relative large>
+<div moe relative wide>
 	<a href="" start show class="">Manual Determination for Medicaid</a>
 	<form url="/api/clientPrimaryCoverage/manualDeterminationForMedicare" class="mcp-theme-1">
 		<input type="hidden" name="clientPrimaryCoverageUid" value="{{$cpc->uid}}" class="form-control input-sm" />
-		<div class="form-group">
-			<label for="" class="control-label">Manual Determination Strategy</label>
-			<select name="manualDeterminationStrategy" class="form-control input-sm">
-				<option value="">--select--</option>
-				<option value="REVIEWED_ELECTRONIC">Reviewed electronic</option>
-				<option value="CALLED_PAYER">Called payer</option>
-			</select>
-		</div>
-		<div class="form-group">
-			<label for="" class="control-label">Manual Determination Category</label>
-			<select name="manualDeterminationCategory" class="form-control input-sm">
-				<option value="">--select--</option>
-				<option value="COVERED">Covered</option>
-				<option value="NOT_COVERED">Not Covered</option>
-				<option value="INVALID">Invalid</option>
-				<option value="UNKNOWN">Unknown</option>
-			</select>
-		</div>
-		<div class="form-group">
-			<label for="" class="control-label">Manual Determination Category Memo</label>
-			<input type="text" name="manualDeterminationCategoryMemo" class="form-control input-sm" />
+		<div class="row">
+			<div class="form-group col-md-6">
+				<label for="" class="control-label">Manual Determination Strategy</label>
+				<select name="manualDeterminationStrategy" class="form-control input-sm">
+					<option value="">--select--</option>
+					<option value="REVIEWED_ELECTRONIC">Reviewed electronic</option>
+					<option value="CALLED_PAYER">Called payer</option>
+				</select>
+			</div>
+			<div class="form-group col-md-6">
+				<label for="" class="control-label">Manual Determination Category</label>
+				<select name="manualDeterminationCategory" class="form-control input-sm">
+					<option value="">--select--</option>
+					<option value="COVERED">Covered</option>
+					<option value="NOT_COVERED">Not Covered</option>
+					<option value="INVALID">Invalid</option>
+					<option value="UNKNOWN">Unknown</option>
+				</select>
+			</div>
+			<div class="form-group col-md-12">
+				<label for="" class="control-label">Manual Determination Category Memo</label>
+				<input type="text" name="manualDeterminationCategoryMemo" class="form-control input-sm" />
+			</div>
 		</div>
 
 		<div class="form-group text-nowrap mb-0">

resources/views/app/patient/primary-coverage-manual-determination-medicare.blade.php

@@ -1,90 +1,92 @@
 <?php
 	$mdc = 'UNKNOWN';
 ?>
-<div moe relative large>
+<div moe relative wide>
 	<a href="" start show class="">Manual Determination for Medicare Part B (Primary)</a>
 	<form url="/api/clientPrimaryCoverage/manualDeterminationForMedicare" class="mcp-theme-1">
 		<input type="hidden" name="clientPrimaryCoverageUid" value="{{$cpc->uid}}" class="form-control input-sm" />
-		<div class="form-group">
-			<label for="" class="control-label">Manual Determination Strategy</label>
-			<select name="manualDeterminationStrategy" class="form-control input-sm">
-				<option value="">--select--</option>
-				<option value="REVIEWED_ELECTRONIC">Reviewed electronic</option>
-				<option value="CALLED_PAYER">Called payer</option>
-			</select>
-		</div>
-		<div class="form-group">
-			<label for="" class="control-label">Manual Determination Category</label>
-			<select name="manualDeterminationCategory" class="form-control input-sm">
-				<option value="">--select--</option>
-				<option value="COVERED">Covered</option>
-				<option value="NOT_COVERED">Not Covered</option>
-				<option value="INVALID">Invalid</option>
-				<option value="UNKNOWN">Unknown</option>
-			</select>
-		</div>
-		<div class="form-group">
-			<label for="" class="control-label">Manual Determination Category Memo</label>
-			<input type="text" name="manualDeterminationCategoryMemo" class="form-control input-sm" />
-		</div>
+		<div class="row">
+			<div class="form-group col-md-6">
+				<label for="" class="control-label">Manual Determination Strategy</label>
+				<select name="manualDeterminationStrategy" class="form-control input-sm">
+					<option value="">--select--</option>
+					<option value="REVIEWED_ELECTRONIC">Reviewed electronic</option>
+					<option value="CALLED_PAYER">Called payer</option>
+				</select>
+			</div>
+			<div class="form-group col-md-6">
+				<label for="" class="control-label">Manual Determination Category</label>
+				<select name="manualDeterminationCategory" class="form-control input-sm">
+					<option value="">--select--</option>
+					<option value="COVERED">Covered</option>
+					<option value="NOT_COVERED">Not Covered</option>
+					<option value="INVALID">Invalid</option>
+					<option value="UNKNOWN">Unknown</option>
+				</select>
+			</div>
+			<div class="form-group col-md-12">
+				<label for="" class="control-label">Manual Determination Category Memo</label>
+				<textarea name="manualDeterminationCategoryMemo" class="form-control"></textarea>
+			</div>
 
-		<div class="form-group">
-			<label for="" class="control-label">Manual Medicare Is Part B Active</label>
-			<select name="manualMedicareIsPartBActive" class="form-control input-sm">
-				<option value="">--select--</option>
-				<option value="YES">Yes</option>
-				<option value="NO">No</option>
-				<option value="UNKNOWN">Unknown</option>
-			</select>
-		</div>
-		<div class="form-group">
-			<label for="" class="control-label">Manual Medicare Is Part B Primary</label>
-			<select name="manualMedicareIsPartBPrimary" class="form-control input-sm">
-				<option value="">--select--</option>
-				<option value="YES">Yes</option>
-				<option value="NO">No</option>
-				<option value="UNKNOWN">Unknown</option>
-			</select>
-		</div>
-		<div class="form-group">
-			<label for="" class="control-label">Manual Medicare Is Part C Active</label>
-			<select name="manualMedicareIsPartCActive" class="form-control input-sm">
-				<option value="">--select--</option>
-				<option value="YES">Yes</option>
-				<option value="NO">No</option>
-				<option value="UNKNOWN">Unknown</option>
-			</select>
-		</div>
-		<div class="form-group">
-			<label for="" class="control-label">Manual Medicare Is Inpatient</label>
-			<select name="manualMedicareIsInpatient" class="form-control input-sm">
-				<option value="">--select--</option>
-				<option value="YES">Yes</option>
-				<option value="NO">No</option>
-				<option value="UNKNOWN">Unknown</option>
-			</select>
-		</div>
-		<div class="form-group">
-			<label for="" class="control-label">Manual Medicare Is Hospice Or Home Health</label>
-			<select name="manualMedicareIsHospiceOrHomeHealth" class="form-control input-sm">
-				<option value="">--select--</option>
-				<option value="YES">Yes</option>
-				<option value="NO">No</option>
-				<option value="UNKNOWN">Unknown</option>
-			</select>
-		</div>
-		<div class="form-group">
-			<label for="" class="control-label">Manual Medicare Is Msp</label>
-			<select name="manualMedicareIsMsp" class="form-control input-sm">
-				<option value="">--select--</option>
-				<option value="YES">Yes</option>
-				<option value="NO">No</option>
-				<option value="UNKNOWN">Unknown</option>
-			</select>
-		</div>
-		<div class="form-group">
-			<label for="" class="control-label">Manual Medicare Msp Memo</label>
-			<textarea name="manualMedicareMspMemo" class="form-control"></textarea>
+			<div class="form-group col-md-6">
+				<label for="" class="control-label">Manual Medicare Is Part B Active</label>
+				<select name="manualMedicareIsPartBActive" class="form-control input-sm">
+					<option value="">--select--</option>
+					<option value="YES">Yes</option>
+					<option value="NO">No</option>
+					<option value="UNKNOWN">Unknown</option>
+				</select>
+			</div>
+			<div class="form-group col-md-6">
+				<label for="" class="control-label">Manual Medicare Is Part B Primary</label>
+				<select name="manualMedicareIsPartBPrimary" class="form-control input-sm">
+					<option value="">--select--</option>
+					<option value="YES">Yes</option>
+					<option value="NO">No</option>
+					<option value="UNKNOWN">Unknown</option>
+				</select>
+			</div>
+			<div class="form-group col-md-6">
+				<label for="" class="control-label">Manual Medicare Is Part C Active</label>
+				<select name="manualMedicareIsPartCActive" class="form-control input-sm">
+					<option value="">--select--</option>
+					<option value="YES">Yes</option>
+					<option value="NO">No</option>
+					<option value="UNKNOWN">Unknown</option>
+				</select>
+			</div>
+			<div class="form-group col-md-6">
+				<label for="" class="control-label">Manual Medicare Is Inpatient</label>
+				<select name="manualMedicareIsInpatient" class="form-control input-sm">
+					<option value="">--select--</option>
+					<option value="YES">Yes</option>
+					<option value="NO">No</option>
+					<option value="UNKNOWN">Unknown</option>
+				</select>
+			</div>
+			<div class="form-group col-md-12">
+				<label for="" class="control-label">Manual Medicare Is Hospice Or Home Health</label>
+				<select name="manualMedicareIsHospiceOrHomeHealth" class="form-control input-sm">
+					<option value="">--select--</option>
+					<option value="YES">Yes</option>
+					<option value="NO">No</option>
+					<option value="UNKNOWN">Unknown</option>
+				</select>
+			</div>
+			<div class="form-group col-md-12">
+				<label for="" class="control-label">Manual Medicare Is Msp</label>
+				<select name="manualMedicareIsMsp" class="form-control input-sm">
+					<option value="">--select--</option>
+					<option value="YES">Yes</option>
+					<option value="NO">No</option>
+					<option value="UNKNOWN">Unknown</option>
+				</select>
+			</div>
+			<div class="form-group col-md-12">
+				<label for="" class="control-label">Manual Medicare Msp Memo</label>
+				<textarea name="manualMedicareMspMemo" class="form-control"></textarea>
+			</div>
 		</div>
 
 

resources/views/app/patient/primary-coverage-manual-determination.blade.php

@@ -1,120 +0,0 @@
-<?php
-	$mdc = 'UNKNOWN';
-?>
-<div moe relative large>
-	<a href="" start show class="">Manual Determination {{$planType}}</a>
-	<form url="/api/clientPrimaryCoverage/manualDeterminationForMedicare" class="mcp-theme-1">
-		<input type="hidden" name="clientPrimaryCoverageUid" value="{{$cpc->uid}}" class="form-control input-sm" />
-		<div class="form-group">
-			<label for="" class="control-label">Manual Determination Strategy</label>
-			<select name="manualDeterminationStrategy" class="form-control input-sm">
-				<option value="">--select--</option>
-				<option value="REVIEWED_ELECTRONIC">Reviewed electronic</option>
-				<option value="CALLED_PAYER">Called payer</option>
-			</select>
-		</div>
-		<div class="form-group">
-			<label for="" class="control-label">Manual Determination Category</label>
-			<select name="manualDeterminationCategory" class="form-control input-sm">
-				<option value="">--select--</option>
-				<option value="ALLOW">Allow</option>
-				<option value="COVERED">Covered</option>
-				<option value="NOT_COVERED">Not Covered</option>
-				<option value="INVALID">Invalid</option>
-				<option value="UNKNOWN">Unknown</option>
-			</select>
-		</div>
-		<div class="form-group">
-			<label for="" class="control-label">Manual Determination Category Memo</label>
-			<input type="text" name="manualDeterminationCategoryMemo" class="form-control input-sm" />
-		</div>
-		
-		@if($planType == 'COMMERCIAL' && $cpc->mcr_number)
-		<div class="form-group">
-			<label for="" class="control-label">Manual Medicare Is Matched</label>
-			<select name="manualMedicareIsMatched" class="form-control input-sm">
-				<option value="">--select--</option>
-				<option value="YES">Yes</option>
-				<option value="NO">No</option>
-				<option value="UNKNOWN">Unknown</option>
-			</select>
-		</div>
-		@endif
-		@if($planType == 'MEDICARE' || ($planType == 'COMMERCIAL' && $cpc->mcr_number ) ) <!-- and manualMedicareIsMatched  -->
-		<div class="form-group">
-			<label for="" class="control-label">Manual Medicare Is Part B Active</label>
-			<select name="manualMedicareIsPartBActive" class="form-control input-sm">
-				<option value="">--select--</option>
-				<option value="YES">Yes</option>
-				<option value="NO">No</option>
-				<option value="UNKNOWN">Unknown</option>
-			</select>
-		</div>
-		<div class="form-group">
-			<label for="" class="control-label">Manual Medicare Is Part B Primary</label>
-			<select name="manualMedicareIsPartBPrimary" class="form-control input-sm">
-				<option value="">--select--</option>
-				<option value="YES">Yes</option>
-				<option value="NO">No</option>
-				<option value="UNKNOWN">Unknown</option>
-			</select>
-		</div>
-		<div class="form-group">
-			<label for="" class="control-label">Manual Medicare Is Part C Active</label>
-			<select name="manualMedicareIsPartCActive" class="form-control input-sm">
-				<option value="">--select--</option>
-				<option value="YES">Yes</option>
-				<option value="NO">No</option>
-				<option value="UNKNOWN">Unknown</option>
-			</select>
-		</div>
-		<div class="form-group">
-			<label for="" class="control-label">Manual Medicare Is Inpatient</label>
-			<select name="manualMedicareIsInpatient" class="form-control input-sm">
-				<option value="">--select--</option>
-				<option value="YES">Yes</option>
-				<option value="NO">No</option>
-				<option value="UNKNOWN">Unknown</option>
-			</select>
-		</div>
-		<div class="form-group">
-			<label for="" class="control-label">Manual Medicare Is Hospice Or Home Health</label>
-			<select name="manualMedicareIsHospiceOrHomeHealth" class="form-control input-sm">
-				<option value="">--select--</option>
-				<option value="YES">Yes</option>
-				<option value="NO">No</option>
-				<option value="UNKNOWN">Unknown</option>
-			</select>
-		</div>
-		<div class="form-group">
-			<label for="" class="control-label">Manual Medicare Is Msp</label>
-			<select name="manualMedicareIsMsp" class="form-control input-sm">
-				<option value="">--select--</option>
-				<option value="YES">Yes</option>
-				<option value="NO">No</option>
-				<option value="UNKNOWN">Unknown</option>
-			</select>
-		</div>
-		<div class="form-group">
-			<label for="" class="control-label">Manual Medicare Msp Memo</label>
-			<textarea name="manualMedicareMspMemo" class="form-control"></textarea>
-		</div>
-		@endif
-		@if($planType == 'COMMERCIAL' && $cpc->mcd_number)
-		<div class="form-group">
-			<label for="" class="control-label">Manual Medicaid Is Matched</label>
-			<select name="manualMedicaidIsMatched" class="form-control input-sm">
-				<option value="">--select--</option>
-				<option value="YES">Yes</option>
-				<option value="NO">No</option>
-				<option value="UNKNOWN">Unknown</option>
-			</select>
-		</div>
-		@endif
-		
-		<div class="form-group text-nowrap mb-0">
-			<button class="btn btn-sm btn-primary" submit>Submt</button>
-			<button class="btn btn-sm btn-default border" cancel>Close</button>
-		</div>
-	</form>
-</div>

resources/views/app/patient/primary-coverage-new-commercial.blade.php

@@ -1,69 +1,71 @@
-<div moe relative large>
+<div moe relative wide>
 	<a href="" start show>
 		+ Commercial
 	</a>
 	<form id="commercialComponent" url="/api/clientPrimaryCoverage/createNewCoverageForMedicare" right class="mcp-theme-1">
 		<input type="hidden" name="clientUid" value="{{$patient->uid}}" class="form-control input-sm" />
 
-		<div class="form-group">
-			<label for="" class="control-label">Commercial Payer</label>
-			<select name="commercialPayerUid" id="" class="form-control input-sm">
-				<option value="">--</option>
-			</select>
-		</div>
-		<div class="form-group">
-			<label class="control-label">Patient Member Identifier</label>
-			<input type="text" name="commercialMemberIdentifier"  class="form-control input-sm">
-		</div>
-		<div class="form-group">
-			<label class="control-label">Patient Group Number</label>
-			<input type="text" name="commercialGroupNumber"  class="form-control input-sm">
-		</div>
-		<div class="form-group">
-			<label class="control-label">Patient First Name</label>
-			<input type="text" name="patientNameFirst" value="{{$patient->name_first}}" class="form-control input-sm">
-		</div>
-		<div class="form-group">
-			<label class="control-label">Patient Middle Name / MI</label>
-			<input type="text" name="patientNameMiddle" value="{{$patient->name_middle}}" class="form-control input-sm">
-		</div>
-		<div class="form-group">
-			<label class="control-label">Patient Last Name</label>
-			<input type="text" name="patientNameLast" value="{{$patient->name_last}}" class="form-control input-sm">
-		</div>
-		<div class="form-group">
-			<label class="control-label">Patient Suffix</label>
-			<input type="text" name="patientNameSuffix" value="{{$patient->name_suffix}}" class="form-control input-sm">
-		</div>
-		<div class="form-group">
-			<label class="control-label">Patient Dob</label>
-			<input type="date" name="patientDob" value="{{$patient->dob}}" class="form-control input-sm">
-		</div>
-		<div class="form-group">
-			<label class="control-label">Patient Sex</label>
-			<select class="form-control input-sm" name="patientSex">
-				<option value="">--</option>
-				<option value="MALE">Male</option>
-				<option value="FEMALE">Female</option>
-				<option value="UNKNOWN">Unknown</option>
-			</select>
-		</div>
-		<div class="form-group">
-			<label class="control-label">Date Of Service</label>
-			<input type="date" name="dateOfService" value="{{date('Y-m-d')}}" class="form-control input-sm">
-		</div>
-		<div class="form-group">
-			<p class="mb-1">Is Patient Subscriber?</p>
-			<label class="mr-2">
-				<input type="radio" name="isPatientSubscriber" v-model="isPatientSubscriber" value="1"> Yes
-			</label>
-			<label class="">
-				<input type="radio" name="isPatientSubscriber" v-model="isPatientSubscriber" value="0"> No
-			</label>
+		<div class="row">
+			<div class="form-group col-md-12">
+				<label for="" class="control-label">Commercial Payer</label>
+				<select name="commercialPayerUid" id="" class="form-control input-sm">
+					<option value="">--</option>
+				</select>
+			</div>
+			<div class="form-group col-md-6">
+				<label class="control-label">Patient Member Identifier</label>
+				<input type="text" name="commercialMemberIdentifier"  class="form-control input-sm">
+			</div>
+			<div class="form-group col-md-6">
+				<label class="control-label">Patient Group Number</label>
+				<input type="text" name="commercialGroupNumber"  class="form-control input-sm">
+			</div>
+			<div class="form-group col-md-6">
+				<label class="control-label">Patient First Name</label>
+				<input type="text" name="patientNameFirst" value="{{$patient->name_first}}" class="form-control input-sm">
+			</div>
+			<div class="form-group col-md-6">
+				<label class="control-label">Patient Middle Name / MI</label>
+				<input type="text" name="patientNameMiddle" value="{{$patient->name_middle}}" class="form-control input-sm">
+			</div>
+			<div class="form-group col-md-6">
+				<label class="control-label">Patient Last Name</label>
+				<input type="text" name="patientNameLast" value="{{$patient->name_last}}" class="form-control input-sm">
+			</div>
+			<div class="form-group col-md-6">
+				<label class="control-label">Patient Suffix</label>
+				<input type="text" name="patientNameSuffix" value="{{$patient->name_suffix}}" class="form-control input-sm">
+			</div>
+			<div class="form-group col-md-6">
+				<label class="control-label">Patient Dob</label>
+				<input type="date" name="patientDob" value="{{$patient->dob}}" class="form-control input-sm">
+			</div>
+			<div class="form-group col-md-6">
+				<label class="control-label">Patient Sex</label>
+				<select class="form-control input-sm" name="patientSex">
+					<option value="">--</option>
+					<option value="M">Male</option>
+					<option value="F">Female</option>
+					<option value="UNKNOWN">Unknown</option>
+				</select>
+			</div>
+			<div class="form-group col-md-6">
+				<label class="control-label">Date Of Service</label>
+				<input type="date" name="dateOfService" value="{{date('Y-m-d')}}" class="form-control input-sm">
+			</div>
+			<div class="form-group col-md-12">
+				<p class="mb-1">Is Patient Subscriber?</p>
+				<label class="mr-2">
+					<input type="radio" name="isPatientSubscriber" v-model="isPatientSubscriber" value="1"> Yes
+				</label>
+				<label class="">
+					<input type="radio" name="isPatientSubscriber" v-model="isPatientSubscriber" value="0"> No
+				</label>
+			</div>
 		</div>
 
-		<div v-if="isPatientSubscriber == 0">
-			<div class="form-group">
+		<div v-if="isPatientSubscriber == 0" class="row">
+			<div class="form-group col-md-6">
 				<label class="control-label">Patient Relationship To Subscriber</label>
 				<select name="patientRelationshipToSubscriber" class="form-control input-sm">
 					<option value="">--</option>
@@ -77,23 +79,23 @@
 					<option value="UNKNOWN">Unknown</option>
 				</select>
 			</div>
-			<div class="form-group">
+			<div class="form-group col-md-6">
 				<label class="control-label">Subscriber First Name</label>
 				<input type="text" name="subscriberNameFirst" value="{{$patient->name_first}}" class="form-control input-sm">
 			</div>
-			<div class="form-group">
+			<div class="form-group col-md-6">
 				<label class="control-label">Subscriber Middle Name / MI</label>
 				<input type="text" name="subscriberNameMiddle" value="{{$patient->name_middle}}" class="form-control input-sm">
 			</div>
-			<div class="form-group">
+			<div class="form-group col-md-6">
 				<label class="control-label">Subscriber Last Name</label>
 				<input type="text" name="subscriberNameLast" value="{{$patient->name_last}}" class="form-control input-sm">
 			</div>
-			<div class="form-group">
+			<div class="form-group col-md-6">
 				<label class="control-label">Subscriber Suffix</label>
 				<input type="text" name="subscriberNameSuffix" value="{{$patient->name_suffix}}" class="form-control input-sm">
 			</div>
-			<div class="form-group">
+			<div class="form-group col-md-6">
 				<label class="control-label">Subscriber Sex</label>
 				<select class="form-control input-sm" name="subscriberSex">
 					<option value="">--</option>
@@ -102,83 +104,85 @@
 					<option value="UNKNOWN">Unknown</option>
 				</select>
 			</div>
-			<div class="form-group">
+			<div class="form-group col-md-6">
 				<label class="control-label">Subscriber Dob</label>
 				<input type="date" name="subscriberDob" value="{{$patient->dob}}" class="form-control input-sm">
 			</div>
 		</div>
 
-		<div class="form-group">
-			<label class="control-label">Medicare Number</label>
-			<input type="text" name="mcrNumber" class="form-control input-sm">
-		</div>
+		<div class="row">
+			<div class="form-group col-md-6">
+				<label class="control-label">Medicare Number</label>
+				<input type="text" name="mcrNumber" class="form-control input-sm">
+			</div>
 
-		<div class="form-group">
-			<label class="control-label">Medicaid Number</label>
-			<input type="text" name="mcdNumber"  class="form-control input-sm">
-		</div>
+			<div class="form-group col-md-6">
+				<label class="control-label">Medicaid Number</label>
+				<input type="text" name="mcdNumber"  class="form-control input-sm">
+			</div>
 
-		<div class="form-group">
-			<label for="" class="control-label">Medicaid Payer</label>
-			<select name="mcdPayerUid" id="" class="form-control input-sm">
-				<option value="">--</option>
-				<option>MEDICAID ALABAMA</option>
-				<option>MEDICAID ALASKA</option>
-				<option>MEDICAID ARIZONA</option>
-				<option>MEDICAID ARKANSAS</option>
-				<option>MEDICAID CALIFORNIA MEDI-CAL</option>
-				<option>MEDICAID COLORADO</option>
-				<option>MEDICAID CONNECTICUT</option>
-				<option>MEDICAID DELAWARE</option>
-				<option>MEDICAID DISTRICT OF COLUMBIA</option>
-				<option>MEDICAID FLORIDA</option>
-				<option>MEDICAID GEORGIA</option>
-				<option>MEDICAID HAWAII</option>
-				<option>MEDICAID IDAHO</option>
-				<option>MEDICAID ILLINOIS</option>
-				<option>MEDICAID INDIANA</option>
-				<option>MEDICAID IOWA</option>
-				<option>MEDICAID KANSAS</option>
-				<option>MEDICAID KENTUCKY</option>
-				<option>MEDICAID LOUISIANA</option>
-				<option>MEDICAID MAINE</option>
-				<option>MEDICAID MARYLAND</option>
-				<option>MEDICAID MARYLAND DHMH</option>
-				<option>MEDICAID MASSACHUSETTS</option>
-				<option>MEDICAID MICHIGAN</option>
-				<option>MEDICAID MINNESOTA</option>
-				<option>MEDICAID MISSISSIPPI</option>
-				<option>MEDICAID MISSISSIPPI</option>
-				<option>MEDICAID MISSOURI</option>
-				<option>MEDICAID MONTANA</option>
-				<option>MEDICAID NEBRASKA</option>
-				<option>MEDICAID NEVADA</option>
-				<option>MEDICAID NEW HAMPSHIRE</option>
-				<option>MEDICAID NEW JERSEY</option>
-				<option>MEDICAID NEW MEXICO</option>
-				<option>MEDICAID NEW YORK</option>
-				<option>MEDICAID NEW YORK</option>
-				<option>MEDICAID NORTH CAROLINA</option>
-				<option>MEDICAID NORTH DAKOTA</option>
-				<option>MEDICAID OHIO</option>
-				<option>MEDICAID OKLAHOMA</option>
-				<option>MEDICAID OREGON</option>
-				<option>MEDICAID OREGON (DHS OMAP)</option>
-				<option>MEDICAID PENNSYLVANIA</option>
-				<option>MEDICAID RHODE ISLAND</option>
-				<option>MEDICAID SOUTH CAROLINA</option>
-				<option>MEDICAID SOUTH DAKOTA</option>
-				<option>MEDICAID TENNESSEE</option>
-				<option>MEDICAID TEXAS</option>
-				<option>MEDICAID TEXAS AND TEXAS HEALTH STEPS</option>
-				<option>MEDICAID UTAH</option>
-				<option>MEDICAID VERMONT</option>
-				<option>MEDICAID VIRGINIA</option>
-				<option>MEDICAID WASHINGTON (PROVIDER ONE)</option>
-				<option>MEDICAID WEST VIRGINIA</option>
-				<option>MEDICAID WISCONSIN</option>
-				<option>MEDICAID WYOMING</option>
-			</select>
+			<div class="form-group col-md-12">
+				<label for="" class="control-label">Medicaid Payer</label>
+				<select name="mcdPayerUid" id="" class="form-control input-sm">
+					<option value="">--</option>
+					<option>MEDICAID ALABAMA</option>
+					<option>MEDICAID ALASKA</option>
+					<option>MEDICAID ARIZONA</option>
+					<option>MEDICAID ARKANSAS</option>
+					<option>MEDICAID CALIFORNIA MEDI-CAL</option>
+					<option>MEDICAID COLORADO</option>
+					<option>MEDICAID CONNECTICUT</option>
+					<option>MEDICAID DELAWARE</option>
+					<option>MEDICAID DISTRICT OF COLUMBIA</option>
+					<option>MEDICAID FLORIDA</option>
+					<option>MEDICAID GEORGIA</option>
+					<option>MEDICAID HAWAII</option>
+					<option>MEDICAID IDAHO</option>
+					<option>MEDICAID ILLINOIS</option>
+					<option>MEDICAID INDIANA</option>
+					<option>MEDICAID IOWA</option>
+					<option>MEDICAID KANSAS</option>
+					<option>MEDICAID KENTUCKY</option>
+					<option>MEDICAID LOUISIANA</option>
+					<option>MEDICAID MAINE</option>
+					<option>MEDICAID MARYLAND</option>
+					<option>MEDICAID MARYLAND DHMH</option>
+					<option>MEDICAID MASSACHUSETTS</option>
+					<option>MEDICAID MICHIGAN</option>
+					<option>MEDICAID MINNESOTA</option>
+					<option>MEDICAID MISSISSIPPI</option>
+					<option>MEDICAID MISSISSIPPI</option>
+					<option>MEDICAID MISSOURI</option>
+					<option>MEDICAID MONTANA</option>
+					<option>MEDICAID NEBRASKA</option>
+					<option>MEDICAID NEVADA</option>
+					<option>MEDICAID NEW HAMPSHIRE</option>
+					<option>MEDICAID NEW JERSEY</option>
+					<option>MEDICAID NEW MEXICO</option>
+					<option>MEDICAID NEW YORK</option>
+					<option>MEDICAID NEW YORK</option>
+					<option>MEDICAID NORTH CAROLINA</option>
+					<option>MEDICAID NORTH DAKOTA</option>
+					<option>MEDICAID OHIO</option>
+					<option>MEDICAID OKLAHOMA</option>
+					<option>MEDICAID OREGON</option>
+					<option>MEDICAID OREGON (DHS OMAP)</option>
+					<option>MEDICAID PENNSYLVANIA</option>
+					<option>MEDICAID RHODE ISLAND</option>
+					<option>MEDICAID SOUTH CAROLINA</option>
+					<option>MEDICAID SOUTH DAKOTA</option>
+					<option>MEDICAID TENNESSEE</option>
+					<option>MEDICAID TEXAS</option>
+					<option>MEDICAID TEXAS AND TEXAS HEALTH STEPS</option>
+					<option>MEDICAID UTAH</option>
+					<option>MEDICAID VERMONT</option>
+					<option>MEDICAID VIRGINIA</option>
+					<option>MEDICAID WASHINGTON (PROVIDER ONE)</option>
+					<option>MEDICAID WEST VIRGINIA</option>
+					<option>MEDICAID WISCONSIN</option>
+					<option>MEDICAID WYOMING</option>
+				</select>
+			</div>
 		</div>
 
 		<div class="form-group text-nowrap mb-0">

resources/views/app/patient/primary-coverage-new-medicaid.blade.php

@@ -1,113 +1,115 @@
-<div moe relative large>
+<div moe relative wide>
 	<a href="" start show>
 		+ Medicaid
 	</a>
 	<form url="/api/clientPrimaryCoverage/createNewCoverageForMedicare" right class="mcp-theme-1">
 		<input type="hidden" name="clientUid" value="{{$patient->uid}}" class="form-control input-sm" />
 
-		<div class="form-group">
-			<label class="control-label">Patient First Name</label>
-			<input type="text" name="patientNameFirst" value="{{$patient->name_first}}" class="form-control input-sm">
-		</div>
-		<div class="form-group">
-			<label class="control-label">Patient Middle Name / MI</label>
-			<input type="text" name="patientNameMiddle" value="{{$patient->name_middle}}" class="form-control input-sm">
-		</div>
-		<div class="form-group">
-			<label class="control-label">Patient Last Name</label>
-			<input type="text" name="patientNameLast" value="{{$patient->name_last}}" class="form-control input-sm">
-		</div>
-		<div class="form-group">
-			<label class="control-label">Patient Suffix</label>
-			<input type="text" name="patientNameSuffix" value="{{$patient->name_suffix}}" class="form-control input-sm">
-		</div>
-		<div class="form-group">
-			<label class="control-label">Patient Sex</label>
-			<select class="form-control input-sm" name="patientSex">
-				<option value="">--</option>
-				<option value="MALE">Male</option>
-				<option value="FEMALE">Female</option>
-				<option value="UNKNOWN">Unknown</option>
-			</select>
-		</div>
-		<div class="form-group">
-			<label class="control-label">Patient Dob</label>
-			<input type="date" name="patientDob" value="{{$patient->dob}}" class="form-control input-sm">
-		</div>
+		<div class="row">
+			<div class="form-group col-md-6">
+				<label class="control-label">Patient First Name</label>
+				<input type="text" name="patientNameFirst" value="{{$patient->name_first}}" class="form-control input-sm">
+			</div>
+			<div class="form-group col-md-6">
+				<label class="control-label">Patient Middle Name / MI</label>
+				<input type="text" name="patientNameMiddle" value="{{$patient->name_middle}}" class="form-control input-sm">
+			</div>
+			<div class="form-group col-md-6">
+				<label class="control-label">Patient Last Name</label>
+				<input type="text" name="patientNameLast" value="{{$patient->name_last}}" class="form-control input-sm">
+			</div>
+			<div class="form-group col-md-6">
+				<label class="control-label">Patient Suffix</label>
+				<input type="text" name="patientNameSuffix" value="{{$patient->name_suffix}}" class="form-control input-sm">
+			</div>
+			<div class="form-group col-md-6">
+				<label class="control-label">Patient Sex</label>
+				<select class="form-control input-sm" name="patientSex">
+					<option value="">--</option>
+					<option value="M">Male</option>
+					<option value="F">Female</option>
+					<option value="UNKNOWN">Unknown</option>
+				</select>
+			</div>
+			<div class="form-group col-md-6">
+				<label class="control-label">Patient Dob</label>
+				<input type="date" name="patientDob" value="{{$patient->dob}}" class="form-control input-sm">
+			</div>
 
-		<div class="form-group">
-			<label for="" class="control-label">Medicaid Payer</label>
-			<select name="mcdPayerUid" id="" class="form-control input-sm">
-				<option value="">--</option>
-				<option>MEDICAID ALABAMA</option>
-				<option>MEDICAID ALASKA</option>
-				<option>MEDICAID ARIZONA</option>
-				<option>MEDICAID ARKANSAS</option>
-				<option>MEDICAID CALIFORNIA MEDI-CAL</option>
-				<option>MEDICAID COLORADO</option>
-				<option>MEDICAID CONNECTICUT</option>
-				<option>MEDICAID DELAWARE</option>
-				<option>MEDICAID DISTRICT OF COLUMBIA</option>
-				<option>MEDICAID FLORIDA</option>
-				<option>MEDICAID GEORGIA</option>
-				<option>MEDICAID HAWAII</option>
-				<option>MEDICAID IDAHO</option>
-				<option>MEDICAID ILLINOIS</option>
-				<option>MEDICAID INDIANA</option>
-				<option>MEDICAID IOWA</option>
-				<option>MEDICAID KANSAS</option>
-				<option>MEDICAID KENTUCKY</option>
-				<option>MEDICAID LOUISIANA</option>
-				<option>MEDICAID MAINE</option>
-				<option>MEDICAID MARYLAND</option>
-				<option>MEDICAID MARYLAND DHMH</option>
-				<option>MEDICAID MASSACHUSETTS</option>
-				<option>MEDICAID MICHIGAN</option>
-				<option>MEDICAID MINNESOTA</option>
-				<option>MEDICAID MISSISSIPPI</option>
-				<option>MEDICAID MISSISSIPPI</option>
-				<option>MEDICAID MISSOURI</option>
-				<option>MEDICAID MONTANA</option>
-				<option>MEDICAID NEBRASKA</option>
-				<option>MEDICAID NEVADA</option>
-				<option>MEDICAID NEW HAMPSHIRE</option>
-				<option>MEDICAID NEW JERSEY</option>
-				<option>MEDICAID NEW MEXICO</option>
-				<option>MEDICAID NEW YORK</option>
-				<option>MEDICAID NEW YORK</option>
-				<option>MEDICAID NORTH CAROLINA</option>
-				<option>MEDICAID NORTH DAKOTA</option>
-				<option>MEDICAID OHIO</option>
-				<option>MEDICAID OKLAHOMA</option>
-				<option>MEDICAID OREGON</option>
-				<option>MEDICAID OREGON (DHS OMAP)</option>
-				<option>MEDICAID PENNSYLVANIA</option>
-				<option>MEDICAID RHODE ISLAND</option>
-				<option>MEDICAID SOUTH CAROLINA</option>
-				<option>MEDICAID SOUTH DAKOTA</option>
-				<option>MEDICAID TENNESSEE</option>
-				<option>MEDICAID TEXAS</option>
-				<option>MEDICAID TEXAS AND TEXAS HEALTH STEPS</option>
-				<option>MEDICAID UTAH</option>
-				<option>MEDICAID VERMONT</option>
-				<option>MEDICAID VIRGINIA</option>
-				<option>MEDICAID WASHINGTON (PROVIDER ONE)</option>
-				<option>MEDICAID WEST VIRGINIA</option>
-				<option>MEDICAID WISCONSIN</option>
-				<option>MEDICAID WYOMING</option>
-			</select>
-		</div>
+			<div class="form-group col-md-6">
+				<label for="" class="control-label">Medicaid Payer</label>
+				<select name="mcdPayerUid" id="" class="form-control input-sm">
+					<option value="">--</option>
+					<option>MEDICAID ALABAMA</option>
+					<option>MEDICAID ALASKA</option>
+					<option>MEDICAID ARIZONA</option>
+					<option>MEDICAID ARKANSAS</option>
+					<option>MEDICAID CALIFORNIA MEDI-CAL</option>
+					<option>MEDICAID COLORADO</option>
+					<option>MEDICAID CONNECTICUT</option>
+					<option>MEDICAID DELAWARE</option>
+					<option>MEDICAID DISTRICT OF COLUMBIA</option>
+					<option>MEDICAID FLORIDA</option>
+					<option>MEDICAID GEORGIA</option>
+					<option>MEDICAID HAWAII</option>
+					<option>MEDICAID IDAHO</option>
+					<option>MEDICAID ILLINOIS</option>
+					<option>MEDICAID INDIANA</option>
+					<option>MEDICAID IOWA</option>
+					<option>MEDICAID KANSAS</option>
+					<option>MEDICAID KENTUCKY</option>
+					<option>MEDICAID LOUISIANA</option>
+					<option>MEDICAID MAINE</option>
+					<option>MEDICAID MARYLAND</option>
+					<option>MEDICAID MARYLAND DHMH</option>
+					<option>MEDICAID MASSACHUSETTS</option>
+					<option>MEDICAID MICHIGAN</option>
+					<option>MEDICAID MINNESOTA</option>
+					<option>MEDICAID MISSISSIPPI</option>
+					<option>MEDICAID MISSISSIPPI</option>
+					<option>MEDICAID MISSOURI</option>
+					<option>MEDICAID MONTANA</option>
+					<option>MEDICAID NEBRASKA</option>
+					<option>MEDICAID NEVADA</option>
+					<option>MEDICAID NEW HAMPSHIRE</option>
+					<option>MEDICAID NEW JERSEY</option>
+					<option>MEDICAID NEW MEXICO</option>
+					<option>MEDICAID NEW YORK</option>
+					<option>MEDICAID NEW YORK</option>
+					<option>MEDICAID NORTH CAROLINA</option>
+					<option>MEDICAID NORTH DAKOTA</option>
+					<option>MEDICAID OHIO</option>
+					<option>MEDICAID OKLAHOMA</option>
+					<option>MEDICAID OREGON</option>
+					<option>MEDICAID OREGON (DHS OMAP)</option>
+					<option>MEDICAID PENNSYLVANIA</option>
+					<option>MEDICAID RHODE ISLAND</option>
+					<option>MEDICAID SOUTH CAROLINA</option>
+					<option>MEDICAID SOUTH DAKOTA</option>
+					<option>MEDICAID TENNESSEE</option>
+					<option>MEDICAID TEXAS</option>
+					<option>MEDICAID TEXAS AND TEXAS HEALTH STEPS</option>
+					<option>MEDICAID UTAH</option>
+					<option>MEDICAID VERMONT</option>
+					<option>MEDICAID VIRGINIA</option>
+					<option>MEDICAID WASHINGTON (PROVIDER ONE)</option>
+					<option>MEDICAID WEST VIRGINIA</option>
+					<option>MEDICAID WISCONSIN</option>
+					<option>MEDICAID WYOMING</option>
+				</select>
+			</div>
 
-		<div class="form-group">
-			<label class="control-label">Medicaid Number</label>
-			<input type="text" name="mcdNumber"  class="form-control input-sm">
-		</div>
+			<div class="form-group col-md-6">
+				<label class="control-label">Medicaid Number</label>
+				<input type="text" name="mcdNumber"  class="form-control input-sm">
+			</div>
 
-		<div class="form-group">
-			<label class="control-label">Date Of Service</label>
-			<input type="date" name="dateOfService" value="{{date('Y-m-d')}}" class="form-control input-sm">
-		</div>
+			<div class="form-group col-md-6">
+				<label class="control-label">Date Of Service</label>
+				<input type="date" name="dateOfService" value="{{date('Y-m-d')}}" class="form-control input-sm">
+			</div>
 
+		</div>
 
 
 		<div class="form-group text-nowrap mb-0">

resources/views/app/patient/primary-coverage-new-medicare.blade.php

@@ -1,39 +1,40 @@
-<div moe relative large>
+<div moe relative wide>
 	<a href="" start show>
 		+ Medicare Part B (Primary)
 	</a>
 	<form url="/api/clientPrimaryCoverage/createNewCoverageForMedicare" right class="mcp-theme-1">
 		<input type="hidden" name="clientUid" value="{{$patient->uid}}" class="form-control input-sm" />
+		<div class="row">
+			<div class="form-group col-md-6">
+				<label class="control-label">Patient First Name</label>
+				<input type="text" name="patientNameFirst" value="{{$patient->name_first}}" class="form-control input-sm">
+			</div>
+			<div class="form-group col-md-6">
+				<label class="control-label">Patient Middle Name / MI</label>
+				<input type="text" name="patientNameMiddle" value="{{$patient->name_middle}}" class="form-control input-sm">
+			</div>
+			<div class="form-group col-md-6">
+				<label class="control-label">Patient Last Name</label>
+				<input type="text" name="patientNameLast" value="{{$patient->name_last}}" class="form-control input-sm">
+			</div>
+			<div class="form-group col-md-6">
+				<label class="control-label">Patient Suffix</label>
+				<input type="text" name="patientNameSuffix" value="{{$patient->name_suffix}}" class="form-control input-sm">
+			</div>
+			<div class="form-group col-md-6">
+				<label class="control-label">Patient Dob</label>
+				<input type="date" name="patientDob" value="{{$patient->dob}}" class="form-control input-sm">
+			</div>
 
-		<div class="form-group">
-			<label class="control-label">Patient First Name</label>
-			<input type="text" name="patientNameFirst" value="{{$patient->name_first}}" class="form-control input-sm">
-		</div>
-		<div class="form-group">
-			<label class="control-label">Patient Middle Name / MI</label>
-			<input type="text" name="patientNameMiddle" value="{{$patient->name_middle}}" class="form-control input-sm">
-		</div>
-		<div class="form-group">
-			<label class="control-label">Patient Last Name</label>
-			<input type="text" name="patientNameLast" value="{{$patient->name_last}}" class="form-control input-sm">
-		</div>
-		<div class="form-group">
-			<label class="control-label">Patient Suffix</label>
-			<input type="text" name="patientNameSuffix" value="{{$patient->name_suffix}}" class="form-control input-sm">
-		</div>
-		<div class="form-group">
-			<label class="control-label">Patient Dob</label>
-			<input type="date" name="patientDob" value="{{$patient->dob}}" class="form-control input-sm">
-		</div>
-
-		<div class="form-group">
-			<label class="control-label">Medicare Number</label>
-			<input type="text" name="mcrNumber" class="form-control input-sm">
-		</div>
+			<div class="form-group col-md-6">
+				<label class="control-label">Medicare Number</label>
+				<input type="text" name="mcrNumber" class="form-control input-sm">
+			</div>
 
-		<div class="form-group">
-			<label class="control-label">Date Of Service</label>
-			<input type="date" name="dateOfService" value="{{date('Y-m-d')}}" class="form-control input-sm">
+			<div class="form-group col-md-6">
+				<label class="control-label">Date Of Service</label>
+				<input type="date" name="dateOfService" value="{{date('Y-m-d')}}" class="form-control input-sm">
+			</div>
 		</div>
 
 		<div class="form-group text-nowrap mb-0">

resources/views/app/patient/primary-coverage-new.blade.php

@@ -1,130 +0,0 @@
-<div moe relative large>
-	<a href="" start show>
-		@if($planType == 'MEDICARE')
-		+ Medicare Part B (Primary)
-		@elseif($planType == 'MEDICAID')
-		+ Medicaid
-		@elseif($planType == 'COMMERCIAL')
-		+ Commercial
-		@endif
-	</a>
-	<form url="/api/clientPrimaryCoverage/createNewCoverageForMedicare" right class="mcp-theme-1">
-		<input type="hidden" name="clientUid" value="{{$patient->uid}}" class="form-control input-sm" />
-
-		<div class="form-group">
-			<label class="control-label">Patient Name First</label>
-			<input type="text" name="patientNameFirst" value="{{$patient->name_first}}" class="form-control input-sm">
-		</div>
-		<div class="form-group">
-			<label class="control-label">Patient Name Middle</label>
-			<input type="text" name="patientNameMiddle" value="{{$patient->name_middle}}" class="form-control input-sm">
-		</div>
-		<div class="form-group">
-			<label class="control-label">Patient Name Last</label>
-			<input type="text" name="patientNameLast" value="{{$patient->name_last}}" class="form-control input-sm">
-		</div>
-		<div class="form-group">
-			<label class="control-label">Patient Name Suffix</label>
-			<input type="text" name="patientNameSuffix" value="{{$patient->name_suffix}}" class="form-control input-sm">
-		</div>
-		<div class="form-group">
-			<label class="control-label">Patient Sex</label>
-			<input type="text" name="patientSex" value="{{$patient->sex}}" class="form-control input-sm">
-		</div>
-		<div class="form-group">
-			<label class="control-label">Patient Dob</label>
-			<input type="text" name="patientDob" value="{{$patient->dob}}" class="form-control input-sm">
-		</div>
-		<div class="form-group">
-			<label class="control-label">
-				<input type="checkbox" name="isPatientSubscriber">
-				Is Patient Subscriber
-			</label>
-		</div>
-		<div class="form-group">
-			<label class="control-label">Patient Relationship To Subscriber</label>
-			<select name="patientRelationshipToSubscriber" class="form-control input-sm">
-				<option value="">--</option>
-				<option value="SELF">Self</option>
-				<option value="SPOUSE">Spouse</option>
-				<option value="CHILD">Child</option>
-				<option value="EMPLOYEE">Employee</option>
-				<option value="ORGAN_DONOR">Organ Donor</option>
-				<option value="CADAVER_DONOR">Cadaver Donor</option>
-				<option value="LIFE_PARTNER">Life Partner</option>
-				<option value="OTHER_RELATIONSHIP">Other Relationship</option>
-				<option value="UNKNOWN">Unknown</option>
-			</select>
-		</div>
-		<div class="form-group">
-			<label class="control-label">Subscriber Name First</label>
-			<input type="text" name="subscriberNameFirst" value="{{$patient->name_first}}" class="form-control input-sm">
-		</div>
-		<div class="form-group">
-			<label class="control-label">Subscriber Name Middle</label>
-			<input type="text" name="subscriberNameMiddle" value="{{$patient->name_middle}}" class="form-control input-sm">
-		</div>
-		<div class="form-group">
-			<label class="control-label">Subscriber Name Last</label>
-			<input type="text" name="subscriberNameLast" value="{{$patient->name_last}}" class="form-control input-sm">
-		</div>
-		<div class="form-group">
-			<label class="control-label">Subscriber Name Suffix</label>
-			<input type="text" name="subscriberNameSuffix" value="{{$patient->name_suffix}}" class="form-control input-sm">
-		</div>
-		<div class="form-group">
-			<label class="control-label">Subscriber Sex</label>
-			<input type="text" name="subscriberSex" value="{{$patient->sex}}" class="form-control input-sm">
-		</div>
-		<div class="form-group">
-			<label class="control-label">Subscriber Dob</label>
-			<input type="date" name="subscriberDob" value="{{$patient->dob}}" class="form-control input-sm">
-		</div>
-		<div class="form-group">
-			<label class="control-label">Date Of Service</label>
-			<input type="date" name="dateOfService" value="{{date('Y-m-d')}}" class="form-control input-sm">
-		</div>
-
-		@if($planType == 'MEDICARE' || $planType == 'COMMERCIAL')
-		<div class="form-group">
-			<label class="control-label">Medicare Number</label>
-			<input type="text" name="mcrNumber" class="form-control input-sm">
-		</div>
-		@endif
-
-		@if($planType == 'MEDICAID' || $planType == 'COMMERCIAL')
-		<div class="form-group">
-			<label class="control-label">Medicaid Number</label>
-			<input type="text" name="mcdNumber"  class="form-control input-sm">
-		</div>
-		<div class="form-group">
-			<label for="" class="control-label">Medicaid Payer</label>
-			<select name="mcdPayerUid" id="" class="form-control input-sm">
-				<option value="">--</option>
-			</select>
-		</div>
-		@endif
-
-		@if($planType == 'COMMERCIAL')
-		<div class="form-group">
-			<label for="" class="control-label">Commercial Payer</label>
-			<select name="commercialPayerUid" id="" class="form-control input-sm">
-				<option value="">--</option>
-			</select>
-		</div>
-		<div class="form-group">
-			<label class="control-label">Commercial Member Identifier</label>
-			<input type="text" name="commercialMemberIdentifier"  class="form-control input-sm">
-		</div>
-		<div class="form-group">
-			<label class="control-label">Commercial Group Number</label>
-			<input type="text" name="commercialGroupNumber"  class="form-control input-sm">
-		</div>
-		@endif
-
-		<div class="form-group text-nowrap mb-0">
-			<button class="btn btn-sm btn-primary" submit>Submt</button>
-			<button class="btn btn-sm btn-default border" cancel>Close</button>
-		</div>
-	</form>
-</div>

resources/views/app/patient/primary-coverage.blade.php

@@ -27,7 +27,7 @@
             @if($cpc->plan_type == 'MEDICARE')
                 @include('app.patient.primary-coverage-refresh', ['endpoint'=>'refreshCoverageForMedicare'])
                 <span class="mx-2 text-secondary text-sm">|</span>
-                @include('app.patient.primary-coverage-manual-determination-medicare')
+                @include('app.patient.primary-coverage-manual-determination-commercial')
             @endif
             @if($cpc->plan_type == 'MEDICAID')
                 @include('app.patient.primary-coverage-refresh', ['endpoint'=>'refreshCoverageForMedicaid'])