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@@ -172,6 +172,49 @@
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</tbody>
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</table>
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</div>
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+ <div class="row">
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+ <div class="col-md-12">
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+ <div class="form-group">
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+ <label>Plan Effective Date</label>
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+ <input type="date" name="planEffectiveDate" class="form-control" v-model="uiState.planEffectiveDate" />
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+ </div>
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+ </div>
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+ <div class="col-md-12">
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+ <div class="form-group">
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+ <label>Plan Description</label>
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+ <textarea name="planDescription" class="form-control" v-model="uiState.planDescription"></textarea>
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+ </div>
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+ </div>
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+ <div class="col-md-6">
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+ <div class="form-group">
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+ <label>Provider Status</label>
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+ <select name="providerStatus" class="form-control" v-model="uiState.providerStatus">
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+ <option value=""></option>
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+ <option value="IN_NETWORK">IN NETWORK</option>
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+ <option value="OUT_OF_NETWORK">OUT_OF_NETWORK</option>
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+ </select>
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+ </div>
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+ </div>
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+ <div class="col-md-6">
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+ <div class="form-group">
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+ <label>Member Health Coverage</label>
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+ <input type="text" name="memberHealthCoverage" class="form-control" v-model="uiState.memberHealthCoverage" />
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+ </div>
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+ </div>
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+ <div class="col-md-6">
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+ <div class="form-group">
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+ <label>Telehealth Coverage</label>
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+ <input type="text" name="telehealthCoverage" class="form-control" v-model="uiState.telehealthCoverage" />
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+ </div>
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+ </div>
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+ <div class="col-md-6">
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+ <div class="form-group">
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+ <label>Telehealth Coverage</label>
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+ <input type="text" name="telehealthCoverage" class="form-control" v-model="uiState.telehealthCoverage" />
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+ </div>
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+ </div>
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+
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+ </div>
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<div class="row">
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<div class="form-group col-md-12">
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<label for="" class="control-label">Memo</label>
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