Fields

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

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