primary coverage ui changes

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

@@ -0,0 +1,116 @@
+<?php
+	$mdc = 'UNKNOWN';
+?>
+<div moe relative large>
+	<a href="" start show class="">Manual Determination for Commercial</a>
+	<form url="/api/clientPrimaryCoverage/manualDeterminationForMedicare" class="mcp-theme-1">
+		<input type="hidden" name="clientPrimaryCoverageUid" value="{{$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>
+		<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>
+			<button class="btn btn-sm btn-default border" cancel>Close</button>
+		</div>
+	</form>
+</div>

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

@@ -0,0 +1,36 @@
+<?php
+	$mdc = 'UNKNOWN';
+?>
+<div moe relative large>
+	<a href="" start show class="">Manual Determination for Medicaid</a>
+	<form url="/api/clientPrimaryCoverage/manualDeterminationForMedicare" class="mcp-theme-1">
+		<input type="hidden" name="clientPrimaryCoverageUid" value="{{$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>
+
+		<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-manual-determination-medicare.blade.php

@@ -0,0 +1,96 @@
+<?php
+	$mdc = 'UNKNOWN';
+?>
+<div moe relative large>
+	<a href="" start show class="">Manual Determination for Medicare Part B (Primary)</a>
+	<form url="/api/clientPrimaryCoverage/manualDeterminationForMedicare" class="mcp-theme-1">
+		<input type="hidden" name="clientPrimaryCoverageUid" value="{{$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="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>
+
+
+		<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

@@ -0,0 +1,198 @@
+<div moe relative large>
+	<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>
+
+		<div v-if="isPatientSubscriber == 0">
+			<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="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 First Name</label>
+				<input type="text" name="subscriberNameFirst" value="{{$patient->name_first}}" class="form-control input-sm">
+			</div>
+			<div class="form-group">
+				<label class="control-label">Subscriber Middle Name / MI</label>
+				<input type="text" name="subscriberNameMiddle" value="{{$patient->name_middle}}" class="form-control input-sm">
+			</div>
+			<div class="form-group">
+				<label class="control-label">Subscriber Last Name</label>
+				<input type="text" name="subscriberNameLast" value="{{$patient->name_last}}" class="form-control input-sm">
+			</div>
+			<div class="form-group">
+				<label class="control-label">Subscriber Suffix</label>
+				<input type="text" name="subscriberNameSuffix" value="{{$patient->name_suffix}}" class="form-control input-sm">
+			</div>
+			<div class="form-group">
+				<label class="control-label">Subscriber Sex</label>
+				<select class="form-control input-sm" name="subscriberSex">
+					<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">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="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>
+				<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 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>
+
+<script type="text/javascript">
+	var commercialComponent = new Vue({
+		el: '#commercialComponent',
+		data: {
+			isPatientSubscriber: 1
+		}
+	})
+</script>

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

@@ -0,0 +1,118 @@
+<div moe relative large>
+	<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="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">
+			<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 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-medicare.blade.php

@@ -0,0 +1,44 @@
+<div moe relative large>
+	<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="{{$patient->uid}}" class="form-control input-sm" />
+
+		<div class="form-group">
+			<label class="control-label">Patient First Name</label>
+			<input type="text" name="patientNameFirst" value="{{$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">
+			<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 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

@@ -4,11 +4,11 @@
 <div class="d-flex align-items-baseline">
     <h4 class="font-weight-bold m-0 font-size-16 text-nowrap">Client Latest Coverage</h4>
     <div class="ml-4 d-inline-flex justify-content-center">
-        @include('app.patient.primary-coverage-new', ['planType' => 'MEDICARE'])
+        @include('app.patient.primary-coverage-new-medicare')
         <span class="mx-2 text-secondary text-sm">|</span>
-        @include('app.patient.primary-coverage-new', ['planType' => 'MEDICAID'])
+        @include('app.patient.primary-coverage-new-medicaid')
         <span class="mx-2 text-secondary text-sm">|</span>
-        @include('app.patient.primary-coverage-new', ['planType' => 'COMMERCIAL'])
+        @include('app.patient.primary-coverage-new-commercial')
     </div>
 </div>
 
@@ -27,17 +27,17 @@
             @if($cpc->plan_type == 'MEDICARE')
                 @include('app.patient.primary-coverage-refresh', ['endpoint'=>'refreshCoverageForMedicare'])
                 <span class="mx-2 text-secondary text-sm">|</span>
-                @include('app.patient.primary-coverage-manual-determination', ['planType' => 'MEDICARE'])
+                @include('app.patient.primary-coverage-manual-determination-medicare')
             @endif
             @if($cpc->plan_type == 'MEDICAID')
                 @include('app.patient.primary-coverage-refresh', ['endpoint'=>'refreshCoverageForMedicaid'])
                 <span class="mx-2 text-secondary text-sm">|</span>
-                @include('app.patient.primary-coverage-manual-determination', ['planType' => 'MEDICAID'])
+                @include('app.patient.primary-coverage-manual-determination-medicaid')
             @endif
             @if($cpc->plan_type == 'COMMERCIAL')
                 @include('app.patient.primary-coverage-refresh', ['endpoint'=>'refreshCoverageForCommercial'])
                 <span class="mx-2 text-secondary text-sm">|</span>
-                @include('app.patient.primary-coverage-manual-determination', ['planType' => 'COMMERCIAL'])
+                @include('app.patient.primary-coverage-manual-determination-commercial')
             @endif
         </div>
 
@@ -54,4 +54,4 @@
         </div>
     @endif
 </div>
-@endsection
+@endsection