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@@ -2,330 +2,370 @@
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@section('content')
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- <?php
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- $patients = [1,2,3,4];
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- $medicaidStates = Config::get('constants.medicaid_states');
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- ?>
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+<?php
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+$patients = [1, 2, 3, 4];
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+$medicaidStates = Config::get('constants.medicaid_states');
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+?>
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- <div class="p-3 mcp-theme-1" id="newPatientContainer" v-cloak>
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- <div class="col-12 col-lg-6 px-0">
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- <div class="card d-block mb-3" moe="">
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+<div class="p-3 mcp-theme-1" id="newPatientContainer" v-cloak>
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+ <div class="col-12">
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+ <div class="card d-block mb-3" moe="">
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- <div class="card-header">
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- <strong>
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- <i class="fas fa-user-plus"></i>
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- New Patient
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- </strong>
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- </div>
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- <div class="card-body">
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- <form show url="/api/client/create" class="px-2 pb-1 primary-form" redir="patients/view/[data]">
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- @if (session('message'))
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- <div class="alert alert-danger">{{ session('message') }}</div>
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- @endif
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- <div class="row">
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- <div class="col-md-12 bg-light p-3 mb-2">
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- <h5 class="m-0 font-weight-bold">Patient Name / Demographics:</h5>
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- </div>
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- <div class="form-group col-md-4">
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- <label class="control-label">First Name <span class="text-danger">*</span> </label>
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- <input type="text" required name="patientNameFirst" value="" class="form-control input-sm">
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- </div>
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- <div class="form-group col-md-4">
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- <label class="control-label">Middle Name / MI</label>
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- <input type="text" name="patientNameMiddle" value="" class="form-control input-sm">
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- </div>
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- <div class="form-group col-md-4">
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- <label class="control-label">Last Name <span class="text-danger">*</span></label>
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- <input type="text" required name="patientNameLast" value="" class="form-control input-sm">
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- </div>
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- <div class="form-group col-md-4">
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- <label class="control-label">Prefix</label>
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- <input type="text" name="patientNamePrefix" value="" class="form-control input-sm">
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- </div>
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- <div class="form-group col-md-4">
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- <label class="control-label">Suffix</label>
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- <input type="text" name="patientNameSuffix" value="" class="form-control input-sm">
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- </div>
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- <div class="form-group col-md-4">
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- <label class="control-label">Sex</label>
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- <select class="form-control input-sm" name="patientSex" select2>
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- <option value="">--</option>
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- <option value="M">Male</option>
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- <option value="F">Female</option>
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- <option value="UNKNOWN">Unknown</option>
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- </select>
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- </div>
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- <div class="form-group col-md-6">
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- <label class="control-label">Date of Birth <span class="text-danger">*</span></label>
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- <input type="date" required name="patientDob" value="" class="form-control input-sm">
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- </div>
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- <div class="form-group col-md-6">
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- <label class="control-label">Date Of Service</label>
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- <input type="date" name="dateOfService" value="{{date('Y-m-d')}}" class="form-control input-sm">
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- </div>
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- </div>
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- @if($pro->pro_type === 'ADMIN')
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- <div class='form-group mb-3'>
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- <label class='control-label'>HCP Pro</label>
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- <select name="hcpProUid" class="form-control" provider-search provider-type="hcp">
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- <option value="">--select--</option>
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- </select>
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- </div>
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- <div class='form-group mb-3'>
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- <label class='control-label'>Care Coordinator</label>
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- <select name="assistantProUid" class="form-control" provider-search provider-type="default-na">
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- <option value="">--select--</option>
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- </select>
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- </div>
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- @elseif($pro->is_hcp === true)
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- <div class='form-group mb-3'>
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- <label class='control-label'>HCP Pro</label>
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- <input type="text" class="form-control" readonly value="{{$pro->displayName()}}">
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- <input type="hidden" name="hcpProUid" value="{{$pro->uid}}">
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- </div>
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- @elseif($pro->isDefaultNA())
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- <div class='form-group mb-3'>
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- <label class='control-label'>HCP Pro</label>
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- <?php $teams = $pro->teamsWhereAssistant; ?>
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- <select name="hcpProUid" class="form-control">
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- <option value="">--select--</option>
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- @foreach($teams as $team)
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- <option value="{{$team->mcp->uid}}">{{$team->mcp->displayName()}}</option>
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- @endforeach
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- </select>
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- </div>
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- <div class='form-group mb-3'>
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- <label class='control-label'>Care Coordinator</label>
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- <input type="text" class="form-control" readonly value="{{$pro->displayName()}}">
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- <input type="hidden" name="assistantProUid" value="{{$pro->uid}}">
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- </div>
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- @endif
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+ <div class="card-header">
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+ <strong>
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+ <i class="fas fa-user-plus"></i>
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+ New Patient
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+ </strong>
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+ </div>
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+ <div class="card-body">
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+ <form show url="/api/client/create" class="px-2 pb-1 primary-form" redir="patients/view/[data]">
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+ @if (session('message'))
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+ <div class="alert alert-danger">{{ session('message') }}</div>
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+ @endif
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+ <div class="row">
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+ <div class="col-md-6">
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+ <div class="row">
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+ <div class="col-md-12 bg-light p-3 mb-2">
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+ <h5 class="m-0 font-weight-bold">Patient Name / Demographics:</h5>
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+ </div>
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+ <div class="form-group col-md-4">
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+ <label class="control-label">First Name <span class="text-danger">*</span> </label>
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+ <input type="text" required name="patientNameFirst" value="" class="form-control input-sm">
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+ </div>
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+ <div class="form-group col-md-4">
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+ <label class="control-label">Middle Name / MI</label>
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+ <input type="text" name="patientNameMiddle" value="" class="form-control input-sm">
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+ </div>
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+ <div class="form-group col-md-4">
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+ <label class="control-label">Last Name <span class="text-danger">*</span></label>
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+ <input type="text" required name="patientNameLast" value="" class="form-control input-sm">
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+ </div>
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+ <div class="form-group col-md-4">
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+ <label class="control-label">Prefix</label>
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+ <input type="text" name="patientNamePrefix" value="" class="form-control input-sm">
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+ </div>
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+ <div class="form-group col-md-4">
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+ <label class="control-label">Suffix</label>
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+ <input type="text" name="patientNameSuffix" value="" class="form-control input-sm">
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+ </div>
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+ <div class="form-group col-md-4">
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+ <label class="control-label">Sex</label>
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+ <select class="form-control input-sm" name="patientSex" select2>
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+ <option value="">--</option>
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+ <option value="M">Male</option>
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+ <option value="F">Female</option>
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+ <option value="UNKNOWN">Unknown</option>
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+ </select>
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+ </div>
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+ <div class="form-group col-md-6">
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+ <label class="control-label">Date of Birth <span class="text-danger">*</span></label>
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+ <input type="date" required name="patientDob" value="" class="form-control input-sm">
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+ </div>
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+ <div class="form-group col-md-6">
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+ <label class="control-label">Date Of Service</label>
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+ <input type="date" name="dateOfService" value="{{date('Y-m-d')}}" class="form-control input-sm">
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+ </div>
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+ </div>
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+ @if($pro->pro_type === 'ADMIN')
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+ <div class="row">
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+ <div class="col-md-6">
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+ <div class='form-group mb-3'>
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+ <label class='control-label'>HCP Pro</label>
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+ <select name="hcpProUid" class="form-control" provider-search provider-type="hcp">
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+ <option value="">--select--</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 mb-3'>
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+ <label class='control-label'>Care Coordinator</label>
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+ <select name="assistantProUid" class="form-control" provider-search provider-type="default-na">
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+ <option value="">--select--</option>
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+ </select>
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+ </div>
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+ </div>
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+ </div>
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+ @elseif($pro->is_hcp === true)
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+ <div class="row">
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+ <div class="col-md-12">
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+ <div class='form-group mb-3'>
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+ <label class='control-label'>HCP Pro</label>
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+ <input type="text" class="form-control" readonly value="{{$pro->displayName()}}">
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+ <input type="hidden" name="hcpProUid" value="{{$pro->uid}}">
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+ </div>
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+ </div>
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+ </div>
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+ @elseif($pro->isDefaultNA())
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+ <div class="row">
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+ <div class="col-md-6">
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+ <div class='form-group mb-3'>
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+ <label class='control-label'>HCP Pro</label>
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+ <?php $teams = $pro->teamsWhereAssistant; ?>
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+ <select name="hcpProUid" class="form-control">
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+ <option value="">--select--</option>
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+ @foreach($teams as $team)
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+ <option value="{{$team->mcp->uid}}">{{$team->mcp->displayName()}}</option>
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+ @endforeach
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+ </select>
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+ </div>
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- <div class='form-group mb-3'>
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- <label class='control-label d-flex align-items-center'>
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- <span>Home Phone Number</span>
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- <a v-if="form.homeNumber" @click="hpnToCpn"
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- class="ml-2 px-1 on-hover-opaque hpn-to-cpn pointer">
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- <i class="fa fa-arrow-down"></i>
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- </a>
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- <a v-if="form.cellNumber && form.homeNumber" @click="swapHpnCpn"
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- class="ml-2 px-1 on-hover-opaque swap-pns pointer">
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- <i class="fa fa-retweet"></i>
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- </a>
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- </label>
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- <input class='form-control' stag-input-phone type='tel' name='homeNumber' v-model="form.homeNumber">
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- </div>
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- <div class='form-group mb-3'>
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- <label class='control-label d-flex align-items-center'>
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- <span>Cell Phone Number</span>
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- <a v-if="form.cellNumber" @click="cpnToHpn" class="ml-2 px-1 on-hover-opaque cpn-to-hpn pointer">
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- <i class="fa fa-arrow-up"></i>
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- </a>
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- </label>
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- <input class='form-control' stag-input-phone type='tel' name='cellNumber' v-model="form.cellNumber">
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- </div>
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- <div class='form-group mb-3'>
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- <label class='control-label'>Email Address </label>
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- <input class='form-control' type='email' name='emailAddress'>
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- </div>
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- <hr class="m-neg-4">
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- <div class="row">
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- <div class="form-group col-md-12">
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- <p class="mb-1 font-weight-bold">Type of insurance card:</p>
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- <div class="form-check form-check-inline">
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- <label class="form-check-label"><input class="form-check-input" type="radio" v-model="planType" name="planType" value="MEDICARE">Medicare Part B (Primary)</label>
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- </div>
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- <div class="form-check form-check-inline">
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- <label class="form-check-label"><input class="form-check-input" type="radio" v-model="planType" name="planType" value="MEDICAID">Medicaid (Primary)</label>
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- </div>
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- <div class="form-check form-check-inline">
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- <label class="form-check-label"><input class="form-check-input" type="radio" v-model="planType" name="planType" value="COMMERCIAL">Commercial / Third Party (Primary)</label>
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- </div>
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- </div>
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- </div>
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- <div class="row" v-show="planType == 'COMMERCIAL'">
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- <div class="form-group col-md-12">
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- <label for="" class="control-label">Commercial Payer</label>
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- <input name="commercialPayerUidSuggest" class="form-control input-sm" value="" stag-suggest stag-suggest-ep="/search-payer/json" />
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- <input type="hidden" name="commercialPayerUid" />
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- </div>
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- <div class="form-group col-md-6">
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- <label class="control-label">Patient Member Identifier</label>
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- <input type="text" name="commercialMemberIdentifier" class="form-control input-sm">
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- </div>
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- <div class="form-group col-md-6">
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- <label class="control-label">Patient Group Number</label>
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- <input type="text" name="commercialGroupNumber" class="form-control input-sm">
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- </div>
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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 mb-3'>
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+ <label class='control-label'>Care Coordinator</label>
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+ <input type="text" class="form-control" readonly value="{{$pro->displayName()}}">
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+ <input type="hidden" name="assistantProUid" value="{{$pro->uid}}">
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+ </div>
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+ </div>
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+ </div>
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+ @endif
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- <div class="row">
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- <div class="form-group col-md-12" v-if="planType == 'MEDICAID' || planType == 'COMMERCIAL'">
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- <div class="form-check form-check-inline">
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- <label class="form-check-label"><input class="form-check-input" type="checkbox" name="isPatientSubscriber" v-model="isPatientSubscriber">Is Patient The Subscriber?</label>
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- </div>
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- </div>
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- </div>
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+ <div class="row">
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+ <div class="col-md-4">
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+ <div class='form-group mb-3'>
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+ <label class='control-label d-flex align-items-center'>
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+ <span>Home Phone Number</span>
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+ <a v-if="form.homeNumber" @click="hpnToCpn" class="ml-1 px-1 on-hover-opaque hpn-to-cpn c-pointer">
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+ <i class="fa fa-arrow-right"></i>
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+ </a>
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+ <a v-if="form.cellNumber && form.homeNumber" @click="swapHpnCpn" class="ml-1 px-1 on-hover-opaque swap-pns c-pointer">
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+ <i class="fa fa-retweet"></i>
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+ </a>
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+ </label>
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+ <input class='form-control' stag-input-phone type='tel' name='homeNumber' v-model="form.homeNumber">
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+ </div>
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+ </div>
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+ <div class="col-md-4">
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+ <div class='form-group mb-3'>
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+ <label class='control-label d-flex align-items-center'>
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+ <span>Cell Phone Number</span>
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+ <a v-if="form.cellNumber" @click="cpnToHpn" class="ml-1 px-1 on-hover-opaque cpn-to-hpn c-pointer">
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+ <i class="fa fa-arrow-left"></i>
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+ </a>
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+ </label>
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+ <input class='form-control' stag-input-phone type='tel' name='cellNumber' v-model="form.cellNumber">
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+ </div>
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+ </div>
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+ <div class="col-md-4">
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+ <div class='form-group mb-3'>
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+ <label class='control-label'>Email Address </label>
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+ <input class='form-control' type='email' name='emailAddress'>
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+ </div>
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+ </div>
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+ </div>
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- <div v-if="!isPatientSubscriber && (planType == 'MEDICAID' || planType == 'COMMERCIAL')" class="row">
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- <div class="col-md-12 bg-light p-3 mb-2">
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- <h5 class="m-0 font-weight-bold">Subscriber Details:</h5>
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- </div>
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- <div class="form-group col-md-4">
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- <label class="control-label">Subscriber First Name</label>
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- <input type="text" name="subscriberNameFirst" value="" class="form-control input-sm">
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- </div>
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- <div class="form-group col-md-4">
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- <label class="control-label">Subscriber Middle Name / MI</label>
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- <input type="text" name="subscriberNameMiddle" value="" class="form-control input-sm">
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- </div>
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- <div class="form-group col-md-4">
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- <label class="control-label">Subscriber Last Name</label>
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- <input type="text" name="subscriberNameLast" value="" class="form-control input-sm">
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- </div>
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- <div class="form-group col-md-4">
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- <label class="control-label">Subscriber Suffix</label>
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- <input type="text" name="subscriberNameSuffix" value="" class="form-control input-sm">
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- </div>
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- <div class="form-group col-md-4">
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- <label class="control-label">Subscriber Sex</label>
|
|
|
- <select class="form-control input-sm" name="subscriberSex">
|
|
|
- <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-4">
|
|
|
- <label class="control-label">Subscriber Dob</label>
|
|
|
- <input type="date" name="subscriberDob" value="" class="form-control input-sm">
|
|
|
- </div>
|
|
|
- <div class="form-group col-md-12">
|
|
|
- <label class="control-label">What is the patient's relationship to the 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>
|
|
|
- <div class="mb-1" v-if="planType == 'COMMERCIAL'">
|
|
|
- <h6 class="font-weight-bold">Does the patient also have either a Medicare or Medicaid #? (optional)</h6>
|
|
|
- </div>
|
|
|
- <div class="row" v-if="planType == 'MEDICAID' || planType == 'COMMERCIAL'" :class="planType == 'COMMERCIAL' ? 'mx-0' : ''">
|
|
|
- <div class="col-md-12 bg-light p-3 mb-2">
|
|
|
- <h5 class="m-0 font-weight-bold">Medicaid Information:</h5>
|
|
|
- </div>
|
|
|
- <div class="form-group col-md-6">
|
|
|
- <label for="" class="control-label">Medicaid State</label>
|
|
|
- <input class="form-control input-sm" list="mcdPayer" name="mcdPayerName" id="mcdPayerName">
|
|
|
- <datalist id="mcdPayer">
|
|
|
- <option value="">--</option>
|
|
|
- @foreach($medicaidStates as $state)
|
|
|
- <option>{{ $state }}</option>
|
|
|
- @endforeach
|
|
|
- </datalist>
|
|
|
- </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>
|
|
|
+ <div class='form-group mb-3'>
|
|
|
+ <label class='control-label'>How did you hear about us?</label>
|
|
|
+ <textarea class='form-control' type='text' required="" name='initiative'></textarea>
|
|
|
+ </div>
|
|
|
|
|
|
- <div class="row" v-if="planType == 'MEDICARE' || planType == 'COMMERCIAL'" :class="planType == 'COMMERCIAL' ? 'mx-0' : ''">
|
|
|
- <div class="col-md-12 bg-light p-3 mb-2">
|
|
|
- <h5 class="m-0 font-weight-bold">Medicare Information:</h5>
|
|
|
- </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>
|
|
|
+ <div class="col-md-6">
|
|
|
+ <div class="col-md-12 bg-light p-3 mb-2">
|
|
|
+ <h5 class="m-0 font-weight-bold">Insurance Cover Details:</h5>
|
|
|
+ </div>
|
|
|
+ <div class="px-1">
|
|
|
+ <div class="row">
|
|
|
+ <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>
|
|
|
+ </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>
|
|
|
+ </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>
|
|
|
+ </div>
|
|
|
+ </div>
|
|
|
+ </div>
|
|
|
+ <div class="px-1">
|
|
|
+ <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="" stag-suggest stag-suggest-ep="/search-payer/json" />
|
|
|
+ <input type="hidden" name="commercialPayerUid" />
|
|
|
+ </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>
|
|
|
+ <div class="row">
|
|
|
+ <div class="form-group col-md-12" v-if="planType == 'MEDICAID' || planType == 'COMMERCIAL'">
|
|
|
+ <div class="form-check form-check-inline">
|
|
|
+ <label class="form-check-label"><input class="form-check-input" type="checkbox" name="isPatientSubscriber" v-model="isPatientSubscriber">Is Patient The Subscriber?</label>
|
|
|
+ </div>
|
|
|
+ </div>
|
|
|
+ </div>
|
|
|
|
|
|
- </div>
|
|
|
+ <div v-if="!isPatientSubscriber && (planType == 'MEDICAID' || planType == 'COMMERCIAL')" class="row">
|
|
|
+ <div class="col-md-12 bg-light p-3 mb-2">
|
|
|
+ <h5 class="m-0 font-weight-bold">Subscriber Details:</h5>
|
|
|
+ </div>
|
|
|
+ <div class="form-group col-md-4">
|
|
|
+ <label class="control-label">Subscriber First Name</label>
|
|
|
+ <input type="text" name="subscriberNameFirst" value="" class="form-control input-sm">
|
|
|
+ </div>
|
|
|
+ <div class="form-group col-md-4">
|
|
|
+ <label class="control-label">Subscriber Middle Name / MI</label>
|
|
|
+ <input type="text" name="subscriberNameMiddle" value="" class="form-control input-sm">
|
|
|
+ </div>
|
|
|
+ <div class="form-group col-md-4">
|
|
|
+ <label class="control-label">Subscriber Last Name</label>
|
|
|
+ <input type="text" name="subscriberNameLast" value="" class="form-control input-sm">
|
|
|
+ </div>
|
|
|
+ <div class="form-group col-md-4">
|
|
|
+ <label class="control-label">Subscriber Suffix</label>
|
|
|
+ <input type="text" name="subscriberNameSuffix" value="" class="form-control input-sm">
|
|
|
+ </div>
|
|
|
+ <div class="form-group col-md-4">
|
|
|
+ <label class="control-label">Subscriber Sex</label>
|
|
|
+ <select class="form-control input-sm" name="subscriberSex">
|
|
|
+ <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-4">
|
|
|
+ <label class="control-label">Subscriber Dob</label>
|
|
|
+ <input type="date" name="subscriberDob" value="" class="form-control input-sm">
|
|
|
+ </div>
|
|
|
+ <div class="form-group col-md-12">
|
|
|
+ <label class="control-label">What is the patient's relationship to the 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>
|
|
|
+ <div class="mb-1" v-if="planType == 'COMMERCIAL'">
|
|
|
+ <h6 class="font-weight-bold">Does the patient also have either a Medicare or Medicaid #? (optional)</h6>
|
|
|
+ </div>
|
|
|
+ <div class="row" v-if="planType == 'MEDICAID' || planType == 'COMMERCIAL'" :class="planType == 'COMMERCIAL' ? 'mx-0' : ''">
|
|
|
+ <div class="col-md-12">
|
|
|
+ <div class="bg-light p-3 mb-2">
|
|
|
+ <h5 class="m-0 font-weight-bold">Medicaid Information:</h5>
|
|
|
+ </div>
|
|
|
+
|
|
|
+ </div>
|
|
|
+ <div class="form-group col-md-6">
|
|
|
+ <label for="" class="control-label">Medicaid State</label>
|
|
|
+ <input class="form-control input-sm" list="mcdPayer" name="mcdPayerName" id="mcdPayerName">
|
|
|
+ <datalist id="mcdPayer">
|
|
|
+ <option value="">--</option>
|
|
|
+ @foreach($medicaidStates as $state)
|
|
|
+ <option>{{ $state }}</option>
|
|
|
+ @endforeach
|
|
|
+ </datalist>
|
|
|
+ </div>
|
|
|
|
|
|
- <hr class="m-neg-4">
|
|
|
- <div class='form-group mb-3'>
|
|
|
- <label class='control-label'>How did you hear about us?</label>
|
|
|
- <textarea class='form-control' type='text' required="" name='initiative'></textarea>
|
|
|
- </div>
|
|
|
- </form>
|
|
|
- </div>
|
|
|
- <div class="card-footer">
|
|
|
- <button class="btn btn-primary" submit>Create New Patient</button>
|
|
|
- </div>
|
|
|
- </div>
|
|
|
- </div>
|
|
|
- </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>
|
|
|
|
|
|
- <link href="/select2/select2.min.css" rel="stylesheet" />
|
|
|
- <script src="/select2/select2.min.js"></script>
|
|
|
- <script src="/inputmask-5.x/dist/inputmask.js"></script>
|
|
|
- <script>
|
|
|
- (function() {
|
|
|
- function init() {
|
|
|
- let im = new Inputmask("(999) 999-9999").mask('[stag-input-phone]');
|
|
|
- $(document)
|
|
|
- .off('change.insurance', '.insurance')
|
|
|
- .on('change.insurance', '.insurance', function() {
|
|
|
- $('[data-insurance]').addClass('d-none');
|
|
|
- $('[data-insurance="' + $(this).val() + '"]').removeClass('d-none');
|
|
|
- $(this).closest('form').attr('url', '/api/client/' + ($(this).val() === 'medicare' ? 'create' : 'createNonMcn'))
|
|
|
- $(this).closest('[moe]').removeAttr('initialized');
|
|
|
- initMoes();
|
|
|
- return false;
|
|
|
- });
|
|
|
- $('.select2').select2({
|
|
|
- width: '100%'
|
|
|
- });
|
|
|
- }
|
|
|
- addMCInitializer('new-patient', init, '#newPatientContainer');
|
|
|
- }).call(window);
|
|
|
+ <div class="row" v-if="planType == 'MEDICARE' || planType == 'COMMERCIAL'" :class="planType == 'COMMERCIAL' ? 'mx-0' : ''">
|
|
|
+ <div class="col-md-12">
|
|
|
+ <div class="bg-light p-3 mb-2">
|
|
|
+ <h5 class="m-0 font-weight-bold">Medicare Information:</h5>
|
|
|
+ </div>
|
|
|
+ </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>
|
|
|
|
|
|
- var newPatientContainer = new Vue({
|
|
|
- el: '#newPatientContainer',
|
|
|
- data: {
|
|
|
- form:{},
|
|
|
- planType: 'MEDICARE',
|
|
|
- isPatientSubscriber: true
|
|
|
- },
|
|
|
- methods: {
|
|
|
- hpnToCpn: function(){
|
|
|
+ </div>
|
|
|
+ </div>
|
|
|
+ </div>
|
|
|
+ </div>
|
|
|
+ </div>
|
|
|
+ </form>
|
|
|
+ </div>
|
|
|
+ <div class="card-footer">
|
|
|
+ <button class="btn btn-primary" submit>Create New Patient</button>
|
|
|
+ </div>
|
|
|
+ </div>
|
|
|
+ </div>
|
|
|
+</div>
|
|
|
+
|
|
|
+<link href="/select2/select2.min.css" rel="stylesheet" />
|
|
|
+<script src="/select2/select2.min.js"></script>
|
|
|
+<script src="/inputmask-5.x/dist/inputmask.js"></script>
|
|
|
+<script>
|
|
|
+ (function() {
|
|
|
+ function init() {
|
|
|
+ let im = new Inputmask("(999) 999-9999").mask('[stag-input-phone]');
|
|
|
+ $(document)
|
|
|
+ .off('change.insurance', '.insurance')
|
|
|
+ .on('change.insurance', '.insurance', function() {
|
|
|
+ $('[data-insurance]').addClass('d-none');
|
|
|
+ $('[data-insurance="' + $(this).val() + '"]').removeClass('d-none');
|
|
|
+ $(this).closest('form').attr('url', '/api/client/' + ($(this).val() === 'medicare' ? 'create' : 'createNonMcn'))
|
|
|
+ $(this).closest('[moe]').removeAttr('initialized');
|
|
|
+ initMoes();
|
|
|
+ return false;
|
|
|
+ });
|
|
|
+ $('.select2').select2({
|
|
|
+ width: '100%'
|
|
|
+ });
|
|
|
+ }
|
|
|
+ addMCInitializer('new-patient', init, '#newPatientContainer');
|
|
|
+ }).call(window);
|
|
|
+
|
|
|
+ var newPatientContainer = new Vue({
|
|
|
+ el: '#newPatientContainer',
|
|
|
+ data: {
|
|
|
+ form: {},
|
|
|
+ planType: 'MEDICARE',
|
|
|
+ isPatientSubscriber: true
|
|
|
+ },
|
|
|
+ methods: {
|
|
|
+ hpnToCpn: function() {
|
|
|
this.form.cellNumber = this.form.homeNumber;
|
|
|
this.form.homeNumber = null;
|
|
|
},
|
|
|
- cpnToHpn: function(){
|
|
|
+ cpnToHpn: function() {
|
|
|
this.form.homeNumber = this.form.cellNumber;
|
|
|
this.form.cellNumber = null;
|
|
|
},
|
|
|
- swapHpnCpn: function(){
|
|
|
+ swapHpnCpn: function() {
|
|
|
var data = $.extend({}, this.form);
|
|
|
this.form.homeNumber = data.cellNumber;
|
|
|
this.form.cellNumber = data.homeNumber;
|
|
|
},
|
|
|
- onCommercialPayerChange: function() {
|
|
|
- var input = $('input[name=commercialPayerUidSuggest]');
|
|
|
- var hiddenInput = $('input[name=commercialPayerUid]');
|
|
|
- input
|
|
|
- .off('stag-suggest-selected')
|
|
|
- .on('stag-suggest-selected', (e, input, _data) => {
|
|
|
- hiddenInput.val(_data.uid);
|
|
|
- });
|
|
|
- },
|
|
|
- init: function() {
|
|
|
- this.onCommercialPayerChange();
|
|
|
- }
|
|
|
- },
|
|
|
- mounted: function() {
|
|
|
- this.init();
|
|
|
- }
|
|
|
- });
|
|
|
- </script>
|
|
|
+ onCommercialPayerChange: function() {
|
|
|
+ var input = $('input[name=commercialPayerUidSuggest]');
|
|
|
+ var hiddenInput = $('input[name=commercialPayerUid]');
|
|
|
+ input
|
|
|
+ .off('stag-suggest-selected')
|
|
|
+ .on('stag-suggest-selected', (e, input, _data) => {
|
|
|
+ hiddenInput.val(_data.uid);
|
|
|
+ });
|
|
|
+ },
|
|
|
+ init: function() {
|
|
|
+ this.onCommercialPayerChange();
|
|
|
+ }
|
|
|
+ },
|
|
|
+ mounted: function() {
|
|
|
+ this.init();
|
|
|
+ }
|
|
|
+ });
|
|
|
+</script>
|
|
|
|
|
|
-@endsection
|
|
|
+@endsection
|
