|
@@ -35,19 +35,19 @@ $cpc = $patient->getPrimaryCoverage();
|
|
<div class="row" v-show="insuranceCardType == 'commercial'">
|
|
<div class="row" v-show="insuranceCardType == 'commercial'">
|
|
<div class="form-group col-md-6">
|
|
<div class="form-group col-md-6">
|
|
<label class="control-label">Insurance</label>
|
|
<label class="control-label">Insurance</label>
|
|
- <input type="text" name="carrierFreeText" class="form-control input-sm" value="{{$cpc->carrier_free_text}}">
|
|
|
|
|
|
+ <input type="text" name="carrierFreeText" class="form-control input-sm" value="{{@$cpc->carrier_free_text}}">
|
|
</div>
|
|
</div>
|
|
<div class="form-group col-md-6">
|
|
<div class="form-group col-md-6">
|
|
<label class="control-label">ID Number</label>
|
|
<label class="control-label">ID Number</label>
|
|
- <input type="text" name="commercialMemberIdentifier" class="form-control input-sm" value="{{$cpc->commercial_member_identifier}}">
|
|
|
|
|
|
+ <input type="text" name="commercialMemberIdentifier" class="form-control input-sm" value="{{@$cpc->commercial_member_identifier}}">
|
|
</div>
|
|
</div>
|
|
<div class="form-group col-md-6">
|
|
<div class="form-group col-md-6">
|
|
<label class="control-label">Group Number</label>
|
|
<label class="control-label">Group Number</label>
|
|
- <input type="text" name="commercialGroupNumber" class="form-control input-sm" value="{{$cpc->commercial_group_number}}">
|
|
|
|
|
|
+ <input type="text" name="commercialGroupNumber" class="form-control input-sm" value="{{@$cpc->commercial_group_number}}">
|
|
</div>
|
|
</div>
|
|
<div class="form-group col-md-6">
|
|
<div class="form-group col-md-6">
|
|
<label class="control-label">Support Phone Number</label>
|
|
<label class="control-label">Support Phone Number</label>
|
|
- <input type="text" name="primaryInsurancePhoneNumberForHcps" class="form-control input-sm phone" stag-input-phone value="{{$cpc->primary_insurance_phone_number_for_hcps}}">
|
|
|
|
|
|
+ <input type="text" name="primaryInsurancePhoneNumberForHcps" class="form-control input-sm phone" stag-input-phone value="{{@$cpc->primary_insurance_phone_number_for_hcps}}">
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
|
|
@@ -90,6 +90,7 @@ $cpc = $patient->getPrimaryCoverage();
|
|
<label class="control-label">Patient First Name</label>
|
|
<label class="control-label">Patient First Name</label>
|
|
<input type="text" name="patientNameFirst" value="{{ $patient->name_first }}" class="form-control input-sm">
|
|
<input type="text" name="patientNameFirst" value="{{ $patient->name_first }}" class="form-control input-sm">
|
|
</div>
|
|
</div>
|
|
|
|
+ </div>
|
|
<div class="form-group col-md-4">
|
|
<div class="form-group col-md-4">
|
|
<label class="control-label">Patient Middle Name / MI</label>
|
|
<label class="control-label">Patient Middle Name / MI</label>
|
|
<input type="text" name="patientNameMiddle" value="{{ $patient->name_middle }}" class="form-control input-sm">
|
|
<input type="text" name="patientNameMiddle" value="{{ $patient->name_middle }}" class="form-control input-sm">
|
|
@@ -200,7 +201,7 @@ $cpc = $patient->getPrimaryCoverage();
|
|
|
|
|
|
<div class="form-group col-md-6">
|
|
<div class="form-group col-md-6">
|
|
<label class="control-label">Medicaid Number</label>
|
|
<label class="control-label">Medicaid Number</label>
|
|
- <input type="text" name="mcdNumber" class="form-control input-sm" value="{{ $cpc->mcd_number ?? '' }}" oninput="this.value = this.value.toUpperCase()">
|
|
|
|
|
|
+ <input type="text" name="mcdNumber" class="form-control input-sm" value="{{ @$cpc->mcd_number ?? '' }}" oninput="this.value = this.value.toUpperCase()">
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
|
|
@@ -210,7 +211,7 @@ $cpc = $patient->getPrimaryCoverage();
|
|
</div>
|
|
</div>
|
|
<div class="form-group col-md-6">
|
|
<div class="form-group col-md-6">
|
|
<label class="control-label">Medicare Number</label>
|
|
<label class="control-label">Medicare Number</label>
|
|
- <input type="text" name="mcrNumber" class="form-control input-sm" value="{{ $cpc->mcr_number ?? '' }}" oninput="this.value = this.value.toUpperCase()">
|
|
|
|
|
|
+ <input type="text" name="mcrNumber" class="form-control input-sm" value="{{ @$cpc->mcr_number ?? '' }}" oninput="this.value = this.value.toUpperCase()">
|
|
</div>
|
|
</div>
|
|
|
|
|
|
</div>
|
|
</div>
|
|
@@ -226,19 +227,19 @@ $cpc = $patient->getPrimaryCoverage();
|
|
<div class="col-md-12">
|
|
<div class="col-md-12">
|
|
<div class="form-group">
|
|
<div class="form-group">
|
|
<label>Plan Effective Date</label>
|
|
<label>Plan Effective Date</label>
|
|
- <input type="date" name="planEffectiveDate" class="form-control" value="{{ $cpc->plan_effective_date ?? '' }}" />
|
|
|
|
|
|
+ <input type="date" name="planEffectiveDate" class="form-control" value="{{ @$cpc->plan_effective_date ?? '' }}" />
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="col-md-12">
|
|
<div class="col-md-12">
|
|
<div class="form-group">
|
|
<div class="form-group">
|
|
<label>Plan Description</label>
|
|
<label>Plan Description</label>
|
|
- <textarea name="planDescription" class="form-control" value="{{ $cpc->plan_description ?? '' }}"></textarea>
|
|
|
|
|
|
+ <textarea name="planDescription" class="form-control" value="{{ @$cpc->plan_description ?? '' }}"></textarea>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="col-md-6">
|
|
<div class="col-md-6">
|
|
<div class="form-group">
|
|
<div class="form-group">
|
|
<label>Provider Status</label>
|
|
<label>Provider Status</label>
|
|
- <select name="providerStatus" class="form-control" value="{{ $cpc->provider_status ?? '' }}">
|
|
|
|
|
|
+ <select name="providerStatus" class="form-control" value="{{ @$cpc->provider_status ?? '' }}">
|
|
<option value=""></option>
|
|
<option value=""></option>
|
|
<option value="IN_NETWORK" @if ($cpc && $cpc->provider_status && $cpc->provider_status === 'IN_NETWORK') selected @endif>IN
|
|
<option value="IN_NETWORK" @if ($cpc && $cpc->provider_status && $cpc->provider_status === 'IN_NETWORK') selected @endif>IN
|
|
NETWORK</option>
|
|
NETWORK</option>
|
|
@@ -249,7 +250,7 @@ $cpc = $patient->getPrimaryCoverage();
|
|
<div class="col-md-6">
|
|
<div class="col-md-6">
|
|
<div class="form-group">
|
|
<div class="form-group">
|
|
<label>Mental Health Coverage</label>
|
|
<label>Mental Health Coverage</label>
|
|
- <select name="mentalHealthCoverage" class="form-control" value="{{ $cpc->mental_health_coverage ?? '' }}">
|
|
|
|
|
|
+ <select name="mentalHealthCoverage" class="form-control" value="{{ @$cpc->mental_health_coverage ?? '' }}">
|
|
<option value=""></option>
|
|
<option value=""></option>
|
|
<option value="YES" @if ($cpc && $cpc->mental_health_coverage && $cpc->mental_health_coverage === 'YES') selected @endif>YES
|
|
<option value="YES" @if ($cpc && $cpc->mental_health_coverage && $cpc->mental_health_coverage === 'YES') selected @endif>YES
|
|
</option>
|
|
</option>
|
|
@@ -277,31 +278,31 @@ $cpc = $patient->getPrimaryCoverage();
|
|
<div class="col-md-6">
|
|
<div class="col-md-6">
|
|
<div class="form-group">
|
|
<div class="form-group">
|
|
<label>Deductible Amount</label>
|
|
<label>Deductible Amount</label>
|
|
- <input type="number" name="deductibleAmount" class="form-control" value="{{ $cpc->deductible_amount ?? '' }}" />
|
|
|
|
|
|
+ <input type="number" name="deductibleAmount" class="form-control" value="{{ @$cpc->deductible_amount ?? '' }}" />
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="col-md-6">
|
|
<div class="col-md-6">
|
|
<div class="form-group">
|
|
<div class="form-group">
|
|
<label>Family Deductible</label>
|
|
<label>Family Deductible</label>
|
|
- <input type="number" name="familyDeductible" class="form-control" value="{{ $cpc->family_deductible ?? '' }}" />
|
|
|
|
|
|
+ <input type="number" name="familyDeductible" class="form-control" value="{{ @$cpc->family_deductible ?? '' }}" />
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="col-md-6">
|
|
<div class="col-md-6">
|
|
<div class="form-group">
|
|
<div class="form-group">
|
|
<label>Member Accumulated Total</label>
|
|
<label>Member Accumulated Total</label>
|
|
- <input type="number" name="memberAccumulatedTotal" class="form-control" value="{{ $cpc->member_accumulated_total ?? '' }}" />
|
|
|
|
|
|
+ <input type="number" name="memberAccumulatedTotal" class="form-control" value="{{ @$cpc->member_accumulated_total ?? '' }}" />
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="col-md-6">
|
|
<div class="col-md-6">
|
|
<div class="form-group">
|
|
<div class="form-group">
|
|
<label>Total Individual Balance</label>
|
|
<label>Total Individual Balance</label>
|
|
- <input type="number" name="totalIndividualBalance" class="form-control" value="{{ $cpc->total_individual_balance ?? '' }}" />
|
|
|
|
|
|
+ <input type="number" name="totalIndividualBalance" class="form-control" value="{{ @$cpc->total_individual_balance ?? '' }}" />
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="col-md-6">
|
|
<div class="col-md-6">
|
|
<div class="form-group">
|
|
<div class="form-group">
|
|
<label>Total Family Balance</label>
|
|
<label>Total Family Balance</label>
|
|
- <input type="number" name="totalFamilyBalance" class="form-control" value="{{ $cpc->total_family_balance ?? '' }}" />
|
|
|
|
|
|
+ <input type="number" name="totalFamilyBalance" class="form-control" value="{{ @$cpc->total_family_balance ?? '' }}" />
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
|