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@@ -87,14 +87,95 @@
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</select>
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</div>
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- <div>
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+ <div class="max-width-110px mr-2">
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<label class="mb-0 text-sm {{request()->input('f_name') ? 'font-weight-bold text-info' : 'text-secondary'}}">Name</label>
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<input type="text"
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- class="mr-2 form-control form-control-sm min-width-unset max-width-110px"
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+ class="form-control form-control-sm min-width-unset max-width-110px"
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name="f_name" value="{{request()->input('f_name')}}">
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</div>
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<div class="max-width-110px mr-2">
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+ <label class="mb-0 text-sm {{request()->input('f_payer_type') ? 'font-weight-bold text-info' : 'text-secondary'}}">Payer Type</label>
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+ <div class="d-flex align-items-start">
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+ <select name="f_payer_type"
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+ class=" form-control form-control-sm min-width-unset width-140px pl-0">
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+ <option value="">Any</option>
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+ <option {{request()->input('f_payer_type') === 'Medicare' ? 'selected' : ''}} value="Medicare">Medicare</option>
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+ <option {{request()->input('f_payer_type') === 'Non Medicare' ? 'selected' : ''}} value="Non Medicare">Non Medicare</option>
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+ <option {{request()->input('f_payer_type') === 'Medicaid' ? 'selected' : ''}} value="Medicaid">Medicaid</option>
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+ <option {{request()->input('f_payer_type') === 'Commercial' ? 'selected' : ''}} value="Commercial">Commercial</option>
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+ </select>
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+ </div>
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+ </div>
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+
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+ <div class="max-width-110px mr-2">
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+ <label class="mb-0 text-sm {{request()->input('f_payer') ? 'font-weight-bold text-info' : 'text-secondary'}}">Comm. Payer</label>
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+ <input name="f_payer" class="form-control form-control-sm min-width-unset" value="{{request()->input('f_payer')}}" autocomplete="off" stag-suggest stag-suggest-ep="/search-payer/json" />
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+ </div>
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+
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+ <div class="max-width-110px mr-2">
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+ <label class="mb-0 text-sm {{request()->input('f_state') ? 'font-weight-bold text-info' : 'text-secondary'}}">State</label>
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+ <div class="d-flex align-items-start">
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+ <select name="f_state"
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+ class=" form-control form-control-sm min-width-unset pl-0">
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+ <option value="">Any</option>
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+ <option {{request()->input('f_state') === 'NONE' ? 'selected' : ''}} value="NONE">Not Available</option>
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+ <option {{request()->input('f_state') === 'NOT_MD' ? 'selected' : ''}} value="NOT_MD">Not MD</option>
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+ <option {{request()->input('f_state') === 'AL' ? 'selected' : ''}} value="AL">Alabama</option>
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+ <option {{request()->input('f_state') === 'AK' ? 'selected' : ''}} value="AK">Alaska</option>
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+ <option {{request()->input('f_state') === 'AZ' ? 'selected' : ''}} value="AZ">Arizona</option>
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+ <option {{request()->input('f_state') === 'AR' ? 'selected' : ''}} value="AR">Arkansas</option>
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+ <option {{request()->input('f_state') === 'CA' ? 'selected' : ''}} value="CA">California</option>
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+ <option {{request()->input('f_state') === 'CO' ? 'selected' : ''}} value="CO">Colorado</option>
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+ <option {{request()->input('f_state') === 'CT' ? 'selected' : ''}} value="CT">Connecticut</option>
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+ <option {{request()->input('f_state') === 'DE' ? 'selected' : ''}} value="DE">Delaware</option>
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+ <option {{request()->input('f_state') === 'FL' ? 'selected' : ''}} value="FL">Florida</option>
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+ <option {{request()->input('f_state') === 'GA' ? 'selected' : ''}} value="GA">Georgia</option>
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+ <option {{request()->input('f_state') === 'HI' ? 'selected' : ''}} value="HI">Hawaii</option>
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+ <option {{request()->input('f_state') === 'ID' ? 'selected' : ''}} value="ID">Idaho</option>
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+ <option {{request()->input('f_state') === 'IL' ? 'selected' : ''}} value="IL">Illinois</option>
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+ <option {{request()->input('f_state') === 'IN' ? 'selected' : ''}} value="IN">Indiana</option>
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+ <option {{request()->input('f_state') === 'IA' ? 'selected' : ''}} value="IA">Iowa</option>
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+ <option {{request()->input('f_state') === 'KS' ? 'selected' : ''}} value="KS">Kansas</option>
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+ <option {{request()->input('f_state') === 'KY' ? 'selected' : ''}} value="KY">Kentucky</option>
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+ <option {{request()->input('f_state') === 'LA' ? 'selected' : ''}} value="LA">Louisiana</option>
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+ <option {{request()->input('f_state') === 'ME' ? 'selected' : ''}} value="ME">Maine</option>
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+ <option {{request()->input('f_state') === 'MD' ? 'selected' : ''}} value="MD">Maryland</option>
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+ <option {{request()->input('f_state') === 'MA' ? 'selected' : ''}} value="MA">Massachusetts</option>
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+ <option {{request()->input('f_state') === 'MI' ? 'selected' : ''}} value="MI">Michigan</option>
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+ <option {{request()->input('f_state') === 'MN' ? 'selected' : ''}} value="MN">Minnesota</option>
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+ <option {{request()->input('f_state') === 'MS' ? 'selected' : ''}} value="MS">Mississippi</option>
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+ <option {{request()->input('f_state') === 'MO' ? 'selected' : ''}} value="MO">Missouri</option>
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+ <option {{request()->input('f_state') === 'MT' ? 'selected' : ''}} value="MT">Montana</option>
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+ <option {{request()->input('f_state') === 'NE' ? 'selected' : ''}} value="NE">Nebraska</option>
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+ <option {{request()->input('f_state') === 'NV' ? 'selected' : ''}} value="NV">Nevada</option>
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+ <option {{request()->input('f_state') === 'NH' ? 'selected' : ''}} value="NH">New Hampshire</option>
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+ <option {{request()->input('f_state') === 'NJ' ? 'selected' : ''}} value="NJ">New Jersey</option>
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+ <option {{request()->input('f_state') === 'NM' ? 'selected' : ''}} value="NM">NewMexico</option>
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+ <option {{request()->input('f_state') === 'NY' ? 'selected' : ''}} value="NY">New York</option>
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+ <option {{request()->input('f_state') === 'NC' ? 'selected' : ''}} value="NC">North Carolina</option>
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+ <option {{request()->input('f_state') === 'ND' ? 'selected' : ''}} value="ND">North Dakota</option>
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+ <option {{request()->input('f_state') === 'OH' ? 'selected' : ''}} value="OH">Ohio</option>
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+ <option {{request()->input('f_state') === 'OK' ? 'selected' : ''}} value="OK">Oklahoma</option>
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+ <option {{request()->input('f_state') === 'OR' ? 'selected' : ''}} value="OR">Oregon</option>
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+ <option {{request()->input('f_state') === 'PA' ? 'selected' : ''}} value="PA">Pennsylvania</option>
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+ <option {{request()->input('f_state') === 'RI' ? 'selected' : ''}} value="RI">RhodeIsland</option>
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+ <option {{request()->input('f_state') === 'SC' ? 'selected' : ''}} value="SC">South Carolina</option>
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+ <option {{request()->input('f_state') === 'SD' ? 'selected' : ''}} value="SD">South Dakota</option>
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+ <option {{request()->input('f_state') === 'TN' ? 'selected' : ''}} value="TN">Tennessee</option>
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+ <option {{request()->input('f_state') === 'TX' ? 'selected' : ''}} value="TX">Texas</option>
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+ <option {{request()->input('f_state') === 'UT' ? 'selected' : ''}} value="UT">Utah</option>
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+ <option {{request()->input('f_state') === 'VT' ? 'selected' : ''}} value="VT">Vermont</option>
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+ <option {{request()->input('f_state') === 'VA' ? 'selected' : ''}} value="VA">Virginia</option>
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+ <option {{request()->input('f_state') === 'WA' ? 'selected' : ''}} value="WA">Washington</option>
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+ <option {{request()->input('f_state') === 'WV' ? 'selected' : ''}} value="WV">West Virginia</option>
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+ <option {{request()->input('f_state') === 'WI' ? 'selected' : ''}} value="WI">Wisconsin</option>
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+ <option {{request()->input('f_state') === 'WY' ? 'selected' : ''}} value="WY">Wyoming</option>
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+ </select>
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+ </div>
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+ </div>
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+
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+ <div class="max-width-110px mr-2 position-relative">
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<label class="mb-0 text-sm {{request()->input('f_mcp') ? 'font-weight-bold text-info' : 'text-secondary'}}">MCP</label>
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<select name="f_mcp" class="form-control form-control-sm min-width-unset" provider-search provider-type="hcp" data-pro-uid="{{request()->input('f_mcp')}}">
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<option value="">--select--</option>
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