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@@ -28,6 +28,7 @@
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<input class='form-control' type='text' name='nameLast' value='' required>
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</div>
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+
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@if($pro->pro_type === 'ADMIN')
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<div class='form-group mb-3'>
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<label class='control-label'>MCP Pro</label>
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@@ -64,7 +65,7 @@
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<input type="hidden" name="defaultNaProUid" value="{{$pro->uid}}">
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</div>
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@endif
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-
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+
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<div class='form-group mb-3'>
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<label class='control-label'>Sex</label>
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<select class='form-control' name='sex' value='' >
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@@ -106,38 +107,124 @@
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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='form-group mb-3 d-flex align-items-center'>
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- <label class='my-0 mr-3 control-label'>Insurance </label>
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+ <div class='form-group mb-3'>
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+ <label class='mb-3 control-label'>Type of Insurance Card </label>
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<div class="d-inline-flex align-items-center">
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- <label class="my-0 mr-3 d-inline-flex align-items-center">
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- <input class='insurance' type='radio' name='insurance' value="medicare" checked>
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- <span class="ml-1">Medicare</span>
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+ <label class="my-0 mr-4 d-inline-flex align-items-center">
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+ <input class='insurance' type='radio' name='insurance' v-model="insuranceType" value="MEDICARE">
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+ <span class="ml-1">Medicare Part B (Primary)</span>
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</label>
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- <label class="my-0 mr-3 d-inline-flex align-items-center">
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- <input class='insurance' type='radio' name='insurance' value="non-medicare">
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- <span class="ml-1">Non-Medicare</span>
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+ <label class="my-0 mr-4 d-inline-flex align-items-center">
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+ <input class='insurance' type='radio' name='insurance' v-model="insuranceType" value="MEDICAID">
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+ <span class="ml-1">Medicaid (Primary)</span>
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+ </label>
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+ <label class="my-0 mr-4 d-inline-flex align-items-center">
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+ <input class='insurance' type='radio' name='insurance' v-model="insuranceType" value="COMMERCIAL">
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+ <span class="ml-1">Commercial / Third Party (Primary)</span>
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</label>
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</div>
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</div>
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- <div data-insurance="medicare">
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+ <div v-if="insuranceType == 'COMMERCIAL'">
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<div class='form-group mb-3'>
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- <label class='control-label'>Medicare Number</label>
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- <input class='form-control' type='text' name='medicareNumber'>
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+ <label class='control-label d-block'>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>
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- <div data-insurance="non-medicare" class="d-none">
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<div class='form-group mb-3'>
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- <label class='control-label d-block'>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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+ <label class='control-label'>Patient Member ID</label>
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+ <input class='form-control' type='text' name='commercialMemberIdentifier'>
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</div>
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<div class='form-group mb-3'>
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- <label class='control-label'>Member ID</label>
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- <input class='form-control' type='text' name='payerMemberId'>
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+ <label class='control-label'>Patient Group Number</label>
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+ <input class='form-control' type='text' name='commercialGroupNumber'>
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</div>
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+ <p>Does the patient also have either a Medicare or Medicaid #? (optional)</p>
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</div>
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+ <div v-if="insuranceType == 'MEDICARE' || insuranceType == 'COMMERCIAL'">
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+ <div class="mb-3 p-2 bg-light">
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+ <h6 class="font-weight-bold m-0">Medicare Information</h6>
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+ </div>
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+ <div class='form-group mb-3'>
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+ <label class='control-label'>Medicare Number</label>
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+ <input class='form-control' type='text' name='medicareNumber'>
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+ </div>
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+ </div>
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+ <div v-if="insuranceType == 'MEDICAID' || insuranceType == 'COMMERCIAL'">
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+ <div class="mb-3 p-2 bg-light">
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+ <h6 class="font-weight-bold m-0">Medicaid Information</h6>
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+ </div>
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+ <div class="form-group">
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+ <label for="" class="control-label">Medicaid State</label>
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+ <input class="form-control input-sm" list="mcdPayer" name="mcdPayerUid" id="mcdPayerUid">
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+ <datalist id="mcdPayer">
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+ <option value="">--</option>
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+ <option>MEDICAID ALABAMA</option>
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+ <option>MEDICAID ALASKA</option>
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+ <option>MEDICAID ARIZONA</option>
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+ <option>MEDICAID ARKANSAS</option>
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+ <option>MEDICAID CALIFORNIA MEDI-CAL</option>
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+ <option>MEDICAID COLORADO</option>
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+ <option>MEDICAID CONNECTICUT</option>
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+ <option>MEDICAID DELAWARE</option>
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+ <option>MEDICAID DISTRICT OF COLUMBIA</option>
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+ <option>MEDICAID FLORIDA</option>
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+ <option>MEDICAID GEORGIA</option>
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+ <option>MEDICAID HAWAII</option>
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+ <option>MEDICAID IDAHO</option>
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+ <option>MEDICAID ILLINOIS</option>
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+ <option>MEDICAID INDIANA</option>
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+ <option>MEDICAID IOWA</option>
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+ <option>MEDICAID KANSAS</option>
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+ <option>MEDICAID KENTUCKY</option>
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+ <option>MEDICAID LOUISIANA</option>
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+ <option>MEDICAID MAINE</option>
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+ <option>MEDICAID MARYLAND</option>
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+ <option>MEDICAID MARYLAND DHMH</option>
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+ <option>MEDICAID MASSACHUSETTS</option>
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+ <option>MEDICAID MICHIGAN</option>
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+ <option>MEDICAID MINNESOTA</option>
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+ <option>MEDICAID MISSISSIPPI</option>
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+ <option>MEDICAID MISSISSIPPI</option>
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+ <option>MEDICAID MISSOURI</option>
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+ <option>MEDICAID MONTANA</option>
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+ <option>MEDICAID NEBRASKA</option>
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+ <option>MEDICAID NEVADA</option>
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+ <option>MEDICAID NEW HAMPSHIRE</option>
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+ <option>MEDICAID NEW JERSEY</option>
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+ <option>MEDICAID NEW MEXICO</option>
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+ <option>MEDICAID NEW YORK</option>
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+ <option>MEDICAID NEW YORK</option>
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+ <option>MEDICAID NORTH CAROLINA</option>
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+ <option>MEDICAID NORTH DAKOTA</option>
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+ <option>MEDICAID OHIO</option>
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+ <option>MEDICAID OKLAHOMA</option>
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+ <option>MEDICAID OREGON</option>
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+ <option>MEDICAID OREGON (DHS OMAP)</option>
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+ <option>MEDICAID PENNSYLVANIA</option>
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+ <option>MEDICAID RHODE ISLAND</option>
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+ <option>MEDICAID SOUTH CAROLINA</option>
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+ <option>MEDICAID SOUTH DAKOTA</option>
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+ <option>MEDICAID TENNESSEE</option>
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+ <option>MEDICAID TEXAS</option>
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+ <option>MEDICAID TEXAS AND TEXAS HEALTH STEPS</option>
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+ <option>MEDICAID UTAH</option>
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+ <option>MEDICAID VERMONT</option>
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+ <option>MEDICAID VIRGINIA</option>
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+ <option>MEDICAID WASHINGTON (PROVIDER ONE)</option>
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+ <option>MEDICAID WEST VIRGINIA</option>
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+ <option>MEDICAID WISCONSIN</option>
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+ <option>MEDICAID WYOMING</option>
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+ </datalist>
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+ </div>
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+
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+ <div class="form-group">
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+ <label class="control-label">Medicaid Number</label>
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+ <input type="text" name="mcdNumber" class="form-control input-sm">
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+ </div>
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+ </div>
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+
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<hr class="m-neg-4">
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- <div class='form-group mb-3'>
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+ <div class='form-group mb-3'>
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<label class='control-label'>How did you hear about us?</label>
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<textarea class='form-control' type='text' required="" name='initiative'></textarea>
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</div>
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@@ -207,6 +294,13 @@
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}
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addMCInitializer('new-patient', init, '#newPatientContainer');
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}).call(window);
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+
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+ var newPatientContainer = new Vue({
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+ el: '#newPatientContainer',
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+ data: {
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+ insuranceType: 'MEDICARE'
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+ }
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+ })
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</script>
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@endsection
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Peter Muturi