update new patient form

resources/views/app/new-patient.blade.php

@@ -28,6 +28,7 @@
                             <input class='form-control' type='text' name='nameLast' value='' required>
                         </div>
 
+
                         @if($pro->pro_type === 'ADMIN')
                             <div class='form-group mb-3'>
                                 <label class='control-label'>MCP Pro</label>
@@ -64,7 +65,7 @@
                                 <input type="hidden" name="defaultNaProUid" value="{{$pro->uid}}">
                             </div>
                         @endif
-			
+
                         <div class='form-group mb-3'>
                             <label class='control-label'>Sex</label>
                             <select class='form-control' name='sex' value='' >
@@ -106,38 +107,124 @@
                             <input class='form-control' type='email' name='emailAddress'>
                         </div>
                         <hr class="m-neg-4">
-                        <div class='form-group mb-3 d-flex align-items-center'>
-                            <label class='my-0 mr-3 control-label'>Insurance </label>
+                        <div class='form-group mb-3'>
+                            <label class='mb-3 control-label'>Type of Insurance Card </label>
                             <div class="d-inline-flex align-items-center">
-                                <label class="my-0 mr-3 d-inline-flex align-items-center">
-                                    <input class='insurance' type='radio' name='insurance' value="medicare" checked>
-                                    <span class="ml-1">Medicare</span>
+                                <label class="my-0 mr-4 d-inline-flex align-items-center">
+                                    <input class='insurance' type='radio' name='insurance' v-model="insuranceType" value="MEDICARE">
+                                    <span class="ml-1">Medicare Part B (Primary)</span>
                                 </label>
-                                <label class="my-0 mr-3 d-inline-flex align-items-center">
-                                    <input class='insurance' type='radio' name='insurance' value="non-medicare">
-                                    <span class="ml-1">Non-Medicare</span>
+                                <label class="my-0 mr-4 d-inline-flex align-items-center">
+                                    <input class='insurance' type='radio' name='insurance' v-model="insuranceType" value="MEDICAID">
+                                    <span class="ml-1">Medicaid (Primary)</span>
+                                </label>
+                                <label class="my-0 mr-4 d-inline-flex align-items-center">
+                                    <input class='insurance' type='radio' name='insurance' v-model="insuranceType" value="COMMERCIAL">
+                                    <span class="ml-1">Commercial / Third Party (Primary)</span>
                                 </label>
                             </div>
                         </div>
-                        <div data-insurance="medicare">
+                        <div v-if="insuranceType == 'COMMERCIAL'">
                             <div class='form-group mb-3'>
-                                <label class='control-label'>Medicare Number</label>
-                                <input class='form-control' type='text' name='medicareNumber'>
+                                <label class='control-label d-block'>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>
-                        <div data-insurance="non-medicare" class="d-none">
                             <div class='form-group mb-3'>
-                                <label class='control-label d-block'>Payer</label>
-                                <input name="commercialPayerUidSuggest" class="form-control input-sm" value="" stag-suggest stag-suggest-ep="/search-payer/json" />
-						<input type="hidden" name="commercialPayerUid" />
+                                <label class='control-label'>Patient Member ID</label>
+                                <input class='form-control' type='text' name='commercialMemberIdentifier'>
                             </div>
                             <div class='form-group mb-3'>
-                                <label class='control-label'>Member ID</label>
-                                <input class='form-control' type='text' name='payerMemberId'>
+                                <label class='control-label'>Patient Group Number</label>
+                                <input class='form-control' type='text' name='commercialGroupNumber'>
                             </div>
+                            <p>Does the patient also have either a Medicare or Medicaid #? (optional)</p>
                         </div>
+                        <div v-if="insuranceType == 'MEDICARE' || insuranceType == 'COMMERCIAL'">
+                            <div class="mb-3 p-2 bg-light">
+                              <h6 class="font-weight-bold m-0">Medicare Information</h6>
+                            </div>
+                            <div class='form-group mb-3'>
+                                <label class='control-label'>Medicare Number</label>
+                                <input class='form-control' type='text' name='medicareNumber'>
+                            </div>
+                        </div>
+                        <div v-if="insuranceType == 'MEDICAID' || insuranceType == 'COMMERCIAL'">
+                          <div class="mb-3 p-2 bg-light">
+                            <h6 class="font-weight-bold m-0">Medicaid Information</h6>
+                          </div>
+                          <div class="form-group">
+                						<label for="" class="control-label">Medicaid State</label>
+                						<input class="form-control input-sm" list="mcdPayer" name="mcdPayerUid" id="mcdPayerUid">
+                						<datalist id="mcdPayer">
+                							<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>
+                						</datalist>
+                					</div>
+
+                					<div class="form-group">
+                						<label class="control-label">Medicaid Number</label>
+                						<input type="text" name="mcdNumber" class="form-control input-sm">
+                					</div>
+                        </div>
+
                         <hr class="m-neg-4">
-			<div class='form-group mb-3'>
+        			           <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>
@@ -207,6 +294,13 @@
             }
             addMCInitializer('new-patient', init, '#newPatientContainer');
         }).call(window);
+
+        var newPatientContainer = new Vue({
+          el: '#newPatientContainer',
+          data: {
+            insuranceType: 'MEDICARE'
+          }
+        })
     </script>
 
 @endsection