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@@ -130,13 +130,15 @@
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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 mb-3'>
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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'>Patient Group Number</label>
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- <input class='form-control' type='text' name='commercialGroupNumber'>
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+ <div class="row">
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+ <div class='form-group col-md-6 mb-3'>
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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 col-md-6 mb-3'>
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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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</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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@@ -153,74 +155,77 @@
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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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+ <div class="row">
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+ <div class="form-group col-md-6">
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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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- <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 class="form-group col-md-6">
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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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+
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+ </div>
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</div>
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<hr class="m-neg-4">
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Peter Muturi