compact

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

@@ -130,13 +130,15 @@
                                 <input name="commercialPayerUidSuggest" class="form-control input-sm" value="" stag-suggest stag-suggest-ep="/search-payer/json" />
 						                    <input type="hidden" name="commercialPayerUid" />
                             </div>
-                            <div class='form-group mb-3'>
-                                <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'>Patient Group Number</label>
-                                <input class='form-control' type='text' name='commercialGroupNumber'>
+                            <div class="row">
+                              <div class='form-group col-md-6 mb-3'>
+                                  <label class='control-label'>Patient Member ID</label>
+                                  <input class='form-control' type='text' name='commercialMemberIdentifier'>
+                              </div>
+                              <div class='form-group col-md-6 mb-3'>
+                                  <label class='control-label'>Patient Group Number</label>
+                                  <input class='form-control' type='text' name='commercialGroupNumber'>
+                              </div>
                             </div>
                             <p>Does the patient also have either a Medicare or Medicaid #? (optional)</p>
                         </div>
@@ -153,74 +155,77 @@
                           <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="row">
+                            <div class="form-group col-md-6">
+                              <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 class="form-group col-md-6">
+                              <label class="control-label">Medicaid Number</label>
+                              <input type="text" name="mcdNumber" class="form-control input-sm">
+                            </div>
+
+                          </div>
                         </div>
 
                         <hr class="m-neg-4">