stagfe2/resources/views/app/new-patient.blade.php

@extends ('layouts.template')

@section('content')

<?php
$patients = [1, 2, 3, 4];
$medicaidStates = Config::get('constants.medicaid_states');
?>

<div class="p-3 mcp-theme-1" id="newPatientContainer" v-cloak>
	<div class="col-12">
		<div class="card d-block mb-3" moe="">

			<div class="card-header">
				<strong>
					<i class="fas fa-user-plus"></i>
					New Patient
				</strong>
			</div>
			<div class="card-body">
				<form show url="/api/client/create" class="px-2 pb-1 primary-form" redir="patients/view/[data]">
					@if (session('message'))
					<div class="alert alert-danger">{{ session('message') }}</div>
					@endif
					<div class="row">
						<div class="border-lighter col-md-5">
							<div class="row">
								<div class="col-md-12 bg-light p-3 mb-2">
									<h5 class="m-0 font-weight-bold">Patient Name / Demographics:</h5>
								</div>
								<div class="form-group col-md-4">
									<label class="control-label">First Name <span class="text-danger">*</span> </label>
									<input type="text" required name="patientNameFirst" value="" class="form-control input-sm">
								</div>
								<div class="form-group col-md-4">
									<label class="control-label">Middle Name / MI</label>
									<input type="text" name="patientNameMiddle" value="" class="form-control input-sm">
								</div>
								<div class="form-group col-md-4">
									<label class="control-label">Last Name <span class="text-danger">*</span></label>
									<input type="text" required name="patientNameLast" value="" class="form-control input-sm">
								</div>
								<div class="form-group col-md-4">
									<label class="control-label">Prefix</label>
									<input type="text" name="patientNamePrefix" value="" class="form-control input-sm">
								</div>
								<div class="form-group col-md-4">
									<label class="control-label">Suffix</label>
									<input type="text" name="patientNameSuffix" value="" class="form-control input-sm">
								</div>
								<div class="form-group col-md-4">
									<label class="control-label">Sex</label>
									<select class="form-control input-sm" name="patientSex" select2>
										<option value="">--</option>
										<option value="M">Male</option>
										<option value="F">Female</option>
										<option value="UNKNOWN">Unknown</option>
									</select>
								</div>
								<div class="form-group col-md-6">
									<label class="control-label">Date of Birth <span class="text-danger">*</span></label>
									<input type="date" required name="patientDob" value="" class="form-control input-sm">
								</div>
								<div class="form-group col-md-6">
									<label class="control-label">Date Of Service</label>
									<input type="date" name="dateOfService" value="{{date('Y-m-d')}}" class="form-control input-sm">
								</div>
							</div>
							@if($pro->pro_type === 'ADMIN')
							<div class="row">
								<div class="col-md-6">
									<div class='form-group mb-3'>
										<label class='control-label'>HCP Pro</label>
										<select name="hcpProUid" class="form-control" provider-search provider-type="hcp">
											<option value="">--select--</option>
										</select>
									</div>
								</div>
								<div class="col-md-6">
									<div class='form-group mb-3'>
										<label class='control-label'>Care Coordinator</label>
										<select name="assistantProUid" class="form-control" provider-search provider-type="default-na">
											<option value="">--select--</option>
										</select>
									</div>
								</div>
							</div>
							@elseif($pro->is_hcp === true)
							<div class="row">
								<div class="col-md-12">
									<div class='form-group mb-3'>
										<label class='control-label'>HCP Pro</label>
										<input type="text" class="form-control" readonly value="{{$pro->displayName()}}">
										<input type="hidden" name="hcpProUid" value="{{$pro->uid}}">
									</div>
								</div>
							</div>
							@elseif($pro->isDefaultNA())
							<div class="row">
								<div class="col-md-6">
									<div class='form-group mb-3'>
										<label class='control-label'>HCP Pro</label>
										<?php $teams = $pro->teamsWhereAssistant; ?>
										<select name="hcpProUid" class="form-control">
											@if(count($teams) > 1)
											<option value="">--select--</option>
											@endif
											@foreach($teams as $team)
											<option value="{{$team->mcp->uid}}">{{$team->mcp->displayName()}}</option>
											@endforeach
										</select>
									</div>

								</div>
								<div class="col-md-6">
									<div class='form-group mb-3'>
										<label class='control-label'>Care Coordinator</label>
										<input type="text" class="form-control" readonly value="{{$pro->displayName()}}">
										<input type="hidden" name="assistantProUid" value="{{$pro->uid}}">
									</div>
								</div>
							</div>
							@endif

							<div class="row">
								<div class="col-md-4">
									<div class='form-group mb-3'>
										<label class='control-label d-flex align-items-center'>
											<span>Home Phone Number</span>
											<a v-if="form.homeNumber" @click="hpnToCpn" class="ml-1 px-1 on-hover-opaque hpn-to-cpn c-pointer">
												<i class="fa fa-arrow-right"></i>
											</a>
											<a v-if="form.cellNumber && form.homeNumber" @click="swapHpnCpn" class="ml-1 px-1 on-hover-opaque swap-pns c-pointer">
												<i class="fa fa-retweet"></i>
											</a>
										</label>
										<input class='form-control' stag-input-phone type='tel' name='homeNumber' v-model="form.homeNumber">
									</div>
								</div>
								<div class="col-md-4">
									<div class='form-group mb-3'>
										<label class='control-label d-flex align-items-center'>
											<span>Cell Phone Number</span>
											<a v-if="form.cellNumber" @click="cpnToHpn" class="ml-1 px-1 on-hover-opaque cpn-to-hpn c-pointer">
												<i class="fa fa-arrow-left"></i>
											</a>
										</label>
										<input class='form-control' stag-input-phone type='tel' name='cellNumber' v-model="form.cellNumber">
									</div>
								</div>
								<div class="col-md-4">
									<div class='form-group mb-3'>
										<label class='control-label'>Email Address </label>
										<input class='form-control' type='email' name='emailAddress'>
									</div>
								</div>
							</div>


							<div class='form-group mb-3'>
								<label class='control-label'>How did you hear about us?</label>
								<input class='form-control' type='text' required="" name='initiative' />
							</div>

						</div>
						<div class="col-md-7">
							<div class="border-lighter">
								<div class="col-md-12 bg-light py-3 px-3 mb-2 ">
									<h5 class="m-0 font-weight-bold">Insurance Coverage:</h5>
								</div>
								<div class="px-3">
									<div class="row">
										<div class="form-group col-md-12">
											<p class="mb-1 font-weight-bold">Type of insurance card:</p>
											<div class="form-check form-check-inline">
												<label class="form-check-label"><input class="form-check-input" type="radio" v-model="planType" name="planType" value="MEDICARE">Medicare Part B (Primary)</label>
											</div>
											<div class="form-check form-check-inline">
												<label class="form-check-label"><input class="form-check-input" type="radio" v-model="planType" name="planType" value="MEDICAID">Medicaid (Primary)</label>
											</div>
											<div class="form-check form-check-inline">
												<label class="form-check-label"><input class="form-check-input" type="radio" v-model="planType" name="planType" value="COMMERCIAL">Commercial / Third Party (Primary)</label>
											</div>
										</div>
									</div>
									<div class="px-2">
										<div class="row" v-show="planType == 'COMMERCIAL'">
											<div class="form-group col-md-12">
												<label for="" class="control-label">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 class="form-group col-md-6">
												<label class="control-label">Patient Member Identifier</label>
												<input type="text" name="commercialMemberIdentifier" class="form-control input-sm">
											</div>
											<div class="form-group col-md-6">
												<label class="control-label">Patient Group Number</label>
												<input type="text" name="commercialGroupNumber" class="form-control input-sm">
											</div>
										</div>
										<div class="row">
											<div class="form-group col-md-12" v-if="planType == 'MEDICAID' || planType == 'COMMERCIAL'">
												<div class="form-check form-check-inline">
													<label class="form-check-label"><input class="form-check-input" type="checkbox" name="isPatientSubscriber" v-model="isPatientSubscriber">Is Patient The Subscriber?</label>
												</div>
											</div>
										</div>

										<div v-if="!isPatientSubscriber && (planType == 'MEDICAID' || planType == 'COMMERCIAL')" class="row">
											<div class="col-md-12 bg-light p-3 mb-2">
												<h5 class="m-0 font-weight-bold">Subscriber Details:</h5>
											</div>
											<div class="form-group col-md-4">
												<label class="control-label">Subscriber First Name</label>
												<input type="text" name="subscriberNameFirst" value="" class="form-control input-sm">
											</div>
											<div class="form-group col-md-4">
												<label class="control-label">Subscriber Middle Name / MI</label>
												<input type="text" name="subscriberNameMiddle" value="" class="form-control input-sm">
											</div>
											<div class="form-group col-md-4">
												<label class="control-label">Subscriber Last Name</label>
												<input type="text" name="subscriberNameLast" value="" class="form-control input-sm">
											</div>
											<div class="form-group col-md-4">
												<label class="control-label">Subscriber Suffix</label>
												<input type="text" name="subscriberNameSuffix" value="" class="form-control input-sm">
											</div>
											<div class="form-group col-md-4">
												<label class="control-label">Subscriber Sex</label>
												<select class="form-control input-sm" name="subscriberSex">
													<option value="">--</option>
													<option value="M">Male</option>
													<option value="F">Female</option>
													<option value="UNKNOWN">Unknown</option>
												</select>
											</div>
											<div class="form-group col-md-4">
												<label class="control-label">Subscriber Dob</label>
												<input type="date" name="subscriberDob" value="" class="form-control input-sm">
											</div>
											<div class="form-group col-md-12">
												<label class="control-label">What is the patient's relationship to the subscriber?</label>
												<select name="patientRelationshipToSubscriber" class="form-control input-sm">
													<option value="">--</option>
													<option value="SPOUSE">Spouse</option>
													<option value="CHILD">Child</option>
													<option value="EMPLOYEE">Employee</option>
													<option value="ORGAN_DONOR">Organ Donor</option>
													<option value="CADAVER_DONOR">Cadaver Donor</option>
													<option value="LIFE_PARTNER">Life Partner</option>
													<option value="OTHER_RELATIONSHIP">Other Relationship</option>
													<option value="UNKNOWN">Unknown</option>
												</select>
											</div>
										</div>
										<div class="mb-1" v-if="planType == 'COMMERCIAL'">
											<h6 class="font-weight-bold">Does the patient also have either a Medicare or Medicaid #? (optional)</h6>
										</div>
										<div class="row" v-if="planType == 'MEDICAID' || planType == 'COMMERCIAL'" :class="planType == 'COMMERCIAL' ? 'mx-0' : ''">
											<div class="col-md-12">
												<div class="bg-light p-2 mb-2">
													<h5 class="m-0 font-weight-bold">Medicaid Information:</h5>
												</div>
											</div>
											<div class="col-12 px-0">
												<div class="px-2">
													<div class="form-group col-md-6">
														<label for="" class="control-label">Medicaid State</label>
														<input class="form-control input-sm" list="mcdPayer" name="mcdPayerName" id="mcdPayerName">
														<datalist id="mcdPayer">
															<option value="">--</option>
															@foreach($medicaidStates as $state)
															<option>{{ $state }}</option>
															@endforeach
														</datalist>
													</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>
										</div>

										<div class="row" v-if="planType == 'MEDICARE' || planType == 'COMMERCIAL'" :class="planType == 'COMMERCIAL' ? 'mx-0' : ''">
											<div class="col-md-12">
												<div class="bg-light p-2 mb-2">
													<h5 class="m-0 font-weight-bold">Medicare Information:</h5>
												</div>
											</div>
											<div class="col-12 px-0">
												<div class="px-2">
													<div class="form-group col-md-6">
														<label class="control-label">Medicare Number</label>
														<input type="text" name="mcrNumber" class="form-control input-sm">
													</div>
												</div>
											</div>

										</div>
									</div>
								</div>
							</div>
						</div>
					</div>
				</form>
			</div>
			<div class="card-footer text-center">
				<button class="btn btn-primary" submit>Create New Patient</button>
			</div>
		</div>
	</div>
</div>

<link href="/select2/select2.min.css" rel="stylesheet" />
<script src="/select2/select2.min.js"></script>
<script src="/inputmask-5.x/dist/inputmask.js"></script>
<script>
	(function() {
		function init() {
			let im = new Inputmask("(999) 999-9999").mask('[stag-input-phone]');
			$(document)
				.off('change.insurance', '.insurance')
				.on('change.insurance', '.insurance', function() {
					$('[data-insurance]').addClass('d-none');
					$('[data-insurance="' + $(this).val() + '"]').removeClass('d-none');
					$(this).closest('form').attr('url', '/api/client/' + ($(this).val() === 'medicare' ? 'create' : 'createNonMcn'))
					$(this).closest('[moe]').removeAttr('initialized');
					initMoes();
					return false;
				});
			$('.select2').select2({
				width: '100%'
			});
		}
		addMCInitializer('new-patient', init, '#newPatientContainer');
	}).call(window);

	var newPatientContainer = new Vue({
		el: '#newPatientContainer',
		data: {
			form: {},
			planType: 'MEDICARE',
			isPatientSubscriber: true
		},
		methods: {
			hpnToCpn: function() {
				this.form.cellNumber = this.form.homeNumber;
				this.form.homeNumber = null;
			},
			cpnToHpn: function() {
				this.form.homeNumber = this.form.cellNumber;
				this.form.cellNumber = null;
			},
			swapHpnCpn: function() {
				var data = $.extend({}, this.form);
				this.form.homeNumber = data.cellNumber;
				this.form.cellNumber = data.homeNumber;
			},
			onCommercialPayerChange: function() {
				var input = $('input[name=commercialPayerUidSuggest]');
				var hiddenInput = $('input[name=commercialPayerUid]');
				input
					.off('stag-suggest-selected')
					.on('stag-suggest-selected', (e, input, _data) => {
						hiddenInput.val(_data.uid);
					});
			},
			init: function() {
				this.onCommercialPayerChange();
			}
		},
		mounted: function() {
			this.init();
		}
	});
</script>

@endsection