templates/super/facilities/form.html.twig

   1 <html>
   2 <head>
   3 {{ setupHeader(['opener', 'erx']) }}
   4
   5 <script src="../main/calendar/modules/PostCalendar/pnincludes/AnchorPosition.js"></script>
   6 <script src="../main/calendar/modules/PostCalendar/pnincludes/PopupWindow.js"></script>
   7 <script src="../main/calendar/modules/PostCalendar/pnincludes/ColorPicker2.js"></script>
   8
   9 <!-- validation library -->
  10 <!--//Not lbf forms use the new validation, please make sure you have the corresponding values in the list Page validation-->
  11 {% if forceClose %}
  12 <script>
  13 <!--
  14 dlgclose();
  15 //-->
  16 </script>
  17 {% endif %}
  18 <script>
  19 /*
  20 * validation on the form with new client side validation (using validate.js).
  21 * this enable to add new rules for this form in the pageValidation list.
  22 * */
  23 var collectvalidation = {{ collectThis }};
  24
  25 function submitform() {
  26
  27     var valid = submitme(1, undefined, 'facility-form', collectvalidation);
  28     if (!valid) return;
  29
  30     {% if erxEnabled %}
  31     alertMsg = '';
  32     f = document.forms[0];
  33     for (i = 0; i < f.length; i++) {
  34         if (f[i].type == 'text' && f[i].value) {
  35             if (f[i].name == 'facility' || f[i].name == 'Washington') {
  36                 alertMsg += checkLength(f[i].name, f[i].value, 35);
  37                 alertMsg += checkFacilityName(f[i].name, f[i].value);
  38             } else if (f[i].name == 'street') {
  39                 alertMsg += checkLength(f[i].name, f[i].value, 35);
  40                 alertMsg += checkAlphaNumeric(f[i].name, f[i].value);
  41             } else if (f[i].name == 'phone' || f[i].name == 'fax') {
  42                 alertMsg += checkPhone(f[i].name, f[i].value);
  43             } else if (f[i].name == 'federal_ein') {
  44                 alertMsg += checkLength(f[i].name, f[i].value, 10);
  45                 alertMsg += checkFederalEin(f[i].name, f[i].value);
  46             }
  47         }
  48     }
  49     if (alertMsg) {
  50         alert(alertMsg);
  51         return false;
  52     }
  53     {% endif %}
  54
  55     top.restoreSession();
  56
  57     let post_url = $("#facility-form").attr("action");
  58     let request_method = $("#facility-form").attr("method");
  59     let form_data = $("#facility-form").serialize();
  60
  61     $.ajax({
  62         url: post_url,
  63         type: request_method,
  64         data: form_data
  65     }).done(function (r) { //
  66         dlgclose('refreshme', false);
  67     });
  68     return false;
  69 }
  70
  71 function copyAddress(base) {
  72     let _map = [
  73         ["mail_street", "street"],
  74         ["mail_city", "city"],
  75         ["mail_state", "state"],
  76         ["mail_zip", "postal_code"]
  77     ];
  78
  79     _map.forEach(f => {
  80         let s = (base == "mailing") ? f[0] : f[1];
  81         let d = (base == "mailing") ? f[1] : f[0];
  82         let _s = document.querySelector("input[name='" + s + "']");
  83         let _d = document.querySelector("input[name='" + d + "']");
  84         console.log(_s);
  85         console.log(_d);
  86         _d.value = _s.value;
  87     });
  88 }
  89
  90 $(function () {
  91     /**
  92     * add required/star sign to required form fields
  93     */
  94     for (var prop in collectvalidation) {
  95         //if (collectvalidation[prop].requiredSign)
  96         if (collectvalidation[prop].presence)
  97             $("label[for='" + prop + "']").append('*');
  98     }
  99
 100     $("input[name='facility']").focus();
 101     $("#btnCopyMailing").on('click', function() {
 102         copyAddress("mailing");
 103     });
 104     $("#btnCopyPhysical").on('click', function() {
 105         copyAddress("physical");
 106     });
 107 });
 108 var cp = new ColorPicker('window');
 109
 110 // Runs when a color is clicked
 111 function pickColor(color) {
 112     document.getElementById('ncolor').value = color;
 113 }
 114
 115 var field;
 116
 117 function pick(anchorname, target) {
 118     var cp = new ColorPicker('window');
 119     field = target;
 120     cp.show(anchorname);
 121 }
 122
 123 function displayAlert() {
 124     if (document.getElementById('primary_business_entity').checked == false)
 125         alert({{ 'Primary Business Entity tax id is used as the account id for NewCrop ePrescription.'|xlj }});
 126     else if (document.getElementById('primary_business_entity').checked == true)
 127         alert({{ 'Once the Primary Business Facility is set, changing the facility id will affect NewCrop ePrescription.'|xlj }});
 128 }
 129 </script>
 130
 131 </head>
 132 <body class="body_top">
 133     <div class="container-fluid">
 134         <div class="row mb-3">
 135             <div class="col-sm-12 d-flex justify-content-between align-items-center">
 136                 <h5 class="m-0">{{ ((mode == "add") ? "Add Facility" : "Edit Facility")|xlt }}</h5>
 137                 <div>
 138                     <a class="btn btn-text" id='cancel' onclick='dlgclose();' href='#'>{{ 'Cancel'|xlt }}</a>
 139                     <a class="btn btn-primary" name='form_save' id='form_save' onclick='submitform();' href='#'>{{ 'Save'|xlt }}</a>
 140                 </div>
 141             </div>
 142         </div>
 143         <form name='facility-form' id="facility-form" method='post' action="facilities.php">
 144             <input type="hidden" name="csrf_token_form" value="{{ csrfTokenRaw() }}">
 145             <input type="hidden" name='mode' value="facility">
 146             {% if mode == "edit" %}
 147             <input type="hidden" name='newmode' value="admin_facility">
 148             <!-- diffrentiate Admin and add post backs !-->
 149             <input type="hidden" name="fid" value="{{ my_fid|default('')|attr }}">
 150             {% endif %}
 151
 152             <div class="form-row">
 153                 <div class="form-group w-100">
 154                     <label for='facility' class="sr-only">{{ 'Name'|xlt }}</label>
 155                     <input type='text' class='form-control form-control-lg' placeholder="{{ 'Facility Name'|xla }}" name='facility' value='{{ facility.name|default('')|attr }}'>
 156                 </div>
 157             </div>
 158             <div class="form-row mb-2">
 159                 <div class="col-sm-12 col-md-7">
 160                     <div class="bg-light border">
 161                         <ul class="nav nav-pills mt-2" id="addressTab" role="tablist">
 162                             <li class="nav-item py-1 px-2" role="presentation">
 163                                 <button type="button" class="nav-link py-1 px-2 active" id="physical-address-tab" data-toggle="tab" data-target="#physicalAddress" role="tab" aria-controls="physicalAddress" aria-selected="true">{{ 'Physical Address'|xlt }}</button>
 164                             </li>
 165                             <li class="nav-item py-1 px-2" role="presentation">
 166                                 <button type="button" class="nav-link py-1 px-2" id="mailing-address-tab" data-toggle="tab" data-target="#mailingAddress" role="tab" aria-controls="mailingAddress" aria-selected="true">{{ 'Mailing Address'|xlt }}</button>
 167                             </li>
 168                         </ul>
 169                         <div class="tab-content m-2" id="addressTabContent">
 170                             <div class="tab-pane show active" id="physicalAddress" role="tabpanel" aria-labelledby="physical-address-tab">
 171                                 <div class="form-row">
 172                                     <div class="col-sm-12">
 173                                         <div class="form-group">
 174                                             <label for='street' class='col-form-label sr-only'>{{ 'Address'|xlt }} </label>
 175                                             <div class="input-group">
 176                                                 <div class="input-group-prepend">
 177                                                     <button type="button" id="btnCopyMailing" class="btn btn-outline-secondary" title="{{ "Copy from mailing address"|xla }}"><i class="fa fa-clone"></i><span class="sr-only">{{ 'Copy Mailing'|xlt }}</span></button>
 178                                                 </div>
 179                                                 <input type='text' class='form-control' name="street" placeholder="{{ 'Address'|xla }}" value="{{ facility.street|default('')|attr }}">
 180                                             </div>
 181                                         </div>
 182                                     </div>
 183                                 </div>
 184                                 <div class="form-row">
 185                                     <div class="col-sm-4">
 186                                         <div class="form-group">
 187                                             <label for='city' class='col-form-label sr-only'>{{ 'City'|xlt }}: </label>
 188                                             <input type='text' class='form-control' name='city' placeholder="{{ 'City'|xla }}" value="{{ facility.city|default('')|attr }}">
 189                                         </div>
 190                                     </div>
 191                                     <div class="col-sm-2">
 192                                         <div class="form-group">
 193                                             <label for='state' class='col-form-label sr-only'>{{ 'State'|xlt }}</label>
 194                                             <input type='text' class='form-control' name='state' placeholder="{{ 'State'|xla }}" value="{{ facility.state|default('')|attr }}">
 195                                         </div>
 196                                     </div>
 197                                     <div class="col-sm-2">
 198                                         <div class="form-group">
 199                                             <label for='postal_code' class='col-form-label sr-only'>{{ 'Zip Code'|xlt }}</label>
 200                                             <input type="text" class='form-control' placeholder="{{ 'Zip Code'|xla }}" name='postal_code' value="{{ facility.postal_code|default('')|attr }}" />
 201                                         </div>
 202                                     </div>
 203                                     <div class="col-sm-4">
 204                                         <div class="form-group">
 205                                             <label for='country_code' class='col-form-label sr-only'>{{ 'Country'|xlt }}</label>
 206                                             <input type='text' class='form-control' placeholder="{{ 'Country'|xla }}" name='country_code' value="{{ facility.country_code|default('')|attr }}">
 207                                         </div>
 208                                     </div>
 209                                     <div class="col-sm-12">
 210
 211                                     </div>
 212                                 </div>
 213                             </div>
 214                             <div class="tab-pane" id="mailingAddress" role="tabpanel" aria-labelledby="mailing-address-tab">
 215                                 <div class="form-row">
 216                                     <div class="col-sm-12">
 217                                         <div class="form-group">
 218                                             <label for="mail_street" class="col-form-label sr-only">{{ 'Mailing Address'|xlt }}</label>
 219                                             <div class="input-group">
 220                                                 <div class="input-group-prepend">
 221                                                         <button type="button" id="btnCopyPhysical" class="btn btn-outline-secondary" title="{{ "Copy from physical address"|xla }}"><i class="fa fa-clone"></i><span class="sr-only">{{ 'Copy physical address'|xlt }}</span></button>
 222                                                     </div>
 223                                                 <input type="text" class="form-control" placeholder="{{ 'Street Addres'|xla }}" name="mail_street" value="{{ facility.mail_street|default('')|attr }}">
 224                                             </div>
 225                                         </div>
 226                                     </div>
 227                                     <div class="col-sm-12">
 228                                         <div class="form-group">
 229                                             <label for="mail_street2" class="col-form-label sr-only">{{ 'Address Line Two'|xlt }}</label>
 230                                             <input type="text" class="form-control" placeholder="{{ 'Address Line Two'|xla }}" name="mail_street2" value="{{ facility.mail_street2|default('')|attr }}">
 231                                         </div>
 232                                     </div>
 233                                 </div>
 234                                 <div class="form-row">
 235                                     <div class="col-sm-4">
 236                                         <label for="mail_city" class="col-form-label sr-only">{{ 'City'|xlt }}</label>
 237                                         <input type="text" class="form-control" placeholder="{{ 'City'|xla }}" name="mail_city" value="{{ facility.mail_city|default('')|attr }}">
 238                                     </div>
 239                                     <div class="col-sm-4">
 240                                         <label for="mail_state" class="col-form-label sr-only">{{ 'State'|xlt }}</label>
 241                                         <input type="text" class="form-control" placeholder="{{ 'State'|xla }}" name="mail_state" value="{{ facility.mail_state|default('')|attr }}">
 242                                     </div>
 243                                     <div class="col-sm-4">
 244                                         <label for="mail_zip" class="col-form-label sr-only">{{ 'Zip'|xlt }}</label>
 245                                         <input type="text" class="form-control" placeholder="{{ 'Zip Code'|xla }}" name="mail_zip" value="{{ facility.mail_zip|default('')|attr }}">
 246                                     </div>
 247                                 </div>
 248                             </div>
 249                         </div>
 250                     </div>
 251                 </div>
 252                 <div class="col-sm-12 col-md-5">
 253                     <div class="p-2 bg-light border">
 254                         <div class="form-group row">
 255                             <label class="col-form-label col-sm-2" for='phone'>{{ 'Phone'|xlt }}</label>
 256                             <div class="col-sm-10">
 257                                 <input type='text' class='form-control' name='phone' placeholder="{{ 'Phone'|xla }}" value='{{ facility.phone|default('')|attr }}'>
 258                             </div>
 259                         </div>
 260                         <div class="form-group row">
 261                             <label class="col-form-label col-sm-2" for='fax'>{{ 'Fax'|xlt }}</label>
 262                             <div class="col-sm-10">
 263                                 <input type="text" class='form-control' name="fax" placeholder="{{ 'Fax'|xla }}" value='{{ facility.fax|default('')|attr }}'>
 264                             </div>
 265                         </div>
 266                         <div class="form-group row">
 267                             <label class="col-form-label col-sm-2" for='website'>{{ 'Website'|xlt }}</label>
 268                             <div class="col-sm-10">
 269                                 <input type="text" class='form-control' placeholder="{{ 'Website'|xla }}" name='website' value="{{ facility.website|default('')|attr }}">
 270                             </div>
 271                         </div>
 272                         <div class="form-group row">
 273                             <label class="col-form-label col-sm-2" for='email'>{{ 'Email'|xlt }}</label>
 274                             <div class="col-sm-10">
 275                                 <input type="text" class='form-control' placeholder="{{ 'Email'|xla }}" name='email' value="{{ facility.email|default('')|attr }}">
 276                             </div>
 277                         </div>
 278                     </div>
 279                 </div>
 280             </div>
 281             <div class="form-row">
 282             <div class="col-sm-12 col-md-7">
 283                 <div class="border p-2 bg-light d-flex">
 284                     <div class="pr-1">
 285                         <div class="form-group">
 286                             <label for='ncolor'>{{ 'Color'|xlt }}</label>
 287                             <div class="input-group">
 288                                 <input type="text" class='form-control form-control-sm' name='ncolor' id='ncolor' size='20' value="{{ facility.color|attr }}">
 289                                 <div class="input-group-append">
 290                                     <a href="#" onClick="pick('pick','newcolor'); return false;" class="btn btn-outline-secondary" name="pick" id="pick">
 291                                         <i class="fa fa-eye-dropper"></i><span class="sr-only">{{ 'Pick'|xlt }}</span>
 292                                     </a>
 293                                 </div>
 294                             </div>
 295                         </div>
 296                         <div class="form-group">
 297                             <label for='pos_code'>{{ 'POS Code'|xlt }}</label>
 298                             <select name="pos_code" class="form-control form-control-sm">
 299                                 {% for c in pos_code %}
 300                                     <option value="{{ c.code }}" {{ (facility.pos_code == c.code) ? 'selected' : '' }}>{{ c.code|text }}: {{ c.title|text }}</option>
 301                                 {% endfor %}
 302                             </select>
 303                         </div>
 304                         <div class="form-group">
 305                             <label for="domain_identifier">{{ 'CLIA Number'|xlt }}</label>
 306                             <input type="text" class="form-control form-control-sm" name="domain_identifier" size="45" value="{{ facility.domain_identifier|attr }}">
 307                         </div>
 308                         <div class="form-group">
 309                             <label for='federal_ein'>{{ 'Tax ID'|xlt }}</label>
 310                             <div class="input-group">
 311                                 <div class="input-group-prepend">
 312                                     <select name='tax_id_type' class='form-control form-control-sm'>
 313                                         <option value="EI"{{ (facility.tax_id_type != 'SY') ? ' selected' : ''}}>{{ 'EIN'|xlt }}</option>
 314                                         <option value="SY"{{ (facility.tax_id_type == 'SY') ? ' selected' : ''}}>{{ 'SSN'|xlt }}</option>
 315                                     </select>
 316                                 </div>
 317                                 <input type='text' class='form-control form-control-sm' name='federal_ein' value="{{ facility.federal_ein|default('')|attr }}">
 318                             </div>
 319                         </div>
 320                         <div class="form-group">
 321                             <label for='facility_npi'>{{ (simple_dems == true) ? 'Facility Code'|xlt : 'Facility NPI'|xlt }}</label>
 322                             <input type="text" class='form-control form-control-sm' size='20' name='facility_npi' value="{{ facility.facility_npi|default('')|attr }}">
 323                         </div>
 324                     </div>
 325                     <div class="pl-1">
 326                         <div class="form-group">
 327                             <label for='iban'>{{ 'IBAN'|xlt }}</label>
 328                             <input type="text" class='form-control form-control-sm' size='20' name='iban' value="{{ facility.iban|default('')|attr }}">
 329                         </div>
 330                         <div class="form-group">
 331                             <label for='facility_taxonomy'>{{ 'Facility Taxonomy'|xlt }}</label>
 332                             <input type="text" class='form-control form-control-sm' size='20' name='facility_taxonomy' value="{{ facility.facility_taxonomy|default('')|attr }}">
 333                         </div>
 334                         <div class="form-group">
 335                             <label for="attn">{{ 'Billing Attn'|xlt }}</label>
 336                             <input type="text" class="form-control form-control-sm" name="attn" size="45" value="{{ facility.attn|default('')|attr }}">
 337                         </div>
 338                         <div class="form-group">
 339                             <label for="facility_id">{{ 'Facility Lab Code'|xlt }}</label>
 340                             <input type="text" class="form-control form-control-sm" name="facility_id" size="45" value="{{ facility.facility_code|default('')|attr }}">
 341                         </div>
 342                         <div class="form-group">
 343                             <label for="oid">{{ 'OID'|xlt }}: </label>
 344                             <input type="text" class="form-control form-control-sm" size="20" name="oid" value="{{ facility.oid|default('')|attr }}">
 345                         </div>
 346                     </div>
 347                 </div>
 348             </div>
 349             <div class="col-sm-12 col-md-5">
 350                 <div class="border p-2 bg-light">
 351                     <div class="form-row custom-control custom-switch my-2">
 352                         <div class="col">
 353                             <input type='checkbox' class='custom-control-input' name='billing_location' id='billing_location' value='1' {{ facility.billing_location != 0 ? 'checked' : '' }}>
 354                             <label for='billing_location' class='custom-control-label'>{{ 'Billing Location'|xlt }}</label>
 355                         </div>
 356                     </div>
 357                     <div class="form-row custom-control custom-switch my-2">
 358                         <div class="col">
 359                             <input type='checkbox' class='custom-control-input' name='accepts_assignment' id='accepts_assignment' value='1' {{ facility.accepts_assignment == 1 ? 'checked' : '' }}>
 360                             <label for='accepts_assignment' class='custom-control-label'>{{ 'Accepts Assignment'|xlt }}</label>
 361                         </div>
 362                         <div class="col">
 363                             <small class="form-text text-muted mt-0">({{ 'only if billing location'|xlt }})</small>
 364                         </div>
 365                     </div>
 366                     <div class="form-row custom-control custom-switch my-2">
 367                         <div class="col">
 368                             <input type='checkbox' class='custom-control-input' name='service_location' id='service_location' value='1' {{ facility.service_location == 1 ? 'checked' : '' }}>
 369                             <label for='service_location' class='custom-control-label'>{{ 'Service Location'|xlt }}</label>
 370                         </div>
 371                     </div>
 372                     <div class="form-row custom-control custom-switch my-2">
 373                         <div class="col">
 374                             {% set _oc = (erxEnabled) ? 'onchange="return displayAlert()"' : '' %}
 375                             {% set _pbeCheck = (facility.primary_business_entity == 1) ? 'checked' : '' %}
 376                             <input type='checkbox' class='custom-control-input' name='primary_business_entity' id='primary_business_entity'
 377                                    value='1' {{ _pbeCheck }} {{ _oc }} {{ disablePBE }}>
 378                             <label for='primary_business_entity' class='custom-control-label'>{{ 'Primary Business Entity'|xlt }}</label>
 379                         </div>
 380                     </div>
 381                     <div class="form-row custom-control custom-switch my-2">
 382                         <div class="col">
 383                             <input type='checkbox' class='custom-control-input' name='inactive' id='inactive' value='1'{{ facility.inactive != 0 ? ' checked' : '' }}>
 384                             <label for='inactive' class='custom-control-label'>{{ 'Facility Inactive'|xlt }}</label>
 385                         </div>
 386                     </div>
 387                 </div>
 388                 <div class="border p-2 bg-light mt-2">
 389                     <div class="form-group">
 390                         <label for="info">{{ 'Info'|xlt }}</label>
 391                         <textarea class="form-control form-control-sm" rows="5" name="info">{{ facility.info|default('')|text }}</textarea>
 392                     </div>
 393                 </div>
 394                 <div class="p-2">
 395                     <p class="text"><span class="mandatory">*</span> {{ 'Required'|xlt }}</p>
 396                 </div>
 397             </div>
 398         </div>
 399     </form>
 400     </div>
 401 </body>
 402 {% if alertMsg %}
 403 <script>
 404 alert({{ alertMsg|xlj }});
 405 </script>
 406 {% endif %}
 407 </html>