{# Twig file that represents the insurance edit screen and holds all of the javascript templates and embedded twig partial files for editing and adding new insurance policies for a patient. @package OpenEMR @link http://www.open-emr.org @author Stephen Nielson @copyright Copyright (c) 2024 Care Management Solutions, Inc. @license https://github.com/openemr/openemr/blob/master/LICENSE GNU General Public License 3 #} {% block title %}{{ "Insurance Edit"|xlt }}{% endblock %} {{ setupHeader(['common','select2', 'erx', 'select2-translated', 'il8formatting', 'datetime-picker', 'datetime-picker-translated' ]) }} {% block scripts %} {% endblock %} {% block preContent %}{% endblock %} {% block content %} {% set dataTypeSelectList = 1 %} {% set dataTypeText = 2 %} {% set dataTypeDate = 4 %} {# Note that date fields are handled in javascript because we are building a template instead of handling it all via php #} {# Note that empty_title: 'SKIP' is a hack in the function to skip a title... terrible but is the existing code unfortunately in generate_form_field. #} {% set fields = { left: [{ name: "Plan Name"|xl ,required: false ,data_type: dataTypeText ,field_id: "plan_name" ,fld_length: 20 ,max_length: 63 ,smallform: 'true' ,classNames: "js-capitalize-me mb-1 js-swap-insurance" } ,{ name: "Effective Date"|xl ,required: true ,data_type: dataTypeDate ,field_id: "date" ,fld_length: 16 ,max_length: 60 ,smallform: 'true' ,classNames: "datepicker mb-1" ,autocomplete: 'off' },{ name: "Effective Date End"|xl ,required: false ,data_type: dataTypeDate ,field_id: "date_end" ,fld_length: 16 ,max_length: 60 ,smallform: 'true' ,classNames: "datepicker mb-1" ,autocomplete: 'off' }, { name: "Policy Number"|xl ,required: true ,data_type: dataTypeText ,field_id: "policy_number" ,fld_length: 16 ,max_length: 60 ,smallform: 'true' ,classNames: "js-policykeyup mb-1" }, { name: "Group Number"|xl ,required: false ,data_type: dataTypeText ,field_id: "group_number" ,fld_length: 16 ,max_length: 60 ,smallform: 'true' ,classNames: "js-policykeyup mb-1" },{ name: "Subscriber Employer (SE)"|xl ,required: false ,data_type: dataTypeText ,field_id: "subscriber_employer" ,fld_length: 25 ,max_length: 60 ,smallform: 'true' ,classNames: "js-capitalize-me mb-1" ,skip: include_employers ,description: 'if unemployed enter Student'|xl ~','~'PT Student, or leave blank'|xl },{ name: "SE Address"|xl ,required: false ,data_type: dataTypeText ,field_id: "subscriber_employer_street" ,fld_length: 25 ,max_length: 60 ,smallform: 'true' ,classNames: "js-capitalize-me mb-1" ,skip: include_employers },{ name: "SE Address Line 2"|xl ,required: false ,data_type: dataTypeText ,field_id: "subscriber_employer_street_line_2" ,fld_length: 25 ,max_length: 60 ,smallform: 'true' ,classNames: "js-capitalize-me mb-1" ,skip: include_employers },{ name: "SE City"|xl ,required: false ,data_type: dataTypeText ,field_id: "subscriber_employer_city" ,fld_length: 15 ,max_length: 60 ,smallform: 'true' ,classNames: "js-capitalize-me mb-1" ,skip: include_employers },{ name: "SE State"|xl ,required: false ,data_type: state_data_type ,field_id: "subscriber_employer_state" ,fld_length: 15 ,max_length: 63 ,smallform: 'true' ,classNames: "js-capitalize-me mb-1 sel2" ,list_id: state_list ,skip: include_employers and useStateTerminology }, { name: "SE Locality"|xl ,required: false ,data_type: state_data_type ,field_id: "subscriber_employer_state" ,fld_length: 15 ,max_length: 63 ,smallform: 'true' ,classNames: "js-capitalize-me mb-1 sel2" ,list_id: state_list ,skip: include_employers and not useStateTerminology }, { name: "SE Zip Code"|xl ,required: false ,data_type: dataTypeText ,field_id: "subscriber_employer_postal_code" ,fld_length: 15 ,max_length: 63 ,smallform: 'true' ,classNames: "js-capitalize-me mb-1 js-verify-address" ,skip: include_employers and useStateTerminology }, { name: "SE Postal Code"|xl ,required: false ,data_type: dataTypeText ,field_id: "subscriber_employer_postal_code" ,fld_length: 15 ,max_length: 63 ,smallform: 'true' ,classNames: "js-capitalize-me mb-1 js-verify-address" ,skip: include_employers and not useStateTerminology }, { name: "SE Country"|xl ,required: false ,data_type: country_data_type ,field_id: "subscriber_employer_country" ,fld_length: 10 ,max_length: 63 ,smallform: 'true' ,classNames: "js-capitalize-me mb-1 sel2" ,list_id: country_list ,skip: include_employers }] ,right: [{ name: "Subscriber"|xl ,required: true ,compound: [{ data_type: dataTypeText ,name: "Subscriber First Name"|xl ,field_id: "subscriber_fname" ,fld_length: 10 ,max_length: 60 ,smallform: 'true' ,classNames: "js-capitalize-me mb-1" }, { data_type: dataTypeText ,name: "Subscriber Middle Name"|xl ,field_id: "subscriber_mname" ,fld_length: 10 ,max_length: 60 ,smallform: 'true' ,classNames: "js-capitalize-me mb-1" }, { data_type: dataTypeText ,name: "Subscriber Last Name"|xl ,field_id: "subscriber_lname" ,fld_length: 10 ,max_length: 60 ,smallform: 'true' ,classNames: "js-capitalize-me mb-1" }] }, { name: "D.O.B."|xl ,data_type: dataTypeDate ,required: true ,field_id: "subscriber_DOB" ,fld_length: 11 ,max_length: 60 ,smallform: 'true' ,classNames: "datepicker mb-1" ,autocomplete: 'off' }, { name: "Sex"|xl ,data_type: dataTypeSelectList ,required: true ,field_id: "subscriber_sex" ,list_id: 'sex' ,smallform: 'true' ,classNames: "mb-1 sel2" }, { name: "S.S."|xl ,data_type: dataTypeText ,field_id: "subscriber_ss" ,fld_length: 11 ,smallform: 'true' ,classNames: "mb-1" ,required: true }, { name: "Subscriber Address"|xl ,data_type: dataTypeText ,field_id: "subscriber_street" ,fld_length: 20 ,smallform: 'true' ,classNames: "mb-1 js-capitalize-me" ,required: true }, { name: "Address Line 2"|xl ,data_type: dataTypeText ,field_id: "subscriber_street_line_2" ,fld_length: 20 ,smallform: 'true' ,classNames: "mb-1 js-capitalize-me" ,required: false },{ name: "City"|xl ,required: true ,data_type: dataTypeText ,field_id: "subscriber_city" ,fld_length: 15 ,max_length: 60 ,smallform: 'true' ,classNames: "js-capitalize-me mb-1" },{ name: "State"|xl ,required: true ,data_type: state_data_type ,field_id: "subscriber_state" ,fld_length: 15 ,max_length: 63 ,smallform: 'true' ,classNames: "js-capitalize-me mb-1 sel2" ,list_id: state_list ,skip: useStateTerminology }, { name: "Locality"|xl ,required: true ,data_type: state_data_type ,field_id: "subscriber_state" ,fld_length: 15 ,max_length: 63 ,smallform: 'true' ,classNames: "js-capitalize-me mb-1 sel2" ,list_id: state_list ,skip: not useStateTerminology }, { name: "Zip Code"|xl ,required: true ,data_type: dataTypeText ,field_id: "subscriber_postal_code" ,fld_length: 15 ,max_length: 63 ,smallform: 'true' ,classNames: "js-capitalize-me mb-1 js-verify-address" ,skip: useStateTerminology }, { name: "Postal Code"|xl ,required: true ,data_type: dataTypeText ,field_id: "subscriber_postal_code" ,fld_length: 15 ,max_length: 63 ,smallform: 'true' ,classNames: "js-capitalize-me mb-1 js-verify-address" ,skip: not useStateTerminology }, { name: "Country"|xl ,required: false ,data_type: country_data_type ,field_id: "subscriber_country" ,fld_length: 10 ,max_length: 63 ,smallform: 'true' ,classNames: "js-capitalize-me mb-1 sel2" ,list_id: country_list }, { name: "Subscriber Phone"|xl ,required: false ,data_type: dataTypeText ,field_id: "subscriber_phone" ,fld_length: 20 ,max_length: 63 ,smallform: 'true' ,classNames: "mb-1" }, { name: "CoPay"|xl ,required: false ,data_type: dataTypeText ,field_id: "copay" ,fld_length: 6 ,max_length: 63 ,smallform: 'true' ,classNames: "mb-1" }, { name: "Accept Assignment"|xl ,required: true ,data_type: dataTypeSelectList ,field_id: "accept_assignment" ,list_id: 'yesno' ,smallform: 'true' ,classNames: "mb-1 sel2" ,empty_title: 'SKIP' }] } %}

{{ "Loading..."|xlt }}

{{ "Edit Current Insurance"|xlt }}

{{ 'Back to Patient'|xlt }}
{# TODO: @adunsulag note that the form with id DEM here has a number of hard-coded styles which is where the insurance form gets its layout from. look at changing this. #}
{{ "Insurance"|xlt }}
{% include "patient/insurance/_insurance_edit_screen_new.html.twig" %} {% include "patient/insurance/_insurance_edit_screen_edit.html.twig" %}
{% endblock %} {% block postContent %}{% endblock %}