File: /home/imensosw/public_html/imenso.co/dev/mps-new/accounts.html
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<html lang="en-US" >
<head>
<meta charset="UTF-8">
<meta name="viewport" content="width=device-width, initial-scale=1">
<link rel="profile" href="http://gmpg.org/xfn/11">
<title>Patient Portal</title>
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<script>
$(function(){
$("#includedContent").load("sidebar.html");
setTimeout(function(){
$('.sidebar_nav a').removeClass('active');
$('.sidebar_nav a').eq(2).addClass('active');
},100);
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</head>
<body style="background: #F0F4F7;">
<!-- HIPPA Verfication -->
<div class="modal fade" id="hippaVerfication" tabindex="-1" role="dialog" aria-labelledby="" aria-hidden="true">
<div class="modal-dialog" role="document">
<div class="modal-content">
<div class="modal-header">
<h5 class="modal-title" id="">HIPAA Verification</h5>
<button type="button" class="close" data-dismiss="modal" aria-label="Close">
<span aria-hidden="true">×</span>
</button>
</div>
<div class="modal-body">
<form>
<div class="form-group">
<label for="">Payment Code</label>
<input type="text" class="form-control" value="145698752" disabled id="" aria-describedby="emailHelp" placeholder="Payment Code e.g. 14##########">
</div>
<div class="form-group">
<label for="">Enter Date of Birth</label>
<input type="text" class="form-control" id="" placeholder="MM/DD/YYYY">
</div>
</form>
</div>
<div class="modal-footer">
<a href="account-details.html" class="btn btn-login">Submit</a>
</div>
</div>
</div>
</div> <!--/ Add new-->
<!-- HIPPA Verfication -->
<div class="modal fade" id="hippaVerfication2" tabindex="-1" role="dialog" aria-labelledby="" aria-hidden="true">
<div class="modal-dialog" role="document">
<div class="modal-content">
<div class="modal-header">
<h5 class="modal-title" id="">HIPAA Verification</h5>
<button type="button" class="close" data-dismiss="modal" aria-label="Close">
<span aria-hidden="true">×</span>
</button>
</div>
<div class="modal-body">
<form>
<div class="form-group">
<label for="">Payment Code</label>
<input type="text" class="form-control" value="145698752" disabled id="" aria-describedby="emailHelp" placeholder="Payment Code e.g. 14##########">
</div>
<div class="form-group">
<label for="">Enter Date of Birth</label>
<input type="text" class="form-control" id="" placeholder="MM/DD/YYYY">
</div>
</form>
</div>
<div class="modal-footer">
<a href="statements.html" class="btn btn-login">Submit</a>
</div>
</div>
</div>
</div> <!--/ Add new-->
<div class="container-fluid">
<div id="includedContent"></div>
<div class="right right_panel">
<div class="m-5">
<div class="container-fluid">
<div class="row">
<div class="col-md-12 mb-3 header_area">
<div class="d-flex justify-content-between align-items-center">
<h4 calss="mb-0">Account Details</h4>
</div>
<hr />
</div>
</div>
<div class="row mt-2">
<div class="col-md-12">
<div class="ac__card1 p-3 d-flex align-items-center justify-content-between">
<div class="text-left">
<ul class="list-inline">
<li class="list-inline-item align-top">
<span class="opaq">Payment Code</span><br />
<strong>145698905</strong>
</li>
<li class="list-inline-item align-top">
<span class="opaq">Guarantor Name</span><br />
<strong>John Due</strong>
</li>
<li class="list-inline-item align-top">
<span class="opaq">Guarantor Acct. #</span><br />
<strong>1112256478</strong>
</li>
<li class="list-inline-item align-top">
<span class="opaq">Facility Name</span><br />
<strong>The Pediatric Clinic</strong>
</li>
</ul>
</div>
<div>
<a href="javascript:;" data-toggle="modal" data-target="#hippaVerfication" class="btn btn-login mt-1 sml-text"> View Account Details </a>
</div>
</div>
</div>
<div class="col-md-12">
<div class="ac__card1 p-3 d-flex align-items-center justify-content-between">
<div class="text-left">
<ul class="list-inline">
<li class="list-inline-item align-top">
<span class="opaq">Payment Code</span><br />
<strong>145699004</strong>
</li>
<li class="list-inline-item align-top">
<span class="opaq">Guarantor Name</span><br />
<strong>Jolie</strong>
</li>
<li class="list-inline-item align-top">
<span class="opaq">Guarantor Acct. #</span><br />
<strong>111225678</strong>
</li>
<li class="list-inline-item align-top">
<span class="opaq">Facility Name</span><br />
<strong>The Pediatric Clinic</strong>
</li>
</ul>
</div>
<div>
<a href="javascript:;" data-toggle="modal" data-target="#hippaVerfication" class="btn btn-login mt-1 sml-text"> View Account Details </a>
</div>
</div>
</div>
<div class="col-md-12">
<div class="ac__card1 p-3 d-flex align-items-center justify-content-between">
<div class="text-left">
<ul class="list-inline">
<li class="list-inline-item align-top">
<span class="opaq">Payment Code</span><br />
<strong>145698992</strong>
</li>
<li class="list-inline-item align-top">
<span class="opaq">Guarantor Name</span><br />
<strong>Smith</strong>
</li>
<li class="list-inline-item align-top">
<span class="opaq">Guarantor Acct. #</span><br />
<strong>111225634</strong>
</li>
<li class="list-inline-item align-top">
<span class="opaq">Facility Name</span><br />
<strong>The Pediatric Clinic</strong>
</li>
</ul>
</div>
<div>
<a href="javascript:;" data-toggle="modal" data-target="#hippaVerfication" class="btn btn-login mt-1 sml-text"> View Account Details </a>
</div>
</div>
</div>
<div class="col-md-12">
<div class="ac__card1 p-3 d-flex align-items-center justify-content-between">
<div class="text-left">
<ul class="list-inline">
<li class="list-inline-item align-top">
<span class="opaq">Payment Code</span><br />
<strong>145699000</strong>
</li>
<li class="list-inline-item align-top">
<span class="opaq">Guarantor Name</span><br />
<strong>Devid</strong>
</li>
<li class="list-inline-item align-top">
<span class="opaq">Guarantor Acct. #</span><br />
<strong>111225669</strong>
</li>
<li class="list-inline-item align-top">
<span class="opaq">Facility Name</span><br />
<strong>The Pediatric Clinic</strong>
</li>
</ul>
</div>
<div>
<a href="javascript:;" data-toggle="modal" data-target="#hippaVerfication" class="btn btn-login mt-1 sml-text"> View Account Details </a>
</div>
</div>
</div>
<div class="col-md-12">
<div class="ac__card1 p-3 d-flex align-items-center justify-content-between">
<div class="text-left">
<ul class="list-inline">
<li class="list-inline-item align-top">
<span class="opaq">Payment Code</span><br />
<strong>145698885</strong>
</li>
<li class="list-inline-item align-top">
<span class="opaq">Guarantor Name</span><br />
<strong>Mark</strong>
</li>
<li class="list-inline-item align-top">
<span class="opaq">Guarantor Acct. #</span><br />
<strong>111225640</strong>
</li>
<li class="list-inline-item align-top">
<span class="opaq">Facility Name</span><br />
<strong>The Pediatric Clinic</strong>
</li>
</ul>
</div>
<div>
<a href="javascript:;" data-toggle="modal" data-target="#hippaVerfication" class="btn btn-login mt-1 sml-text"> View Account Details </a>
</div>
</div>
</div>
<div class="col-md-12">
<div class="ac__card1 p-3 d-flex align-items-center justify-content-between">
<div class="text-left">
<ul class="list-inline">
<li class="list-inline-item align-top">
<span class="opaq">Payment Code</span><br />
<strong>145698752</strong>
</li>
<li class="list-inline-item align-top">
<span class="opaq">Guarantor Name</span><br />
<strong>Ruby</strong>
</li>
<li class="list-inline-item align-top">
<span class="opaq">Guarantor Acct. #</span><br />
<strong>111225658</strong>
</li>
<li class="list-inline-item align-top">
<span class="opaq">Facility Name</span><br />
<strong>The Pediatric Clinic</strong>
</li>
</ul>
</div>
<div>
<a href="javascript:;" data-toggle="modal" data-target="#hippaVerfication" class="btn btn-login mt-1 sml-text"> View Account Details </a>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</body>
</html>