File: /home/imensosw/public_html/imenso.co/dev/revspring/createvisit.html
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<html>
<head>
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<title>RevSpring</title>
</head>
<body>
<div class="container p-4">
<div class="text-center">
<h2>Create Visit</h2>
</div>
<div class="text-left d-flex">
<div class="d-flex"><span class="text-success"> #</span> <h6> Recommended Fields</h6></div>
<div class="d-flex ms-3"><span class="text-danger"> *</span> <h6> Required Fields</h6></div>
</div>
<div class="mt-5">
<div class="row">
<div class="col-6">
<label for="facilityId">Facility ID</label><span class="text-danger"> *</span><br>
<input class="form-control" placeholder="Facility ID" type="text" id="facilityId" name="facilityId">
</div>
<div class="col-6">
<label for="visitServiceDate">Visit Service Date</label><span class="text-danger"> *</span><br>
<input class="form-control" placeholder="Visit Service Date" type="date" id="visitServiceDate" name="visitServiceDate">
</div>
</div>
<div class="row mt-3">
<div class="col-6">
<label for="serviceCategoryCode">Service Category Code</label><span class="text-danger"> *</span><br>
<input class="form-control" placeholder="Service Category Code" type="text" id="serviceCategoryCode" name="serviceCategoryCode">
</div>
</div>
<div class="row justify-content-left mt-5">
<div class="col-12">
<h4>Patient</h4>
</div>
</div>
<div class="row mt-3">
<div class="col-6">
<label for="pfirstName">First Name</label><span class="text-danger"> *</span><br>
<input class="form-control" placeholder="First Name" type="text" id="pfirstName" name="pfirstName">
</div>
<div class="col-6">
<label for="plastName">Last Name</label><span class="text-danger"> *</span><br>
<input class="form-control" placeholder="Last Name" type="text" id="plastName" name="plastName">
</div>
</div>
<div class="row mt-3">
<div class="col-6">
<label for="patientAccountNumber">Patient Account Number</label><span class="text-danger"> *</span><br>
<input class="form-control" placeholder="Patient Account Number" type="text" id="patientAccountNumber" name="patientAccountNumber">
</div>
<div class="col-6">
<label for="medicalRecordNumber">Medical Record Number</label><span class="text-success"> #</span><br>
<input class="form-control" placeholder="Medical Record Number" type="text" id="medicalRecordNumber" name="medicalRecordNumber">
</div>
</div>
<div class="row mt-3">
<div class="col-6">
<label for="pbirthDate">Birth Date</label><span class="text-danger"> *</span><br>
<input class="form-control" placeholder="Birth Date" type="date" id="pbirthDate" name="pbirthDate">
</div>
<div class="col-6">
<label for="genderCode">Gender Code</label><span class="text-danger"> *</span><br>
<select class="form-select" id="genderCode">
<option value="" selected>Select Gender Code</option>
<option value="M">M</option>
<option value="F">F</option>
</select>
</div>
</div>
<div class="row justify-content-left mt-5">
<div class="col-12">
<h4>Guarantor</h4>
</div>
</div>
<div class="row mt-3">
<div class="col-6">
<label for="gfirstName">First Name</label><span class="text-success"> #</span><br>
<input class="form-control" placeholder="First Name" type="text" id="gfirstName" name="gfirstName">
</div>
<div class="col-6">
<label for="glastName">Last Name</label><span class="text-success"> #</span><br>
<input class="form-control" placeholder="Last Name" type="text" id="glastName" name="glastName">
</div>
</div>
<div class="row mt-3">
<div class="col-6">
<label for="gbirthDate">Birth Date</label><span class="text-success"> #</span><br>
<input class="form-control" placeholder="Birth Date" type="date" id="gbirthDate" name="gbirthDate">
</div>
<div class="col-6">
<label for="ggenderCode">Gender Code</label><span class="text-danger"> *</span><br>
<select class="form-select" id="ggenderCode">
<option value="" selected>Select Gender Code</option>
<option value="M">M</option>
<option value="F">F</option>
</select>
</div>
</div>
<div class="row justify-content-left mt-3">
<div class="col-12">
<h6>Guarantor's Address</h6>
</div>
</div>
<div class="row mt-1">
<div class="col-6">
<label for="line1">Line</label><span class="text-danger"> *</span><br>
<input class="form-control" placeholder="Line" type="text" id="line1" name="line1">
</div>
<div class="col-6">
<label for="city">City</label><span class="text-success"> #</span><br>
<input class="form-control" placeholder="City" type="text" id="city" name="city">
</div>
</div>
<div class="row mt-3">
<div class="col-6">
<label for="stateCode">State Code</label><span class="text-success"> #</span><br>
<input class="form-control" placeholder="State Code" type="text" id="stateCode" name="stateCode">
</div>
<div class="col-6">
<label for="zipCode">Zip Code</label><span class="text-success"> #</span><br>
<input class="form-control" placeholder="Zip Code" type="text" id="zipCode" name="zipCode">
</div>
</div>
<div class="row justify-content-left mt-5">
<div class="col-12">
<h4>Coverages</h4>
</div>
</div>
<div class="row mt-3">
<div class="col-6">
<label for="payerId">Payer Id</label><span class="text-danger"> *</span><br>
<input class="form-control" placeholder="Payer Id" type="text" id="payerId" name="payerId">
</div>
<div class="col-6">
<label for="priorityNumber">Priority Number</label><span class="text-success"> #</span><br>
<input class="form-control" placeholder="Priority Number" type="text" id="priorityNumber" name="priorityNumber">
</div>
</div>
<div class="mt-3">
<label for="serviceTypeCodes">Service Type Codes</label><span class="text-success"> #</span><br>
<div id="stc_div" class="d-flex flex-wrap">
<!-- <div class="row mt-3" id="stc_row_1">
<div class="col-6"> -->
<div class="w-50 pe-2" id="stc_div_1">
<input class="form-control" placeholder="Service Type Codes" type="text" id="serviceTypeCodes_1" name="serviceTypeCodes">
</div>
<!-- </div>
<div class="col-6 mt-auto"> -->
<!-- </div>
</div> -->
</div>
<div class="mt-2">
<button type="button" class="btn btn-primary" id="addMore" data-toggle="tooltip" data-placement="right" title="Add More Service Type Codes" onclick="addMore()"> + </button>
</div>
</div>
<div class="row justify-content-left mt-3">
<div class="col-12">
<h6>Subscriber</h6>
</div>
</div>
<div class="row mt-1">
<div class="col-6">
<label for="sfirstName">First Name</label><span class="text-success"> #</span><br>
<input class="form-control" placeholder="First Name" type="text" id="sfirstName" name="sfirstName">
</div>
<div class="col-6">
<label for="slastName">Last Name</label><span class="text-success"> #</span><br>
<input class="form-control" placeholder="Last Name" type="text" id="slastName" name="slastName">
</div>
</div>
<div class="row mt-3">
<div class="col-6">
<label for="birthDate">Birth Date</label><span class="text-success"> #</span><br>
<input class="form-control" placeholder="Birth Date" type="date" id="birthDate" name="birthDate">
</div>
<div class="col-6">
<label for="sgenderCode">Gender Code</label><span class="text-danger"> *</span><br>
<select class="form-select" id="sgenderCode">
<option value="" selected>Select Gender Code</option>
<option value="M">M</option>
<option value="F">F</option>
</select>
</div>
</div>
<div class="row mt-3">
<div class="col-6">
<label for="memberId">Member Id</label><span class="text-danger"> *</span><br>
<input class="form-control" placeholder="Member Id" type="text" id="memberId" name="memberId">
</div>
<div class="col-6">
<label for="patientRelationship">Patient Relationship</label><span class="text-danger"> *</span><br>
<select class="form-select" id="patientRelationship">
<option value="" selected>Select Patient Relationship</option>
<option value="Self">Self</option>
<option value="Child">Child</option>
<option value="Spouse">Spouse</option>
<option value="Other Adult">Other Adult</option>
</select>
</div>
</div>
<div class="row justify-content-left mt-5">
<div class="col-12">
<h4>Services</h4>
</div>
</div>
<div class="row mt-3">
<div class="col-6">
<label for="procedureCode">Procedure Code</label><span class="text-danger"> *</span><br>
<input class="form-control" placeholder="Procedure Code" type="text" id="procedureCode" name="procedureCode">
</div>
<div class="col-6">
<label for="units">Units</label><span class="text-danger"> *</span><br>
<input class="form-control" placeholder="Units" type="text" id="units" name="units">
</div>
</div>
<div class="row justify-content-left mt-3">
<div class="col-12">
<h6>Ordering Provider</h6>
</div>
</div>
<div class="row mt-1">
<div class="col-6">
<label for="serfirstName">First Name</label><span class="text-success"> #</span><br>
<input class="form-control" placeholder="First Name" type="text" id="serfirstName" name="serfirstName">
</div>
<div class="col-6">
<label for="serlastName">Last Name</label><span class="text-success"> #</span><br>
<input class="form-control" placeholder="Last Name" type="text" id="serlastName" name="serlastName">
</div>
</div>
<div class="row mt-3">
<div class="col-6">
<label for="npi">NPI</label><span class="text-success"> #</span><br>
<input class="form-control" placeholder="NPI" type="text" id="npi" name="npi">
</div>
</div>
</div>
<div class="text-center mt-5">
<button type="button" class="btn btn-primary" id="createVisit" onclick="createVisit()"> Submit </button>
<button class="btn btn-primary" type="button" disabled id="loader" style="display:none;">
<span class="spinner-border spinner-border-sm" role="status" aria-hidden="true"></span>
Loading...
</button>
</div>
<div id="responseDiv" class="px-5 mt-5" style="display: none;">
<h5>Response: </h5>
<div id="showResponse" class="mt-2">
</div>
</div>
</div>
</body>
</html>
<script type="text/javascript">
function createVisit() {
$('#createVisit').hide();
$('#loader').show();
var stcDivChild = $("#stc_div").children().length;
var stcArray = [];
for(var i=0; i<parseInt(stcDivChild); i++) {
stcArray.push($('#serviceTypeCodes_'+(i+1)).val());
}
var facilityId = $('#facilityId').val();
var visitServiceDate = $('#visitServiceDate').val();
var serviceCategoryCode = $('#serviceCategoryCode').val();
var pfirstName = $('#pfirstName').val();
var plastName = $('#plastName').val();
var patientAccountNumber = $('#patientAccountNumber').val();
var medicalRecordNumber = $('#medicalRecordNumber').val();
var pbirthDate = $('#pbirthDate').val();
var genderCode = $('#genderCode').val();
var gfirstName = $('#gfirstName').val();
var glastName = $('#glastName').val();
var gbirthDate = $('#gbirthDate').val();
var ggenderCode = $('#ggenderCode').val();
var line1 = $('#line1').val();
var city = $('#city').val();
var stateCode = $('#stateCode').val();
var zipCode = $('#zipCode').val();
var payerId = $('#payerId').val();
var priorityNumber = $('#priorityNumber').val();
var serviceTypeCodes = stcArray;
var sfirstName = $('#sfirstName').val();
var slastName = $('#slastName').val();
var birthDate = $('#birthDate').val();
var sgenderCode = $('#sgenderCode').val();
var memberId = $('#memberId').val();
var patientRelationship = $('#patientRelationship').val();
var procedureCode = $('#procedureCode').val();
var units = $('#units').val();
var serfirstName = $('#serfirstName').val();
var serlastName = $('#serlastName').val();
var npi = $('#npi').val();
var data = {
"facilityId": facilityId,
"visitServiceDate": visitServiceDate,
"serviceCategoryCode": serviceCategoryCode,
"pfirstName": pfirstName,
"plastName": plastName,
"patientAccountNumber": patientAccountNumber,
"medicalRecordNumber": medicalRecordNumber,
"pbirthDate": pbirthDate,
"genderCode": genderCode,
"gfirstName": gfirstName,
"glastName": glastName,
"gbirthDate": gbirthDate,
"ggenderCode": ggenderCode,
"line1": line1,
"city": city,
"stateCode": stateCode,
"zipCode": zipCode,
"payerId": payerId,
"priorityNumber": priorityNumber,
"serviceTypeCodes": serviceTypeCodes,
"sfirstName": sfirstName,
"slastName": slastName,
"birthDate": birthDate,
"sgenderCode": sgenderCode,
"memberId": memberId,
"patientRelationship": patientRelationship,
"procedureCode": procedureCode,
"units": units,
"serfirstName": serfirstName,
"serlastName": serlastName,
"npi": npi,
}
$.ajax({
type: "POST",
url: 'CreateVisit.php',
data: data,
success: function(response)
{
$('#showResponse').html(response);
$('#responseDiv').show();
$('#createVisit').show();
$('#loader').hide();
}
});
}
function addMore() {
var child = $("#stc_div").children().length;
var childNumber = parseInt(child);
var nextChild = childNumber+1;
var paddingVar = "";
//var stcHTML = '<div class="row mt-3" id="stc_row_'+nextChild+'"><div class="col-6"><input class="form-control" placeholder="Service Type Codes" type="text" id="serviceTypeCodes_'+nextChild+'" name="serviceTypeCodes_'+nextChild+'"></div></div>';
// <div class="col-6"><button type="button" class="btn btn-primary" id="remove_'+nextChild+'" onclick="removeChild('+nextChild+')"> - </button> </div>
//$(stcHTML).insertAfter("#stc_row_"+child);
if(childNumber%2 != 0) {
paddingVar = "ps-2";
} else {
paddingVar = "pe-2";
}
var stcHTML = '<div class="w-50 mb-2 '+paddingVar+'" id="stc_div_'+nextChild+'"><input class="form-control" placeholder="Service Type Codes" type="text" id="serviceTypeCodes_'+nextChild+'" name="serviceTypeCodes_'+nextChild+'"></div>';
$(stcHTML).insertAfter("#stc_div_"+child);
}
$(function () {
$('[data-toggle="tooltip"]').tooltip()
})
</script>