@include('forms/elements/header_start')

<link href="{{ asset('assets/plugins/select2/css/select2.min.css') }}" rel="stylesheet" type="text/css" />
    <link href="{{ asset('assets/plugins/bootstrap-datepicker/css/bootstrap-datepicker.min.css') }}" rel="stylesheet">


@include('patients/elements/header_end')

<!-- Page title -->
<ul class="list-inline menu-left mb-0">
    <li class="list-inline-item">
        <button type="button" class="button-menu-mobile open-left waves-effect">
            <i class="ion-navicon"></i>
        </button>
    </li>
    <li class="hide-phone list-inline-item app-search">
        <h2 class="page-title">Insurance Information</h2>
    </li>
</ul>

<div class="clearfix"></div>
</nav>

</div>
<!-- Top Bar End -->
<style>
    .card-header {
        background-color: #027eaa!important;
    }
    label{
        font-size: 22px;
    }

</style>
<!-- ==================
     PAGE CONTENT START
     ================== -->

<div class="page-content-wrapper">
{{--@include('patients.elements.list')--}}

    <div class="container-fluid col-md-10 offset-md-1">

            <div class="pull-right">
            </div>

{{--        <div class="row">--}}
{{--            <div class="col-md-12 col-xl-12">--}}
{{--                <div class="card m-b-30">--}}
{{--                    <div class="card-header text-center">0% complete</div>--}}

{{--                    <div class="card-body">--}}

{{--                        <h4 class="mt-0 header-title">Animated stripes</h4>--}}
{{--                        <div class="">--}}
{{--                            <div class="progress">--}}
{{--                                <div class="progress-bar progress-bar-striped progress-bar-animated" role="progressbar" aria-valuenow="1" aria-valuemin="0" aria-valuemax="100" style="width: 0%"></div>--}}
{{--                            </div>--}}
{{--                        </div>--}}
{{--                    </div>--}}
{{--                </div>--}}
{{--             </div>--}}

{{--        </div>--}}
{{--        <!-- end row -->--}}

        <div class="row">
            <div class="col-md-9 col-xl-9">
                <div class="card m-b-30">
                    <h4 class="card-header mt-0">Insurance Information</h4>

                    <div class="card-body">

                        <form action="{{ isset($id) ?  route('patients.store.insurance.answer', ['id' => $id]) :  route('patients.store.insurance.answer') }} " method="POST" enctype="multipart/form-data" autocomplete="off">
                            @csrf

                            <div class="row">

                                <div class="col-md-6 col-sm-12">
                                    <div class="form-group">
                                        <label>
                                            Group Number
                                        </label>
                                        <input type="text" class="form-control" id="group_no" name="group_no"  placeholder="Group Number" value="{{ old('group_no', $patient->insurance['group_no']) }}">

                                        @if ($errors->has('group_no'))
                                            <span class="badge badge-danger">{{ $errors->first('group_no') }}</span>
                                        @endif
                                    </div>
                                </div>

                                <div class="col-md-6 col-sm-12">
                                    <div class="form-group">
                                        <label>
                                            Policy Number
                                        </label>
                                        <input type="text" class="form-control" id="policy_no" name="policy_no" placeholder="Policy Number" value="{{ old('policy_no', $patient->insurance['policy_no']) }}">

                                        @if ($errors->has('policy_no'))
                                            <span class="badge badge-danger">{{ $errors->first('policy_no') }}</span>
                                        @endif
                                    </div>
                                </div>

                            </div>

                            <div class="row">
                                <div class="col-md-6 col-sm-12">
                                    <div class="form-group">
                                        <label>
                                            Insurance Type
                                        </label>
                                        <select class="form-control select2" id="type_of_insurance" name="type_of_insurance">
                                            <option value="">Select</option>
                                            <option value="PPO" {{ old('type_of_insurance', $patient->insurance['type_of_insurance'])  == 'PPO' ? 'selected="selected"' : '' }}>Preferred Provider Organization</option>
                                            <option value="HMO" {{ old('type_of_insurance', $patient->insurance['type_of_insurance'])  == 'HMO' ? 'selected="selected"' : '' }}>Health Maintenance Organization</option>
                                            <option value="POS" {{ old('type_of_insurance', $patient->insurance['type_of_insurance'])  == 'POS' ? 'selected="selected"' : '' }}>Point of Service</option>
                                            <option value="EPO" {{ old('type_of_insurance', $patient->insurance['type_of_insurance'])  == 'EPO' ? 'selected="selected"' : '' }}>Exclusive Provider Organization</option>
                                            <option value="INDEMNITY" {{ old('type_of_insurance', $patient->insurance['type_of_insurance'])  == 'INDEMNITY' ? 'selected="selected"' : '' }}>Indemnity Health Insurance Plans</option>
                                            <option value="HSA" {{ old('type_of_insurance', $patient->insurance['type_of_insurance'])  == 'HSA' ? 'selected="selected"' : '' }}>Health Savings Account </option>
                                            <option value="QSEHRA" {{ old('type_of_insurance', $patient->insurance['type_of_insurance'])  == 'QSEHRA' ? 'selected="selected"' : '' }}>Qualified Small Employer Health Reimbursement Arrangements</option>
                                        </select>

                                        @if ($errors->has('type_of_insurance'))
                                            <span class="badge badge-danger">{{ $errors->first('type_of_insurance') }}</span>
                                        @endif

                                    </div>
                                </div>

                                <div class="col-md-6 col-sm-12">
                                    <div class="form-group">
                                        <label>
                                            Tel
                                        </label>
                                        <input type="text" class="form-control" id="tel" name="tel" placeholder="   Phone Number" value="{{ old('tel', $patient->insurance['tel']) }}">

                                        @if ($errors->has('tel'))
                                            <span class="badge badge-danger">{{ $errors->first('tel') }}</span>
                                        @endif
                                    </div>
                                </div>

                            </div>

                            <div class="row">
                                <div class="col-md-12">
                                    <button type="submit" class="btn btn-primary btn-flat pull-right">Submit</button>
                                </div>
                            </div>

                        </form>

                    </div>
                </div>
            </div>
            <div class="col-md-3 col-xl-3">
                <div class="row">
                    <div class="pull-right">
                        <div class="text-center">
                            <button type="button" class="btn btn-primary waves-effect waves-light btn-lg help-modal" data-toggle="modal" data-target="#myModal"><i class="fa fa-info-circle"></i></button>
                        </div>
                    </div>
                </div>
<hr>
                <!-- sample modal content -->
                <div id="myModal" class="modal fade" tabindex="-1" role="dialog" aria-labelledby="myModalLabel" aria-hidden="true">
                    <div class="modal-dialog">
                        <div class="modal-content">
                            <div class="modal-header">
                                <h5 class="modal-title mt-0" id="myModalLabel">Insurance Information</h5>
                                <button type="button" class="close" data-dismiss="modal" aria-hidden="true">×</button>
                            </div>
                            <div class="modal-body">
                                <h4 class="card-header">Enter height & weight in the boxes</h4>
                                <p style="padding:10px;">Please ensure tat all insurance information is kept up-to-date here.</p>
                            </div>
                            <div class="modal-footer">
                                <button type="button" class="btn btn-secondary waves-effect" data-dismiss="modal">Close</button>
                                <button type="button" class="btn btn-primary waves-effect waves-light">Save changes</button>
                            </div>
                        </div><!-- /.modal-content -->
                    </div><!-- /.modal-dialog -->
                </div><!-- /.modal -->

                <div class="row">
                    <div class="card m-b-30">
                        <img class="card-img-top img-fluid" src="{{ asset('assets/images/face-placeholder.png') }}" alt="Card image cap">

                        <div class="card-header text-center">Contact Us</div>
                        <div class="card-body">

                        </div>
                    </div>
                </div>

            </div>
        </div>
        <!-- end row -->

    </div>


</div> <!-- Page content Wrapper -->

</div> <!-- content -->





<!-- sample modal content -->
<div id="myModal" class="modal fade" tabindex="-1" role="dialog" aria-labelledby="myModalLabel" aria-hidden="true">
    <div class="modal-dialog">
        <div class="modal-content">
            <div class="modal-header">
                <h5 class="modal-title mt-0" id="myModalLabel">How to use:</h5>
                <button type="button" class="close" data-dismiss="modal" aria-hidden="true">×</button>
            </div>
            <div class="modal-body">
                <h4 class="card-header">Enter height & weight in the boxes</h4>
                <p style="padding:10px;">This will automatically calculate your BMI and
                    store the value. You are able to change this
                    at a later date to reflect new surcumstances.</p>
                <hr>
                <h4 class="card-header">Choose highest level of education</h4>
                <p style="padding:10px;">Select the highest level you have achieved in education to date.</p>
                <hr>
                <h4 class="card-header">Enter the date of your most recent surgery</h4>
                <p style="padding:10px;">Please enter the date of the most recent surgery you had.
                    This is an optional field, so if this does not apply to you, please leave it blank.</p>
                <hr>
                <h4 class="card-header">Enter any medical allergies you have</h4>
                <p style="padding:10px;">Please enter any allergies that you have within this box.</p>
                <p style="padding:10px;">If you do not have any allergies, please leave this optional field blank</p>
                <p style="padding:10px;">If you have 2 or more allergies, please separate these values with a comma ' , '</p>
                <hr>
            </div>
            <div class="modal-footer">
                <button type="button" class="btn btn-secondary waves-effect" data-dismiss="modal">Close</button>
                <button type="button" class="btn btn-primary waves-effect waves-light">Save changes</button>
            </div>
        </div><!-- /.modal-content -->
    </div><!-- /.modal-dialog -->
</div><!-- /.modal -->


@include('forms/elements/footer_start')

<script src="{{ asset('assets/plugins/select2/js/select2.min.js') }}" type="text/javascript"></script>
<script src="{{ asset('assets/plugins/bootstrap-datepicker/js/bootstrap-datepicker.min.js') }}"></script>

<!-- Plugins Init js -->
<script src="{{ asset('assets/pages/form-advanced.js') }}"></script>


<script>
    $(function(){
        $('#datepicker').datepicker({
            format: "mm/dd/yyyy",
            language: "en"
        });
    });

</script>

@include('forms/elements/footer_end')