71 lines
3.8 KiB
PHP
71 lines
3.8 KiB
PHP
<?php $this->titre = "INTER-SANTE - Refuser Dérogation"; ?>
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<form id="frmderogation" name="frmderogation" method="post" >
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<INPUT class="sr-only" TYPE="text" id="idDemandederogation" name="idDemandederogation" value="<?= $this->nettoyer($derogation['idDemandederogation']) ?>">
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<INPUT class="sr-only" TYPE="text" id="smsGestionPrestataire" name="smsGestionPrestataire" value="<?= $this->nettoyer($derogation['smsGestionPrestataire']) ?>">
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<INPUT class="sr-only" TYPE="text" id="prestataire" name="prestataire" value="<?= $this->nettoyer($derogation['prestataire']) ?>">
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<INPUT class="sr-only" TYPE="text" id="codePrestataire" name="codePrestataire" value="<?= $this->nettoyer($derogation['codePrestataire']) ?>">
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<INPUT class="sr-only" TYPE="text" id="beneficiaire" name="beneficiaire" value="<?= $this->nettoyer($derogation['beneficiaire']) ?>">
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<INPUT class="sr-only" TYPE="text" id="numeroBeneficiaire" name="numeroBeneficiaire" value="<?= $this->nettoyer($derogation['numeroBeneficiaire']) ?>">
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<INPUT class="sr-only" TYPE="text" id="libelleDerogation" name="libelleDerogation" value="<?= $this->nettoyer($derogation['libelleDerogation']) ?>">
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<INPUT class="sr-only" TYPE="text" id="telephonePortableAdherent" name="telephonePortableAdherent" value="<?= $this->nettoyer($derogation['telephonePortableAdherent']) ?>">
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<legend> <?= _("Fiche de demande de dérogation") ?> </legend>
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<table class="table table-responsive table-condensed" style='font-size:10pt;'>
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<tbody>
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<tr>
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<td width="15%" > <?= _("No") ?> </td>
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<td width="20%"> <INPUT id="numeroDerogation" name="numeroDerogation" class="form-control" TYPE="text" style='font-size:10pt;text-align:center;' value="<?= $this->nettoyer($derogation['numeroDerogation']) ?>" readonly> </td>
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<td width="15%" align="center"> <?= _("Dérogation") ?> </td>
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<td> <INPUT class="form-control" TYPE="text" style='font-size:10pt;' value="<?= $this->nettoyer($derogation['libelleDerogation']) ?>" readonly> </td>
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</tr>
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<tr>
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<td> Date </td>
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<td> <INPUT class="form-control" TYPE="text" style='font-size:10pt;' value="<?= dateheureLang($this->nettoyer($derogation['dateSysteme'])) ?>" readonly> </td>
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<td align="center"> <?= _("Prestataire") ?> </td>
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<td> <INPUT class="form-control" TYPE="text" style='font-size:10pt;' value="<?= $this->nettoyer($derogation['prestataire']) ?>" readonly> </td>
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</tr>
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<tr>
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<td> <?= _("Bénéficiaire") ?> </td>
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<td colspan="5"><INPUT class="form-control" TYPE="text" style='font-size:10pt;' value="<?= $this->nettoyer($derogation['beneficiaire']) ?>" readonly> </td>
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</tr>
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<tr>
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<td> <?= _("Motivations") ?> </td>
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<td colspan="3"><INPUT class="form-control" TYPE="text" style='font-size:10pt;' value="<?= $this->nettoyer($derogation['observations']) ?>" readonly> </td>
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</tr>
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<tr>
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<td> <?= _("Motif Réel") ?> </td>
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<td colspan="3"><INPUT class="form-control" TYPE="text" id="motifReel" NAME="motifReel" style='font-size:10pt;' required AUTOCOMPLETE="OFF" autofocus ></td>
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</tr>
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<tr>
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<td> <?= _("Motif à l'assuré") ?> </td>
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<td colspan="3"><INPUT class="form-control" TYPE="text" id="motifRefusAssure" NAME="motifRefusAssure" style='font-size:10pt;' required AUTOCOMPLETE="OFF" ></td>
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</tr>
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<tr>
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<td> </td>
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<td colspan="3"> <input id="btn_enreg" name="btn_enreg" class = "form-control btn btn-primary" type="button" value="<?= _("Valider le refus") ?>" onClick="enregistrerrefusderogation_2();" style='font-size:10pt;' > </td>
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</tr>
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</tbody>
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</table>
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<?php if (isset($msgErreur)): ?>
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<div id ="msgErreur" class="alert alert-danger" style="height:38px; padding:5px;" >
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<H4><?= $msgErreur ?></H4>
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</div>
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<?php endif; ?>
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</form>
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<div id ="div_wait">
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</div>
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