67 lines
3.8 KiB
PHP
67 lines
3.8 KiB
PHP
<?php $this->titre = "INTER-SANTE - Refuser un acte"; ?>
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<form id="frmdententeprealable" name="frmdententeprealable" method="post" >
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<INPUT class="sr-only" TYPE="text" id="idDemandeententeprealable" name="idDemandeententeprealable" value="<?= $this->nettoyer($ententeprealable['idDemandeententeprealable']) ?>">
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<INPUT class="sr-only" TYPE="text" id="smsGestionPrestataire" name="smsGestionPrestataire" value="<?= $this->nettoyer($ententeprealable['smsGestionPrestataire']) ?>">
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<INPUT class="sr-only" TYPE="text" id="prestataire" name="prestataire" value="<?= $this->nettoyer($ententeprealable['prestataire']) ?>">
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<INPUT class="sr-only" TYPE="text" id="codePrestataire" name="codePrestataire" value="<?= $this->nettoyer($ententeprealable['codePrestataire']) ?>">
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<INPUT class="sr-only" TYPE="text" id="beneficiaire" name="beneficiaire" value="<?= $this->nettoyer($ententeprealable['beneficiaire']) ?>">
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<INPUT class="sr-only" TYPE="text" id="numeroBeneficiaire" name="numeroBeneficiaire" value="<?= $this->nettoyer($ententeprealable['numeroBeneficiaire']) ?>">
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<INPUT class="sr-only" TYPE="text" id="libelleActe" name="libelleActe" value="<?= $this->nettoyer($ententeprealable['libelleActe']) ?>">
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<INPUT class="sr-only" TYPE="text" id="telephonePortableAdherent" name="telephonePortableAdherent" value="<?= $this->nettoyer($ententeprealable['telAdherent']) ?>">
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<legend> <?= _("Refuser un acte") ?> </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="10%" > <?= _("No") ?> </td>
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<td width="20%"> <INPUT id="numeroEntentePrealable" name="numeroEntentePrealable" class="form-control" TYPE="text" style='font-size:10pt;text-align:center;' value="<?= $this->nettoyer($ententeprealable['numeroEntentePrealable']) ?>" readonly> </td>
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<td width="10%" align="center"> <?= _("Acte") ?> </td>
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<td colspan="3"> <INPUT class="form-control" TYPE="text" style='font-size:10pt;' value="<?= $this->nettoyer($ententeprealable['libelleActe']) ?>" 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($this->nettoyer($ententeprealable['dateSysteme'])) ?>" readonly> </td>
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<td align="center"> <?= _("Prestataire") ?> </td>
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<td colspan="3"> <INPUT class="form-control" TYPE="text" style='font-size:10pt;' value="<?= $this->nettoyer($ententeprealable['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="<?= $this->nettoyer($ententeprealable['beneficiaire']) . " ( " . $this->nettoyer($ententeprealable['numeroBeneficiaire']) . " )" ?>" 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="enregistrerrefusententepreslable();" 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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