67 lines
2.4 KiB
PHP
Executable File
67 lines
2.4 KiB
PHP
Executable File
<?php
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// $this->titre = "INTER SANTE - Tarif Actes Médicaux";
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?>
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<legend> <?= _("Tarif Négocié Adhérent par prestataire") ?> </legend>
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<input class="sr-only" id="nomForm" name="nomForm" type="text" value= "adherentprestataire" >
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<input class="sr-only" id="idAssure" name="idAssure" type="text" value="<?= $idAdherent ;?>" >
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<input class="sr-only" id="codeLienParente" name="codeLienParente" type="text" value="<?= $codeLienParente ;?>" >
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<div id="div_entete_tarif" >
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<table class="table table-condensed" style="font-size:10pt; padding:0px;">
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<tbody>
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<tr>
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<td width="8%" class="required"> <?= _("No Adhérent") ?> </td>
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<td width="35%">
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<div >
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<input id="searchInput" name="searchInput" style="font-size:12pt; height:30px;" class="form-control" type="text" value="<?= $numeroAdherent ;?>" required autofocus>
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<div id="div_selection" class="div_selection_list">
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</div>
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</div>
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</td>
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<td width="10%" align="center"> <?= _("Nom et Prénoms") ?> </td>
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<td >
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<input id="nomAssure" name="nomAssure" style="font-size:12pt; height:30px;" class="form-control" type="text" value="<?= $adherent ;?>" readonly>
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</td>
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</tr>
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<tr>
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<td > <?= _("Police") ?> </td>
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<td >
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<input id="nomPolice" name="nomPolice" style="font-size:12pt; height:30px;" class="form-control" type="text" value="<?= $nomPolice ;?>" readonly>
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</td>
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<td align="center" > <?= _("Collège") ?> </td>
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<td >
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<input id="nomCollege" name="nomCollege" style="font-size:12pt; height:30px;" class="form-control" type="text" value="<?= $nomCollege ;?>" readonly>
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</td>
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</tr>
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<tr>
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<td width="5%" class="required"> <?= _("Tarif") ?> </td>
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<td>
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<select class="form-control selectpicker" data-live-search="true" id="codeTarifActe" NAME="codeTarifActe" style="font-size:10pt;"
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onChange="javascript:ajax_composante_tarif_adherent_prestataire();" required>
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<?php liste_options($tarifs, $codeTarifActe); ?>
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</SELECT>
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</td>
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<td></td>
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<td align='center'>
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<input class="form-control btn btn-primary" type="button" value="<?= _("Actualiser...") ?>"
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onClick="javascript:ajax_composante_tarif_adherent_prestataire();" style="font-size:10pt;">
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</td>
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</tr>
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</tbody>
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</table>
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</div>
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<div id="div_compsante_tarif">
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</div>
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