109 lines
4.3 KiB
PHP
Executable File
109 lines
4.3 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 appliqué pour un bénéficiaire chez un prestataire") ?> </legend>
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<input class="sr-only" id="nomForm" name="nomForm" type="text" value= "tarifappliquebeneficiaire" >
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<input class="sr-only" id="idAssure" name="idAssure" type="text" value="<?= $idBeneficiaire ;?>" >
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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="10%" class="required"> <?= _("No Bénéficiaire") ?> </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="<?= $numeroBeneficiaire ;?>" autofocus required AUTOCOMPLETE="OFF">
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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="<?= $beneficiaire ;?>" readonly>
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</td>
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<td width="5%" align="center"> <?= _("Lien") ?> </td>
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<td width="5%">
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<input id="codeLienParente" name="codeLienParente" style="font-size:12pt; height:30px;" class="form-control" type="text" value="<?= $codeLienParente ;?>" readonly>
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</td>
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</tr>
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<tr>
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<td > <?= _("No Adhérent") ?> </td>
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<td >
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<input id="noAdherent" name="noAdherent" style="font-size:12pt; height:30px;" class="form-control" type="text" value="<?= $noAdherent ;?>" readonly>
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</td>
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<td align="center"> <?= _("Adhérent") ?> </td>
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<td colspan="3">
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<input id="nomAdherent" name="nomAdherent" style="font-size:12pt; height:30px;" class="form-control" type="text" value="<?= $nomAdherent ;?>" 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 colspan="3">
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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="8%" class="required"> <?= _("Prestataire") ?> </td>
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<td colspan="5">
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<input id="searchInputPrestataire" name="searchInputPrestataire" style="font-size:12pt; height:30px;" class="form-control" type="text" required AUTOCOMPLETE="OFF"
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onkeyup="javascript:affichelisteprestataires(this.value);">
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<INPUT class="sr-only" TYPE="text" id="codePrestataire" NAME="codePrestataire" value="">
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<div id="div_selection_prestataire" style="width:92%">
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</div>
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</td>
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</tr>
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<tr>
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<td width="8%" class="required"> <?= _("Acte") ?> </td>
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<td colspan="5">
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<input id="searchInputActe" name="searchInputActe" AUTOCOMPLETE="OFF" style="font-size:12pt; height:30px;" class="form-control" type="text" required AUTOCOMPLETE="OFF"
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onkeyup="javascript:affichelisteactes(this.value, 'acte');">
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<INPUT class="sr-only" TYPE="text" id="codeActe" NAME="codeActe" value="">
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<div id="div_selection_acte" style="width:92%">
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</div>
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</td>
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</tr>
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<tr>
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<td width="8%" class="required"> <?= _("Date Prestation") ?> </td>
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<td >
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<INPUT style='text-align:center; font-size:12pt;' class="form-control datepicker" TYPE="text" id="datePrestation"
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NAME="datePrestation" value="" required AUTOCOMPLETE="OFF">
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</td>
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<td ></td>
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<td >
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<input style='font-size:12pt;' id="btn_inserer" name="btn_inserer"
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class = "form-control btn btn-primary" type="button" value="<?= _("Afficher le tarif appliqué") ?>"
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onclick="javascript:affichertarifapplique();">
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</td>
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<td colspan="2">
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<input style='font-size:12pt;' id="btn_reinit" name="btn_reinit"
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class = "form-control btn btn-info" type="button" value="<?= _("Réinitialiser") ?>"
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onclick="javascript:reinit_tarifapplique();">
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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_tarif_applique">
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</div>
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