193 lines
9.2 KiB
PHP
Executable File
193 lines
9.2 KiB
PHP
Executable File
<?php
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$this->titre = "INTER SANTE - Modification Dossier Remboursement Classique";
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$numeroLotDecompte = $dossier['numeroLotDecompte'];
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$idDossierClassique = $dossier['idDossierClassique'];
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$regle = $dossier['regle'];
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$affection = $dossier['affection'];
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if(est_anglophone()){
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$affection = $dossier['affectionEng'];
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}
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?>
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<input class="sr-only" type="text" id="nomForm" name="nomForm" value="modifierRembClassique" >
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<input class="sr-only" type="text" id="idDossierClassique" name="idDossierClassique" value="<?= $idDossierClassique ?>" >
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<input class="sr-only" type="text" id="regle" name="regle" value="<?= $regle ?>" >
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<legend>
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<?= _("Dossier de remboursement classique") . " => " . _("No Lot") . " : " . $numeroLotDecompte ?>
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</legend>
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<table class="table table-responsive table-condensed" style='font-size:9pt;'>
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<tbody>
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<tr>
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<td width="10%" > <?= _("Prestataire Consulté") ?> </td>
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<td colspan="5" > <INPUT style='font-size:9pt;' class="form-control" TYPE="text" value="<?= $this->nettoyer($dossier['prestataireConsultation']) ?>" readonly> </td>
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</tr>
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<tr>
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<td width="10%" > <?= _("Affection") ?> </td>
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<td width="24%" > <INPUT style='font-size:9pt;' class="form-control" TYPE="text" value="<?= $affection ?>" readonly> </td>
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<td width="10%" align="center" > <?= _("Date Consultation") ?> </td>
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<td width="23%" > <INPUT style='font-size:9pt;' class="form-control" TYPE="text" value="<?= dateLang($this->nettoyer($dossier['dateConsultation'])) ?>" readonly> </td>
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<td width="10%" align="center" > <?= _("Demandeur") ?> </td>
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<td width="24%" > <INPUT style='font-size:9pt;' class="form-control" TYPE="text" value="<?= $this->nettoyer($dossier['demandeur']) ?>" readonly> </td>
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</tr>
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<tr>
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<td> <?= _("Lien Parenté") ?> </td>
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<td><INPUT style='font-size:9pt;' class="form-control" TYPE="text" value="<?= $dossier['liendemandeur'] ?>" readonly ></td>
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<td align="center" > <?= _("Raison Consultation") ?> </td>
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<td><INPUT style='font-size:9pt;' class="form-control" TYPE="text" value="<?= $dossier['raisonconsultation'] ?>" readonly ></td>
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<td align="center" > <?= _("Hospitalisation?") ?> </td>
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<td><INPUT style='font-size:9pt;' class="form-control" TYPE="text" value="<?= $dossier['libellehospitalisation'] ?>" readonly ></td>
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</tr>
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<tr>
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<td> <?= _("Bénéficiaire") ?> </td>
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<td><INPUT style='font-size:9pt;' class="form-control" TYPE="text" value="<?= $dossier['beneficiaireReglement'] ?>" readonly ></td>
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<td align="center"> <?= _("Lien Parenté") ?> </td>
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<td><INPUT style='font-size:9pt;' class="form-control" TYPE="text" value="<?= $dossier['lienbeneficiaire'] ?>" readonly ></td>
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<td align="center" > Observations </td>
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<td><INPUT style='font-size:9pt;' class="form-control" TYPE="text" value="<?= $dossier['observations'] ?>" readonly ></td>
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</tr>
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<tr>
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<td colspan="6"> <input style='text-align:center; font-size:11pt; background-color:green !important; color:white;' class="form-control" type="text" value= "<?= _("Informations sur le paiement proposées par le bénéficiaire")?>" disabled > </td>
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</tr>
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<tr>
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<td > <?= _("Mode Paiement") ?> </td>
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<td > <INPUT style='font-size:9pt;' class="form-control" TYPE="text" value="<?= $dossier['modepaiementBeneficiaire'] ?>" readonly > </td>
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<td align="center"> <?= _("Banque Bénéf") ?> </td>
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<td > <INPUT style='font-size:9pt;' class="form-control" TYPE="text" value="<?= $dossier['banqueBeneficiaire'] ?>" readonly > </td>
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<td align="center"> <?= _("No Cpte Bénéf") ?> </td>
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<td > <INPUT style='font-size:9pt;' class="form-control" TYPE="text" value="<?= $dossier['numeroCompteBeneficiaire'] ?>" readonly > </td>
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</tr>
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</tbody>
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</table>
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<input style='text-align:center; font-size:11pt; font-weight: bold; background-color:#f5deb3; color:#a0522d;' class="form-control" type="text" value= "<?= _("Nouvelles informations sur la demande de remboursement classique") ?>" readonly >
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<table class="table table-responsive table-condensed" style='font-size:9pt;'>
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<tbody>
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<tr>
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<td width="10%" 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);" value="<?= $this->nettoyer($dossier['prestataireConsultation']) ?>">
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<INPUT class="sr-only" TYPE="text" id="codePrestataire" NAME="codePrestataire" value="">
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<INPUT class="sr-only" TYPE="text" id="prestataireConsultation" NAME="prestataireConsultation" 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 class="required"> <?= _("Affection") ?> </td>
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<td>
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<SELECT id="codeAffection" NAME="codeAffection" class="form-control selectpicker" data-live-search="true" style='font-size:10pt;'>
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<?php liste_options($affections, $this->nettoyer($dossier['codeAffection'])); ?>
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</SELECT>
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</td>
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<td width="10%" align="center" class="required"> <?= _("Date Consultation") ?> </td>
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<td width="23%" > <INPUT style='font-size:10pt;' class="form-control datepicker" TYPE="text" id="dateConsultation" NAME="dateConsultation" value="<?= dateLang($this->nettoyer($dossier['dateConsultation'])) ?>" required AUTOCOMPLETE="OFF" ></td>
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<td width="10%" align="center" > <?= _("Demandeur") ?> </td>
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<td width="24%" > <INPUT id="demandeur" NAME="demandeur" style='font-size:9pt;' class="form-control" TYPE="text" value="<?= $this->nettoyer($dossier['demandeur']) ?>" > </td>
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</tr>
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<tr>
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<td class="required"> <?= _("Lien Parenté") ?> </td>
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<td>
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<select class="form-select" id="codeLienDemandeur" NAME="codeLienDemandeur" required AUTOCOMPLETE="OFF" style='font-size:9pt;'>
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<?php liste_options($liendemandeur, $dossier['codeLienDemandeur']); ?>
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</SELECT>
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</td>
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<td align="center" class="required"> <?= _("Raison Consultation") ?> </td>
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<td>
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<select class="form-select" id="codeRaisonConsultation" NAME="codeRaisonConsultation" required AUTOCOMPLETE="OFF" style='font-size:9pt;'>
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<?php liste_options($raison, $dossier['codeRaisonConsultation']); ?>
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</SELECT>
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</td>
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<td align="center" class="required"> <?= _("Hospitalisation?") ?> </td>
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<td>
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<select class="form-select" id="hospitalisation" NAME="hospitalisation" style='font-size:10pt;' >
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<?php liste_options($ouinonhospit, $dossier['hospitalisation']); ?>
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</SELECT>
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</td>
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</tr>
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<tr>
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<td> <?= _("Bénéficiaire") ?> </td>
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<td><INPUT id="beneficiaireReglement" NAME="beneficiaireReglement" style='font-size:9pt;' class="form-control" TYPE="text" value="<?= $dossier['beneficiaireReglement'] ?>" readonly></td>
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<td align="center" class="required"> <?= _("Lien Parenté") ?> </td>
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<td>
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<select class="form-select" style='font-size:10pt;' disabled>
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<?php liste_options($lienbeneficiaire, $dossier['codeLienBeneficiaire']); ?>
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</SELECT>
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<INPUT class="sr-only" TYPE="text" id="codeLienBeneficiaire" NAME="codeLienBeneficiaire" value="<?= $dossier['codeLienBeneficiaire']; ?>" >
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</td>
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<td align="center" > Observations </td>
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<td ><INPUT id="observations" NAME="observations" style='font-size:9pt;' class="form-control" TYPE="text" value="<?= $dossier['observations'] ?>" ></td>
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</tr>
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<tr>
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<td colspan="6"> <input style='text-align:center; font-size:11pt; background-color:green !important; color:white;' class="form-control" type="text" value= "<?= _("Informations sur le paiement proposées par le bénéficiaire")?>" disabled > </td>
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</tr>
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<tr>
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<td class="required"> <?= _("Mode Paiement") ?> </td>
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<td>
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<select class="form-select" id="codeModePaiementDemande" NAME="codeModePaiementDemande" required AUTOCOMPLETE="OFF" style='font-size:9pt;' >
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<?php liste_options($modepaiement, $dossier['codeModePaiementDemande']); ?>
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</SELECT>
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</td>
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<td align="center"> <?= _("Banque Bénéf") ?> </td>
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<td>
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<SELECT style='font-size:9pt;' class="form-select" id="codeBanqueBeneficiaire" NAME="codeBanqueBeneficiaire" required AUTOCOMPLETE="OFF">
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<?php liste_options($banque, $dossier['codeBanqueBeneficiaire']); ?>
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</SELECT>
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</td>
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<td align="center"> <?= _("No Cpte Bénéf") ?> </td>
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<td > <INPUT style='font-size:9pt;' class="form-control" TYPE="text" id="numeroCompteBeneficiaire" NAME="numeroCompteBeneficiaire" value="<?= $dossier['numeroCompteBeneficiaire'] ?>" required AUTOCOMPLETE="OFF"> </td>
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</tr>
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<tr>
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<td> </td>
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<td colspan="5"> <input id="btn_enreg" name="btn_enreg" class = "form-control btn btn-primary" type="button" value="<?= _("Enregistrer les Modifications") ?>" onClick="enregistrermodificationsdossierclassique();" style='font-size:10pt;' > </td>
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</tr>
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</tbody>
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</table>
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<?php if (isset($msgErreur)): ?>
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<div id ="msgErreur" class="alert alert-danger" style="height:30px; padding:5px;" >
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<H4><?= $msgErreur ?></H4>
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</div>
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<?php endif; ?>
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<div id="div_test">
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</div>
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