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Insurance Form Industrial Alliance HTML

HTML icon IndustrialAllianceMD.HTML — HTML, 20 kB (21392 bytes)

File contents

<HTML>
<head>

<link rel="stylesheet" type="text/css" media="print" href="${oscar_image_path}JSMPC.css" />

<title>Master eform</title>

<style type="text/css" media="print">
 .DoNotPrint {
	 display: none;
 }
 .noborder {
	 border : 0px;
	 background: transparent;
	 scrollbar-3dlight-color: transparent;
	 scrollbar-3dlight-color: transparent;
	 scrollbar-arrow-color: transparent;
	 scrollbar-base-color: transparent;
	 scrollbar-darkshadow-color: transparent;
	 scrollbar-face-color: transparent;
	 scrollbar-highlight-color: transparent;
	 scrollbar-shadow-color: transparent;
	 scrollbar-track-color: transparent;
	 background: transparent;
	 overflow: hidden;
 }
 </style>
 
 <script language="javascript" type="text/javascript">
		/****************************
		startup functions 
		****************************/
		function startUp()
		{			
			// shows the forms on development machine from notepad ++ - saves you from uploading to the server to input alignments
			var strLoc = window.location.href.toLowerCase();
			if(strLoc.indexOf("https") == -1)
			{
				//page1
				var src = document.getElementById('BGImage').src;				
				document.getElementById('BGImage').src = src.replace('$%7Boscar_image_path%7D','');
			}
			setDocumentTitle('Master eform',document.getElementById('PatientName').value);
			setDefaults();			
		}
		
		function setDocumentTitle(Title,PatientName)
		{
			// set document title
			document.title = Title + ' - ' + PatientName;					
							
		}

		/****************************
			submit and print functions 
		****************************/
		function printSubmit()
		{
			printLetter();
			releaseDirtyFlag();			
			submission();
		}

		function printLetter()
		{
			// hide the bottom buttons
			if (document.getElementById('BottomButtons').style.display == '')
				document.getElementById('BottomButtons').style.display = 'none';
			// print the letter
			window.print();
		} 

		function submission()
		{
			setFlag();
			setTimeout('document.FormName.submit()',1000);			
		}

		function setFlag()
		{
		// indicate that the form has been submitted
		if (document.getElementById("newForm").value == 'True')
			document.getElementById("newForm").value = 'False';
		}
		
		function showButtons()
		{
			//show the bottom buttons if they are hidden
			if (document.getElementById('BottomButtons').style.display == 'none')
				document.getElementById('BottomButtons').style.display = '';
		}
		
		/****************************
			checkbox functions 
		****************************/
		function changeValue(x)
		{
			if (document.getElementById(x).value == '')
				document.getElementById(x).value = 'X';
			else
				document.getElementById(x).value = '';
		}

		function displayKeyCode(evt,x)
		{
			var charCode = (evt.which) ? evt.which : event.keyCode
			// any key press except tab will constitute a value change to the checkbox
			if (charCode != 9)
			{
				changeValue(x);
				return false;
			}
		}
		</script>

<!-------Script to optimize window on loading----------->
<script language="JavaScript">
top.window.moveTo(0,0);
if (document.all) {
top.window.resizeTo(screen.availWidth,screen.availHeight);
}
else if (document.layers||document.getElementById) {
if (top.window.outerHeight<screen.availHeight||top.window.outerWidth<screen.availWidth){
top.window.outerHeight = screen.availHeight;
<!-- top.window.outerWidth = 1120; -->
top.window.outerWidth = 1400;
}
}
</script>
<!----------End optimize window script---------->

<!-- scripts to confirm closing of window if it hadn't been saved yet -->
<script language="javascript">
//keypress events trigger dirty flag
var needToConfirm = false;
document.onkeyup=setDirtyFlag;
function setDirtyFlag(){
		needToConfirm = false;
}
function releaseDirtyFlag(){
		needToConfirm = false; //Call this function if doesn't requires an alert.
//this could be called when save button is clicked
}
window.onbeforeunload = confirmExit;
function confirmExit(){
	 if (needToConfirm){
		 return "You have attempted to leave this page. If you have made any changes to the fields without clicking the Save button, your changes will be lost. Are you sure you want to exit this page?";
	 }
}
</script>

<script type="text/javascript" language="javascript">
function checkGender(){
	 if (document.getElementById('PatientGender').value == 'M'){
	 document.getElementById('Male').checked = true;
	 }else if (document.getElementById('PatientGender').value == 'F'){
	 document.getElementById('Female').checked = true;
	}
 }
</script>

</head>

<body>
<form method="post" action="" name="twoPageForm">



<!-- PAGE 1 ----------------------------------------------------------------------------------------------- -->
<div id="page1" style="page-break-after:always;position:relative;" >
<img src="${oscar_image_path}IndustrialAllianceMD1.png" style="position: relative; left: 0px; top: 0px; width:750px">


<input name="patient_name" id="patient_name" type="text" class="noborder" style="position:absolute; left:60px; top:193px; width:280px; height:27px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:center; background-color:transparent;"  oscarDB=patient_name>

<input name="dobc" id="dobc" type="text" class="noborder" style="position:absolute; left:454px; top:179px; width:211px; height:21px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:center; background-color:transparent;"  oscarDB=dobc>

<input name="PolicyNumber" id="PolicyNumber" type="text" class="noborder" style="position:absolute; left:463px; top:210px; width:207px; height:23px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:center; background-color:transparent;" value="">

<input name="Today" id="Today" type="text" class="noborder" style="position:absolute; left:489px; top:270px; width:183px; height:21px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:center; background-color:transparent;"  oscarDB=today>

<textarea name="Diagnosis" id="Diagnosis" class="noborder" style="position:absolute; left:56px; top:356px; width:427px; height:42px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" ></textarea>

<textarea name="DxDate" id="DxDate" class="noborder" style="position:absolute; left:492px; top:361px; width:202px; height:29px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" ></textarea>

<textarea name="SxOnsetDate" id="SxOnsetDate" class="noborder" style="position:absolute; left:57px; top:418px; width:175px; height:28px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" ></textarea>

<textarea name="SxDescription" id="SxDescription" class="noborder" style="position:absolute; left:241px; top:415px; width:464px; height:34px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" ></textarea>

<input name="FirstVisitDate" id="FirstVisitDate" type="text" class="noborder" style="position:absolute; left:56px; top:483px; width:179px; height:17px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">

<textarea name="LocationFirstVisit" id="LocationFirstVisit" class="noborder" style="position:absolute; left:240px; top:467px; width:465px; height:34px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" >Family physician office</textarea>

<input name="ERYes" id="ERYes" type="text" class="Xbox" style="position:absolute; left:295px; top:718px; width:14px; height:14px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:12px; text-align:center; background-color:transparent;" value="">

<input name="ERNo" id="ERNo" type="text" class="Xbox" style="position:absolute; left:334px; top:718px; width:14px; height:14px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:12px; text-align:center; background-color:transparent;" value="">

<input name="HospitalizedYes" id="HospitalizedYes" type="text" class="Xbox" style="position:absolute; left:568px; top:717px; width:14px; height:14px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:12px; text-align:center; background-color:transparent;" value="">

<input name="HospitalizedNo" id="HospitalizedNo" type="text" class="Xbox" style="position:absolute; left:623px; top:717px; width:14px; height:14px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:12px; text-align:center; background-color:transparent;" value="">

<textarea name="HospitalNames" id="HospitalNames" class="noborder" style="position:absolute; left:57px; top:767px; width:360px; height:31px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" ></textarea>

<textarea name="HospitalDates" id="HospitalDates" class="noborder" style="position:absolute; left:420px; top:767px; width:133px; height:30px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" ></textarea>

<textarea name="DischargeDates" id="DischargeDates" class="noborder" style="position:absolute; left:555px; top:767px; width:151px; height:30px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" ></textarea>

<input name="SurgeryYes" id="SurgeryYes" type="text" class="Xbox" style="position:absolute; left:88px; top:819px; width:14px; height:14px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:12px; text-align:center; background-color:white;" value="">

<input name="SurgeryNo" id="SurgeryNo" type="text" class="Xbox" style="position:absolute; left:150px; top:819px; width:14px; height:14px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:12px; text-align:center; background-color:transparent;" value="">

<textarea name="Procedure" id="Procedure" class="noborder" style="position:absolute; left:233px; top:815px; width:321px; height:28px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" ></textarea>

<textarea name="ProcedureDates" id="ProcedureDates" class="noborder" style="position:absolute; left:557px; top:814px; width:151px; height:28px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" ></textarea>

<input name="SurgeonName" id="SurgeonName" type="text" class="noborder" style="position:absolute; left:57px; top:862px; width:370px; height:26px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" value="">

<input name="Specialty" id="Specialty" type="text" class="noborder" style="position:absolute; left:431px; top:861px; width:277px; height:26px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" value="">

</div>

<!-- PAGE 2 ----------------------------------------------------------------------------------------------- -->
<div id="page2" style="page-break-after:always;position:relative;" >
<img src="${oscar_image_path}IndustrialAllianceMD2.png" width="750">

<textarea name="TxPlan" id="TxPlan" class="noborder" style="position:absolute; left:52px; top:118px; width:651px; height:51px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" ></textarea>

<input name="SameYes" id="SameYes" type="text" class="Xbox" style="position:absolute; left:371px; top:173px; width:14px; height:14px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:12px; text-align:center; background-color:white;" value="">

<input name="SameNo" id="SameNo" type="text" class="Xbox" style="position:absolute; left:427px; top:173px; width:14px; height:14px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:12px; text-align:center; background-color:white;" value="">

<input name="SameUnknown" id="SameUnknown" type="text" class="Xbox" style="position:absolute; left:480px; top:174px; width:14px; height:14px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:12px; text-align:center; background-color:white;" value="">

<textarea name="ExplainYes" id="ExplainYes" class="noborder" style="position:absolute; left:51px; top:198px; width:651px; height:48px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" ></textarea>

<input name="GPName" id="GPName" type="text" class="noborder" style="position:absolute; left:213px; top:264px; width:321px; height:22px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">

<input name="DateFirstVisit" id="DateFirstVisit" type="text" class="noborder" style="position:absolute; left:55px; top:329px; width:187px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">

<input name="ReferringMD" id="ReferringMD" type="text" class="noborder" style="position:absolute; left:251px; top:338px; width:273px; height:21px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">

<input name="ReferralDate" id="ReferralDate" type="text" class="noborder" style="position:absolute; left:528px; top:337px; width:175px; height:22px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">

<textarea name="OtherMDs" id="OtherMDs" class="noborder" style="position:absolute; left:53px; top:400px; width:269px; height:68px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" ></textarea>

<textarea name="Specialties" id="Specialties" class="noborder" style="position:absolute; left:325px; top:400px; width:225px; height:68px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" ></textarea>

<textarea name="ConsultDates" id="ConsultDates" class="noborder" style="position:absolute; left:554px; top:400px; width:149px; height:68px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" ></textarea>

<textarea name="BloodRelatives" id="BloodRelatives" class="noborder" style="position:absolute; left:52px; top:516px; width:217px; height:38px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" ></textarea>

<textarea name="NatueofIllness" id="NatueofIllness" class="noborder" style="position:absolute; left:270px; top:517px; width:215px; height:37px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" ></textarea>

<textarea name="AgeofDx" id="AgeofDx" class="noborder" style="position:absolute; left:488px; top:518px; width:217px; height:35px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" ></textarea>

<input name="TobaccoYes" id="TobaccoYes" type="text" class="Xbox" style="position:absolute; left:375px; top:558px; width:14px; height:14px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:12px; text-align:center; background-color:white;" value="">

<input name="TobaccoNo" id="TobaccoNo" type="text" class="Xbox" style="position:absolute; left:423px; top:558px; width:14px; height:14px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:12px; text-align:center; background-color:white;" value="">

<input name="TobaccoUnknown" id="TobaccoUnknown" type="text" class="Xbox" style="position:absolute; left:470px; top:558px; width:14px; height:14px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:12px; text-align:center; background-color:white;" value="">

<input name="Tobacco2Yes" id="Tobacco2Yes" type="text" class="Xbox" style="position:absolute; left:375px; top:576px; width:14px; height:14px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:12px; text-align:center; background-color:transparent;" value="">

<input name="Tobacco2No" id="Tobacco2No" type="text" class="Xbox" style="position:absolute; left:424px; top:576px; width:14px; height:14px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:12px; text-align:center; background-color:transparent;" value="">

<input name="Tobacco2Unknown" id="Tobacco2Unknown" type="text" class="Xbox" style="position:absolute; left:471px; top:576px; width:14px; height:14px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:12px; text-align:center; background-color:transparent;" value="">

<input name="DateQuit" id="DateQuit" type="text" class="noborder" style="position:absolute; left:244px; top:598px; width:117px; height:24px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">

<textarea name="OtherComments" id="OtherComments" class="noborder" style="position:absolute; left:165px; top:633px; width:541px; height:43px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" ></textarea>

<input name="MDName" id="MDName" type="text" class="noborder" style="position:absolute; left:56px; top:712px; width:315px; height:24px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=doctor>

<input name="MDSpecialty" id="MDSpecialty" type="text" class="noborder" style="position:absolute; left:377px; top:712px; width:175px; height:27px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="Family Medicine">

<input name="MDTel" id="MDTel" type="text" class="noborder" style="position:absolute; left:555px; top:712px; width:150px; height:26px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=doctor_work_phone>

<textarea name="ClinicLabel" id="ClinicLabel" class="noborder" style="position:absolute; left:124px; top:745px; width:240px; height:61px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:10px; text-align:left; background-color:white;"  oscarDB=clinic_label></textarea>

<input name="ClinicFax" id="ClinicFax" type="text" class="noborder" style="position:absolute; left:554px; top:762px; width:150px; height:31px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:10px; text-align:left; background-color:transparent;"  oscarDB=clinic_fax>

<input name="Signature" id="Signature" type="text" class="noborder" style="position:absolute; left:121px; top:832px; width:422px; height:22px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:10px; text-align:left; background-color:white;" value="Signed digitally in Electronic Medical Record">

<input name="Date" id="Date" type="text" class="noborder" style="position:absolute; left:556px; top:830px; width:149px; height:23px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:10px; text-align:left; background-color:white;"  oscarDB=today>

<input name="RelativeYes" id="RelativeYes" type="text" class="Xbox" style="position:absolute; left:506px; top:474px; width:14px; height:14px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:12px; text-align:center; background-color:white;" value="">

<input name="RelativeNo" id="RelativeNo" type="text" class="Xbox" style="position:absolute; left:554px; top:472px; width:14px; height:14px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:12px; text-align:center; background-color:transparent;" value="">

<input name="RelativeUnknown" id="RelativeUnknown" type="text" class="Xbox" style="position:absolute; left:602px; top:474px; width:14px; height:14px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:12px; text-align:center; background-color:transparent;" value="">



</div>


<div class="DoNotPrint" style="position: absolute; top: 1870px; left: 40px;">

<table>
	<tr>
		<td class="subjectline">

			Description: <input name="subject" size="20" type="text">
			<input value="Submit" name="SubmitButton" type="submit">
			<input value="Reset" name="ResetButton" type="reset">
			<input value="Print" name="PrintButton" type="button" onClick="window.print();">
            <input value="Print and Submit" name="PrintSubmitButton" type="button" onClick="window.print();document.forms[0].submit();releaseDirtyFlag()">
		</td>
	</tr>
</table>

</div>
</body>
</html>

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