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University Health Insurance Plan - Sun Life

HTML with "x box" code

HTML icon UHIP-ClaimForm-Community.html — HTML, 13 kB (13737 bytes)

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<html>
<head>
	<title>UHIP</title>

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

	<!--<script language="javascript" type="text/javascript" src="${oscar_image_path}JSMPC.js"></script>	-->
	<script language="javascript" type="text/javascript">
		/****************************
		startup functions 
		****************************/
		function startUp()
		{			
			// shows the forms on development machine from notepad ++ - saves you from uploading to the server to input alignments
			var strLoc = window.location.href.toLowerCase();
			if(strLoc.indexOf("https") == -1)
			{
				//page1
				var src = document.getElementById('BGImage').src;				
				document.getElementById('BGImage').src = src.replace('$%7Boscar_image_path%7D','');
				// page2
				var src2 = document.getElementById('BGImage2').src;
				document.getElementById('BGImage2').src = src2.replace('$%7Boscar_image_path%7D','');
			}
			setDocumentTitle('UHIP Claim Form',document.getElementById('patient_nameL').value);
			setDefaults();			
		}
		
		function setDocumentTitle(Title,PatientName)
		{
			// set document title
			document.title = Title + ' - ' + PatientName;					
							
		}
		
		function setDefaults()
		{	            
			// check the newform flag to ensure this is the initial load of the form
			if (document.getElementById("newForm").value == 'True')
			{
				document.getElementById("Female").value = 'X';	
				document.getElementById("ToMember").value = 'X';
			}   
		}
		/****************************
			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>
</head>

<body onload="startUp();" onMouseDown="showButtons();">
	<form method="post" action="" name="FormName" id="FormName" >
		<div id="page1" style="position: relative; left: 0px; top: 0px; width:750px;" class="pagebreak">
			<img id="BGImage" src="${oscar_image_path}UCF-1.png" width="750">	

			<input name="University-14" id="University-14" type="text" class="noborder" style="position:absolute; left:189px; top:287px; width:280px; height:21px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" value="">


			<input name="hinc" id="hinc" type="text" class="noborder" style="position:absolute; left:475px; top:287px; width:238px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=hinc>


			<input name="UHIP-13" id="UHIP-13" type="text" class="noborder" style="position:absolute; left:189px; top:318px; width:279px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" value="">


			<input name="UHIP-12" id="UHIP-12" type="text" class="noborder" style="position:absolute; left:476px; top:318px; width:237px; height:21px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" value="">


			<input name="UHIP-11" id="UHIP-11" type="text" class="noborder" style="position:absolute; left:190px; top:349px; width:189px; height:25px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" value="">


			<input name="Male" id="Male"  type="text" style="position:absolute; left:405px; top:338px;width:16px; height:16px;border: 1px solid #000000;font-weight:bold;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">


			<input name="Female" id="Female"  type="text" style="position:absolute; left:405px; top:351px;width:16px; height:16px;border: 1px solid #000000;font-weight:bold;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">


			<input name="Sex-8" id="Sex-8" type="text" class="noborder" style="position:absolute; left:476px; top:352px; width:93px; height:21px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" value="">


			<input name="Email-7" id="Email-7" type="text" class="noborder" style="position:absolute; left:573px; top:352px; width:141px; height:22px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" value="">


			<input name="addressline" id="addressline" type="text" class="noborder" style="position:absolute; left:189px; top:385px; width:525px; height:21px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=addressline>


			<input name="city" id="city" type="text" class="noborder" style="position:absolute; left:190px; top:417px; width:191px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=city>


			<input name="province" id="province" type="text" class="noborder" style="position:absolute; left:386px; top:417px; width:173px; height:21px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=province>


			<input name="postal" id="postal" type="text" class="noborder" style="position:absolute; left:562px; top:418px; width:152px; height:21px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=postal>


			<input name="patient_nameL" id="patient_nameL" type="text" class="noborder" style="position:absolute; left:191px; top:481px; width:302px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=patient_nameL>


			<input name="patient_nameF" id="patient_nameF" type="text" class="noborder" style="position:absolute; left:503px; top:479px; width:210px; height:23px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=patient_nameF>


			<input name="dob1" id="dob1" type="text" class="noborder" style="position:absolute; left:193px; top:514px; width:219px; height:21px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=dob>


			<input name="Member" id="Member"  type="text" style="position:absolute; left:535px; top:501px;width:16px; height:16px;border: 1px solid #000000;font-weight:bold;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">


			<input name="Spouse" id="Spouse"  type="text" style="position:absolute; left:535px; top:514px;width:16px; height:16px;border: 1px solid #000000;font-weight:bold;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">


			<input name="Son" id="Son"  type="text" style="position:absolute; left:610px; top:501px;width:16px; height:16px;border: 1px solid #000000;font-weight:bold;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">


			<input name="Daughter" id="Daughter"  type="text" style="position:absolute; left:610px; top:514px;width:16px; height:16px;border: 1px solid #000000;font-weight:bold;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
		</div>
		<div id="page2" style="position: relative;" class="pagebreak">
			<img id="BGImage2" src="${oscar_image_path}UCF-2.png" width="750">
		
			<input name="ToMember" id="ToMember"  type="text" style="position:absolute; left:369px; top:142px; width:16px; height:16px;border: 1px solid #000000;font-weight:bold;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">


			<input name="ToProvider" id="ToProvider"  type="text" style="position:absolute; left:369px; top:160px; width:16px; height:16px;border: 1px solid #000000;font-weight:bold;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">


			<input name="provider_name" id="provider_name" type="text" class="noborder" style="position:absolute; left:189px; top:331px; width:290px; height:21px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=provider_name>


			<input name="Payment-1" id="Payment-1" type="text" class="noborder" style="position:absolute; left:487px; top:331px; width:224px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" value="Obstetrics & Gynecology">


			<input name="clinic_addressLineFull" id="clinic_addressLineFull" type="text" class="noborder" style="position:absolute; left:188px; top:362px; width:523px; height:23px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=clinic_addressLineFull>


			<input name="clinic_city" id="clinic_city" type="text" class="noborder" style="position:absolute; left:190px; top:397px; width:206px; height:24px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=clinic_city>


			<input name="clinic_province" id="clinic_province" type="text" class="noborder" style="position:absolute; left:402px; top:397px; width:180px; height:24px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=clinic_province>


			<input name="clinic_postal" id="clinic_postal" type="text" class="noborder" style="position:absolute; left:588px; top:398px; width:120px; height:22px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=clinic_postal>


			<input name="clinic_phone" id="clinic_phone" type="text" class="noborder" style="position:absolute; left:354px; top:430px; width:234px; height:25px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=clinic_phone>


			<input name="today" id="today" type="text" class="noborder" style="position:absolute; left:556px; top:749px; width:156px; height:24px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=today>


			<input name="Services" id="Services" type="text" class="noborder" style="position:absolute; left:37px; top:523px; width:252px; height:26px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" value="See attached invoice">
		</div>

		 <div class="DoNotPrint" id="BottomButtons">
			 <table>
			<tr><td>
				<input type="hidden" id="newForm" name="newForm" value="True" />				
				 Subject: <input name="subject" size="40" type="text"> 
					<input value="Submit" name="SubmitButton" id="SubmitButton" type="button" onclick="javascript:submission();"> 			
					<input value="Reset" name="ResetButton" id="ResetButton" type="reset"> 
					<input value="Print" name="PrintButton" id="PrintButton" type="button" onclick="printLetter()"> 			
					<input value="Print & Submit" name="PrintSubmitButton" id="PrintSubmitButton" type="button" onclick="printSubmit()"> 
			 </td></tr></table>
		 </div>
	 </form>

</body>
</html>

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