<%@ taglib uri="http://tiles.apache.org/tags-tiles" prefix="tiles"%>
<%@ taglib prefix="form" uri="http://www.springframework.org/tags/form" %>
<%@ taglib uri="http://java.sun.com/jsp/jstl/core" prefix="c" %>
<tiles:insertDefinition name="defaultTemplate">
<tiles:putAttribute name="body">
<%@page trimDirectiveWhitespaces="true" %>
<%@page contentType="text/html" pageEncoding="UTF-8"%>
<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN"
   "http://www.w3.org/TR/html4/loose.dtd">
<html>
<head>
 <meta charset="utf-8">
  <title>Search Claim Attachments</title>
  <link rel="stylesheet" href="//code.jquery.com/ui/1.11.4/themes/smoothness/jquery-ui.css">
  <script src="//code.jquery.com/jquery-1.10.2.js"></script>
  <script src="//code.jquery.com/ui/1.11.4/jquery-ui.js"></script>
  <link rel="stylesheet" href="/resources/demos/style.css">
  <script>
  $(function() {
    $( "#datepicker" ).datepicker();
  });
  </script>
</head>
<body>
    <td bgcolor=navy blue>
   	  <font size=4 color=white>
     	<a href="secureSearch">Main Search Menu</a>
   	  </font>
 	</td>
	<div align="center">
		<h1>Edit Attachment</h1>
		<form:form action="saveClaimAttachment" method="post" modelAttribute="ClaimAttachment">
		<table>
			<tr>
				<td>Attachment Id:</td>
				<td><form:input path="id" disabled="disabled" /></td>
			</tr>
			<tr>
				<td>Provider Name:</td>
				<td><form:input path="providerName" /></td>
			</tr>
			<tr>
				<td>Provider Identifier:</td>
				<td><form:input path="providerIdentifier" /></td>
			</tr>
			<tr>
				<td>Patient First Name:</td>
				<td><form:input path="patientFirstName" /></td>
			</tr>
			<tr>
				<td>Patient Last Name:</td>
				<td><form:input path="patientLastName" /></td>
			</tr>
			<tr>
				<td>Patient Control#:</td>
				<td><form:input path="patientControlNumber" /></td>
			</tr>
			
			<tr>
			<td>Report Code:</td>
			<td>
			<form:select path="reportCode">
    			<form:options items="${codeList}" />
			</form:select>
			</td>
			</tr>
			
			<tr>
				<td>Medical Record #:</td>
				<td><form:input path="medicalRecordNumber" /></td>
			</tr>
			<tr>
				<td>Patient Identifier:</td>
				<td><form:input path="patientIdentifier" /></td>
			</tr>
			<tr>
				<td>Provider NPI:</td>
				<td><form:input path="providerNpi" /></td>
			</tr>
			<tr>
				<td>Claim Identifier:</td>
				<td><form:input path="claimIdentifier" /></td>
			</tr>
			<tr>
				<td>ClaimServiceDate:</td>
				<td><form:input type="text" id="datepicker" path="claimServiceDate" /></td>
			</tr>
			<tr>
				<td>PayerClaimControlNumber:</td>
				<td><form:input path="payerClaimControlNumber" /></td>
			</tr>
			<tr>
				<td>AttachmentControlNumber:</td>
				<td><form:input path="attachmentControlNumber" /></td>
			</tr>
			<tr>
				<td>AttachmentName:</td>
				<td><form:input path="attachmentName" /></td>
			</tr>
			<tr>
				<td>AttachmentType:</td>
				<td><form:input path="attachmentType" /></td>
			</tr>
			<tr>
				<td>Ver:</td>
				<td><form:input path="ver" /></td>
			</tr>
			<tr>
				<td colspan="2" align="center"><input type="submit" value="Save"></td>
			</tr>
		</table>
		</form:form>
	</div>
</body>
</html>
</tiles:putAttribute>
</tiles:insertDefinition>