<%@ 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">
<body onLoad=sf()>

    <c:choose>
    <c:when test="${adminStatus}">
      <tr>
       <td bgcolor=navy blue>
   		   <font size=4 color=white>
     	   <a href="listUserAuthorization">Manage ARS Users</a>
   		   </font>
 	   </td>
 	  </tr>
 	</c:when>
    </c:choose>

	<div align="center">
		<h1>Search Claim Attachments</h1>
		<form:form action="searchClaimAttachments" method="post" modelAttribute="ClaimAttachment" name="f">
		<table>
			<tr>
				<td>Attachment Id:</td>
				<td><form:input path="id" /></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 Last Name:</td>
				<td><form:input path="patientLastName" /></td>
			</tr>
			<tr>
				<td>Patient First Name:</td>
				<td><form:input path="patientFirstName" /></td>
			</tr>
			<tr>
				<td>Patient Identifier:</td>
				<td><form:input path="patientIdentifier" /></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>Provider NPI:</td>
				<td><form:input path="providerNpi" /></td>
			</tr>
			<tr>
				<td>Claim Identifier:</td>
				<td><form:input path="claimIdentifier" /></td>
			</tr>
			<tr>
				<td>Claim Service Start Date:</td>
				<td><form:input type="text" id="datepicker1" path="claimServiceStartDate" /></td>
			</tr>
			<tr>
				<td>Claim Service End Date:</td>
				<td><form:input type="text" id="datepicker2" path="claimServiceEndDate" /></td>
			</tr>
			<tr>
				<td>Payer Claim Control Number:</td>
				<td><form:input path="payerClaimControlNumber" /></td>
			</tr>
			<tr>
				<td>Attachment Control Number:</td>
				<td><form:input path="attachmentControlNumber" /></td>
			</tr>

        <c:choose>
            <c:when test="${deleteStatus}">
                <tr>
					<td>Status:</td>
					<td>
					 <form:select path="status">
					 <option value="A">Active</option>
				 	 <option value="D">Deleted</option>
				 	 <option value="ALL">Show All</option>
				 	</form:select>
					</td>
				</tr>
            </c:when>
        </c:choose>
		<tr>
				<td colspan="2" align="center"><input type="submit" value="Search"></td>
		</tr>
		</table>
		
		</form:form>
	</div>
</body>
</tiles:putAttribute>
</tiles:insertDefinition>