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| # | Location | File | Last Modified |
|---|---|---|---|
| 1 | Fri Jun 9 19:51:46 2017 UTC | ||
| 2 | eHealth_Exch (eHealth Exchange Enhancements) Build 3 docs & code_May_2017.zip\VAP_CIF_CODE0502.zip\VAP_CIF_CODE0502\VAP_CIF_CODE0502\nvap-web\src\main\webapp\WEB-INF\web | revokeSSA.jsp | Fri Apr 21 20:03:30 2017 UTC |
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| 1 | <%@taglib uri="http: //java.sun .com/jsp/j stl/core" prefix="c" %> | |||||
| 2 | <%@taglib uri="http: //java.sun .com/jsp/j stl/functi ons" prefi x="fn"%> | |||||
| 3 | <%@taglib uri="http: //java.sun .com/jsp/j stl/fmt" p refix="fmt "%> | |||||
| 4 | <%@taglib tagdir="/W EB-INF/tag s/cpp" pre fix="cpp"% > | |||||
| 5 | <%@taglib tagdir="/W EB-INF/tag s/date" pr efix="date "%> | |||||
| 6 | ||||||
| 7 | <div> | |||||
| 8 | <p cla ss="detail Text"> | |||||
| 9 | Th e Veteran is revokin g Social S ecurity Ad ministrati on authori zation. By revoking this | |||||
| 10 | au thorizatio n the Vete ran unders tands that the shari ng of his/ her electr onic healt h informat ion with S ocial | |||||
| 11 | Se curity Adm inistratio n through <c:out val ue="${orga nizationNa me}" /> fo r disabili ty | |||||
| 12 | de terminatio n (coverag e) will st op. | |||||
| 13 | </p> | |||||
| 14 | <p cla ss="detail Text"> | |||||
| 15 | To revoke th is authori zation, ch eck the bo x and ente r the Pati ent Signat ure Date a nd click < strong>Rev oke</stron g>. | |||||
| 16 | </p> | |||||
| 17 | <p cla ss="detail Text"> | |||||
| 18 | To submit a new author ization, s elect New Authorizat ion as the 'Inactiva tion Reaso n' | |||||
| 19 | an d enter th e Patient Signature Date for t he new aut horization form rece ived. | |||||
| 20 | </p> | |||||
| 21 | </div> | |||||
| 22 | <div class ="form-con tainer"> | |||||
| 23 | <field set> | |||||
| 24 | <l egend>Revo ke</legend > | |||||
| 25 | <d iv> | |||||
| 26 | <input t itle="Choo se the rad io button to select Patient re vokes acce ss to all <c:out val ue="${orga nizationNa me}" /> Pr oviders an d Organiza tions" typ e="radio" name="cons entGroup" id="consen tGroup" va lue="revok e" aria-la belledby=" forConsent Group" che cked /> | |||||
| 27 | <span id ="forConse ntGroup">P atient rev okes shari ng of prot ected heal th informa tion to SS A through <c:out val ue="${orga nizationNa me}" />.</ span> | |||||
| 28 | <br /> < br /> | |||||
| 29 | </ div> | |||||
| 30 | <d iv> | |||||
| 31 | <form na me="multiS electListF orm" id="m ultiSelect ListForm" action="Pa tientDetai ls.do_sec" method="P OST" onsub mit="onRev oke(); ret urn doSubm it(this);" enctype=" multipart/ form-data" > | |||||
| 32 | <inp ut type="h idden" nam e="icn" va lue="<c:ou t value="$ {patientDe mographics .icn}" />" /> | |||||
| 33 | <inp ut type="h idden" nam e="request Id" value= "<c:out va lue="${req uestId}" / >" /> | |||||
| 34 | <inp ut type="h idden" nam e="patient Id" value= "<c:out va lue="${con sentDirect ive.patien tIen}" />" /> | |||||
| 35 | <inp ut type="h idden" nam e="consent Type" valu e="SSA Rev ocation" / > | |||||
| 36 | <inp ut type="h idden" nam e="purpose OfUse" val ue="COVERA GE" /> | |||||
| 37 | <inp ut type="h idden" nam e="expirat ionYears" value="2" /> | |||||
| 38 | ||||||
| 39 | <div > | |||||
| 40 | <label for ="authenti catingFaci lity"> | |||||
| 41 | Authen ticating F acility <i mg alt="Re quired fie ld" src="r es/star-ic on_grey_bg .png" /> | |||||
| 42 | </label> | |||||
| 43 | <select id ="authenti catingFaci lity" name ="userFaci lity"> | |||||
| 44 | <c:for Each var=" f" items=" ${allowedF acilities} "> | |||||
| 45 | <o ption valu e="<c:out value="${f .facilityS tation}" / >" | |||||
| 46 | <c:choos e> | |||||
| 47 | <c:w hen test=" ${f.facili tyStation eq default UserFacili ty.facilit yStation}" > | |||||
| 48 | selected | |||||
| 49 | </c: when> | |||||
| 50 | <c:w hen test=" ${cookie.f acility.va lue == f.f acilitySta tion}"> | |||||
| 51 | selected | |||||
| 52 | </c: when> | |||||
| 53 | </c:choo se>> | |||||
| 54 | <c:choos e> | |||||
| 55 | <c:w hen test=" ${f.facili tyName != ''}"> | |||||
| 56 | <c:out val ue="${f.fa cilityName }" /> | |||||
| 57 | </c: when> | |||||
| 58 | <c:o therwise> | |||||
| 59 | <c:out val ue="${fn:s plit(f.fac ilityDns, '.')[0]}" /> | |||||
| 60 | </c: otherwise> | |||||
| 61 | </c:choo se> | |||||
| 62 | (<c:out value="${f .facilityS tation}" / >) | |||||
| 63 | </ option> | |||||
| 64 | </c:fo rEach> | |||||
| 65 | </select> | |||||
| 66 | <br /> <br /> | |||||
| 67 | </di v> | |||||
| 68 | <div id="revok eForm"> | |||||
| 69 | <div> | |||||
| 70 | <label for="reas on">Inacti vation Rea son<img al t="Require d field" s rc="res/st ar-icon_gr ey_bg.png" /> </labe l> | |||||
| 71 | <selec t id="reas on" name=" reason" on change="on OptoutReas onChange(t his);" onk eyup="onOp toutReason Change(thi s);"> | |||||
| 72 | <o ption titl e="Select a Opt out reason fro m the drop down list" value=""> --Select a reason--< /option> | |||||
| 73 | <c :if test=" ${!empty o ptOutReaso ns}"> | |||||
| 74 | <c:forEa ch var="r" items="${ optOutReas ons}" varS tatus="i"> | |||||
| 75 | <c:c hoose> | |||||
| 76 | <c:when te st="${r eq 'New Auth orization' }"> | |||||
| 77 | <c:if test="${is SSANewAuth orizationA llowed eq true}"> | |||||
| 78 | <o ption valu e="<c:out value="${r }" />"><c: out value= "${r}" />< /option> | |||||
| 79 | </c:if > | |||||
| 80 | </c:when> | |||||
| 81 | <c:otherwi se> | |||||
| 82 | <optio n value="< c:out valu e="${r}" / >"><c:out value="${r }" /></opt ion> | |||||
| 83 | </c:otherw ise> | |||||
| 84 | </c: choose> | |||||
| 85 | </c:forE ach> | |||||
| 86 | </ c:if> | |||||
| 87 | </sele ct> | |||||
| 88 | </div> | |||||
| 89 | <br /> | |||||
| 90 | <label id= "formValid ationLabel ">Form Val idation fo r</label>< br /> | |||||
| 91 | <div id="r evokeValid ationCheck Box" style ="display: none;"> | |||||
| 92 | <label for="revo keValidati onCheckBox Input"> | |||||
| 93 | 10 -0484a | |||||
| 94 | <i mg alt="Re quired fie ld" src="r es/star-ic on_grey_bg .png" /> | |||||
| 95 | </labe l> | |||||
| 96 | <input id="revok eValidatio nCheckBoxI nput" type ="checkbox " title="s elect Form Validatio n checkbox if Revoca tion Form 10-0484a w as receive d and vali dated. req uired fiel d" onclick ="enableRe vokeAfterV alidation( 'signature Date', 'Re voke');" n ame="optio n1" value= "Revocatio n Form Rec eived and Validated" aria-labe lledby="fo rmValidati onLabel" / > | |||||
| 97 | Revoca tion Form Received a nd Validat ed | |||||
| 98 | <br /> <br /> | |||||
| 99 | </div> | |||||
| 100 | <div id="n ewValidati onCheckBox " style="d isplay: no ne;"> | |||||
| 101 | <label for="newV alidationC heckBoxInp ut"> | |||||
| 102 | 10 -5345 | |||||
| 103 | <i mg alt="Re quired fie ld" src="r es/star-ic on_grey_bg .png" /> | |||||
| 104 | </labe l> | |||||
| 105 | <input id="newVa lidationCh eckBoxInpu t" type="c heckbox" t itle="sele ct Form Va lidation c heckbox if New Autho rization F orm 10-534 5 was rece ived and v alidated. required f ield" oncl ick="enabl eRevokeAft erValidati on('signat ureDate',' revokeAndA uthorize') ;" name="o ption1" va lue="New A uthorizati on Form Re ceived and Validated " aria-lab elledby="f ormValidat ionLabel" /> | |||||
| 106 | New Au thorizatio n Form Rec eived and Validated | |||||
| 107 | <br /> <br /> | |||||
| 108 | </div> | |||||
| 109 | <div id="r evokeDateA ndUploadVa lidation" style="dis play: none ;"> | |||||
| 110 | <div> | |||||
| 111 | <l abel for=" signatureD ate"> | |||||
| 112 | Patient Signature Date | |||||
| 113 | <img alt ="Required field" sr c="res/sta r-icon_gre y_bg.png" /> | |||||
| 114 | </ label> | |||||
| 115 | <d ate:date i d="signatu reDate" na me="signat ureDate" o nkeyup="en ableRevoke AfterValid ation('sig natureDate ', 'Revoke ');"/> (mm /dd/yyyy) | |||||
| 116 | <b r /> <br / > | |||||
| 117 | </div> | |||||
| 118 | <c:cho ose> | |||||
| 119 | <c :when test ="${isForm UploadAllo wed}"> | |||||
| 120 | <div> | |||||
| 121 | <lab el for="fi le">Upload Consent F orm<br /> | |||||
| 122 | <span styl e="font-we ight: norm al;"><i>(M ax file si ze: <c:out value="${ maxFileUpl oadSize/10 00000}" /> megabytes )</i></spa n> | |||||
| 123 | </la bel> | |||||
| 124 | <inp ut title=" Browse and Upload Co nsent Form " name="up loaded" ty pe="file" id="file" accept="ap plication/ pdf" /> | |||||
| 125 | </div> | |||||
| 126 | </ c:when> | |||||
| 127 | </c:ch oose> | |||||
| 128 | </div> | |||||
| 129 | <div id="r evokeDateA ndUploadVa lidationPa tientDecea sed" style ="display: none;"> | |||||
| 130 | <div> | |||||
| 131 | <l abel for=" deceasedDa te"> | |||||
| 132 | Patient Deceased D ate | |||||
| 133 | <img alt ="Required field" sr c="res/sta r-icon_gre y_bg.png" /> | |||||
| 134 | </ label> | |||||
| 135 | <d ate:date i d="decease dDate" nam e="decease dDate" onk eyup="enab leRevokeAf terValidat ion('decea sedDate', 'Revoke'); "/> (mm/dd /yyyy) | |||||
| 136 | <b r /> <br / > | |||||
| 137 | </div> | |||||
| 138 | </div> | |||||
| 139 | <div> | |||||
| 140 | <label for="comm ents">Comm ents</labe l> | |||||
| 141 | <texta rea title= "Patient C omments no t a requir ed field" id="commen ts" name=" comments" style="wid th: 300px; height: 6 0px;"></te xtarea> | |||||
| 142 | <br /> | |||||
| 143 | </div> | |||||
| 144 | <br /> | |||||
| 145 | <div align ="center" id='revoke Button' st yle="displ ay:"> | |||||
| 146 | <input id="Revok e" title=" Revoke" cl ass="butto n" disable d="disable d" type="s ubmit" val ue="Revoke " name="op tOut" onCl ick="enabl eAllElemen ts()"> | |||||
| 147 | </div> | |||||
| 148 | <div align ="center" id="revoke AndAuthori zeButton" style="dis play: none ;"> | |||||
| 149 | <input id="revok eAndAuthor ize" title ="Revoke" class="but ton" disab led="disab led" type= "submit" v alue="Revo ke and Sub mit New Au thorizatio n" name="o ptOut" onC lick="enab leAllEleme nts()"> | |||||
| 150 | </div> | |||||
| 151 | </di v> | |||||
| 152 | </form> | |||||
| 153 | </ div> | |||||
| 154 | </fiel dset> | |||||
| 155 | </div> |
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