Summary Table

Categories Total Count
PII 0
URL 0
DNS 0
EKL 0
IP 0
PORT 0
VsID 0
CF 0
AI 0
VPD 0
PL 0
Other 0

File Content

<app-fpps-base>
<article>
<!-- Error/Status Messages -->
<app-messages></app-messages>
<!-- Adds Cushion -->
<div class="row"></div>
<!-- Main Content Container -->
<div class="container fade-in">
<!-- Card Tabs -->
<div class="card-tabs blue-tab">
<section>
<!-- Tab 1 -->
<input id="tab1" type="radio" name="tabs" role="tab" aria-label="Form Test Tab. To switch tabs, use arrow keys." checked/>
<label for="tab1" class="tab-label">Form Test</label>
<!-- Tab 1 Content -->
<div class="tab-content">
<div class="row col four-four">
<div class="card-head">
<h3>FPPS Claim Search Test</h3>
<span>Enter search parameters in the form below.</span>
</div>
<form>
<div class="row">
<div class="col one-four">
<label class="label text-field" for="claimType">Claim Type</label>
<select class="form-control" id="claimType" name="claimType" appAutofocus>
<option value="INST" id="claimType option">Institutional</option>
<option value="PROF" id="claimType option">Professional</option>
<option value="DENT" id="claimType option">Dental</option>
<option value="" id="claimType option">All</option>
</select>
</div>
<div class="col one-four">
<label class="label text-field" for="lastName">Last Name
</label>
<input type="text" class="form-control" placeholder="Enter Last Name" id="lastName" name="lastName">
</div>
<div class="col one-four">
<label class="label text-field" for="providerName">Provider Name
</label>
<input type="text" class="form-control" placeholder="Enter Provider" id="providerName" name="providerName">
</div>
<div class="col one-four no-flow">
<label class="label text-field" for="check_Eft_Trn">Check / EFT / TRN
</label>
<input type="text" class="form-control" placeholder="Enter Number" id="check_Eft_Trn" name="check_Eft_Trn">
</div>
<div class="col one-four">
<label class="label text-field" for="claimStatus">Claim Status</label>
<select class="form-control" id="claimStatus" data-toggle="dropdown" name="claimStatus">
<option value="ESTABLISH" selected>Establish</option>
<option value="INPROCESS">In Process</option>
<option value="AGED">Aged</option>
<option value="PAYERROR">Payment Error</option>
<option value="REJECTED">Rejected</option>
<option value="COMPLETE">Complete</option>
<option value="">All</option>
</select>
</div>
<div class="col one-four" id="DIV_ssn_claimLookup_1">
<label class="label text-field" for="ssn" id="LBL_ssn_claimLookup_1">SSN
<span class="required">Reqired</span>
</label>
<input type="text" class="form-control" placeholder="Enter SSN" id="ssn" name="ssn">
</div>
<div class="col one-four" id="DIV_providerTin_claimLookup_1">
<label class="label text-field" for="providerTin" id="LBL_providerTin_claimLookup_1">Provider TIN
<span class="error" role="alert" aria-live="assertive">Inline Error Message</span>
</label>
<input type="text" class="form-control" placeholder="Enter TIN" id="providerTin" name="providerTin">
</div>
<div class="col one-four no-flow" id="DIV_beginDate_claimLookup_1">
<label class="label text-field" for="beginDate" id="LBL_beginDate_claimLookup_1">Begin Service Date
<span class="info">mm/dd/yyyy</span>
</label>
<input type="text" class="form-control calendar" id="beginDate" placeholder="mm/dd/yyyy" name="beginDate">
</div>
<div class="col one-four" id="DIV_claimId_claimLookup_1">
<label class="label text-field" for="claimId" id="LBL_claimId_claimLookup_1">Claim ID
<span class="info">Helper Hint</span>
</label>
<input type="text" class="form-control" placeholder="Enter ID" id="claimId" name="claimId">
</div>
<div class="col one-four" id="DIV_patientControlNumber_claimLookup_1">
<label class="label text-field" for="patientControlNumber" id="LBL_patientControlNumber_claimLookup_1">Patient Control Number
</label>
<input type="text" class="form-control" placeholder="Enter Number" id="patientControlNumber" name="patientControlNumber">
</div>
<div class="col one-four" id="DIV_providerNpi_claimLookup_1">
<label class="label text-field" for="providerNpi" id="LBL_providerNpi_claimLookup_1">Provider NPI
<span class="required"></span>
</label>
<input type="text" class="form-control" placeholder="Enter NPI" id="providerNpi" name="providerNpi">
</div>
<div class="col one-four no-flow" id="DIV_endDate_claimLookup_1">
<label class="label text-field" for="endDate" id="LBL_endDate_claimLookup_1">End Service Date
<span class="info">mm/dd/yyyy</span>
</label>
<input type='text' class="form-control calendar" id="endDate" placeholder="mm/dd/yyyy" name="endDate">
</div>
<div class="col one-four" id="DIV_programIndicator_claimLookup_1">
<label class="label text-field" for="programIndicator" id="LBL_claimStatus_claimLookup_1">Program Indicator</label>
<select class="form-control" id="programIndicator" data-toggle="dropdown" name="programIndicator">
<option value="CHOICE" selected>CHOICE</option>
<option value="PCCC">PCCC</option>
<option value="PCCCRS">PCCCRS</option>
<option value="IHS">IHS</option>
<option value="THP">THP</option>
<option value="HERO">HERO</option>
<option value="P2E">P2E</option>
<option value="VA FEE">VA FEE</option>
<option value="ALL">All</option>
</select>
</div>
<div class="col three-four no-flow" id="DIV_visn_claimLookup_1">
<input type="checkbox" class="form-check-input checkbox-align" name="visn" id="visn">
<label id="LBL_visn_claimLookup_1">&nbsp; Include VISN-only Claims</label>
</div>
<div class="col one-four">
<button type="submit" class="button primary" id="BTN_search_claimLookup_1">Search</button>
<button type="button" class="button secondary" id="BTN_clear_claimLookup_1">Clear Form</button>
</div>
<div class="col one-four icon-link help">
<a role="button" class="clickable" tabindex="0" id="BTN_explainWildcards_claimLookup_1">Explain Wildcards</a>
</div>
</div>
</form>

</div>
</div>
<!-- Tab 2 -->
<input id="tab2" type="radio" name="tabs" role="tab" />
<label for="tab2" class="tab-label">Four Column Grid</label>
<!-- Tab 2 Content -->
<div class="tab-content">
<div class="row col four-four">
<div class="card-head">
<h3>Tab Test Two</h3>
<span>Lorem ipsum dolor sit amet consequetor.</span>
</div>
<div class="row col three-four show">THREE</div>
<div class="row col one-four no-flow show">ONE No-Flow</div>
<div class="row col two-four show">TWO</div>
<div class="row col one-four show">ONE</div>
<div class="row col one-four no-flow show">ONE No-Flow</div>
<div class="row col two-four show">TWO</div>
<div class="row col two-four no-flow show">TWO No-Flow</div>
<div class="row col one-four show">ONE</div>
<div class="row col three-four no-flow show">THREE No-Flow</div>
</div>
</div>
<!-- Tab 3 -->
<input id="tab3" type="radio" name="tabs" role="tab" />
<label for="tab3" class="tab-label">Three Column Grid</label>
<!-- Tab 3 Content -->
<div class="tab-content">
<div class="row col three">
<div class="card-head">
<h3>Tab Test Three</h3>
<span>Lorem ipsum dolor sit amet consequetor.</span>
</div>
<div class="row col three show">THREE</div>
<div class="row col two show">TWO</div>
<div class="row col one no-flow show">ONE No-Flow</div>
<div class="row col one show">ONE</div>
<div class="row col one show">ONE</div>
<div class="row col one show no-flow">ONE No-Flow</div>
<div class="row col one show">ONE</div>
<div class="row col two show no-flow">TWO No-flow</div>
</div>
</div>
</section>
<!-- Card Tabs End -->
</div>
</div>
<div class="container">
<div class="row results">
<div class="row col four-four">
<div class="card-head">
<h4>Results Box</h4>
</div>
<div class="col three">
<table id="TBL_wideTable_pageTest1_1" class="clean-table">
<thead>
<th>Alphabetical</th>
<th>Heading</th>
<th class="right">Numerical</th>
<th>Heading</th>
<th>Heading</th>
<th>Alphabetical</th>
<th>Heading</th>
<th class="right">Numerical</th>
<th>Heading</th>
<th class="center">History</th>
<th class="center">Button</th>
</thead>
<tbody>
<tr>
<td>Whoosiewhatzits</td>
<td>Things</td>
<td class="right">1,456</td>
<td>Stuff</td>
<td>Thingamabobs</td>
<td>Junk</td>
<td>Dohickies</td>
<td class="right">637</td>
<td>Accoutrements</td>
<td class="center">
<img id="" src="../../../assets/images/ic_history_black_24px.svg">
</td>
<td class="center">
<button id="" class="button inline">Inline</button>
</td>
</tr>
<tr>
<td class="tooltip">
<a href="">Tooltip Test</a>
<span>This is the tooltip hover content</span>
</td>
<td>Materials</td>
<td class="right">1,001,857</td>
<td>Doomaflidgies</td>
<td>Goods</td>
<td>Whachamacallits</td>
<td>Materials</td>
<td class="right">1,001,857</td>
<td>Doomaflidgies</td>
<td class="center">
<img id="" src="../../../assets/images/ic_history_black_24px.svg" />
</td>
<td class="center">
<button id="" class="button inline">Inline</button>
</td>
</tr>
<tr>
<td>Elements</td>
<td>Gobbledigook</td>
<td class="right">12,234,326</td>
<td>Impedimenta</td>
<td>Paraphanelia</td>
<td>Junk</td>
<td>Dohickies</td>
<td class="right">637</td>
<td>Accoutrements</td>
<td class="center">
<img id="" src="../../../assets/images/ic_history_black_24px.svg">
</td>
<td class="center">
<button id="" class="button inline">Inline</button>
</td>
</tr>
<tr>
<td>Junk</td>
<td>Dohickies</td>
<td class="right">637</td>
<td>Accoutrements</td>
<td>Items</td>
<td>Junk</td>
<td>Dohickies</td>
<td class="right">637</td>
<td>Accoutrements</td>
<td class="center">
<img src="../../../assets/images/ic_history_black_24px.svg">
</td>
<td class="center">
<button id="" class="button inline">Inline</button>
</td>
</tr>
</tbody>
</table>
</div>
</div>
</div>
</div>
</article>
</app-fpps-base>>