<%@ Page Language="C#" AutoEventWireup="true" CodeBehind="Demographics.aspx.cs" Inherits="GlobalNET.Patient.Demographics" %>
<%@ Register Assembly="Telerik.Web.UI" Namespace="Telerik.Web.UI" TagPrefix="telerik" %>
<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Transitional//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-transitional.dtd">
<html xmlns="http://www.w3.org/1999/xhtml">
<head id="Head1" runat="server">
<link href="../CommonSecurity/CSS/Stylesheet1.css" rel="stylesheet" type="text/css" />
<script type="text/javascript" src="../Common/js/bulkscanmatch.js"></script>
<script type="text/javascript" src="../Common/js/CommonValidations.js"></script>
<script type="text/javascript" src="../Common/js/sortable.js"></script>
<script type="text/javascript" src="../Common/js/DemographicsCoding.js"></script>
<script language="javascript" type="text/javascript" event="OnPostTransfer" for="DynamicWebTwain1">
<!--
DynamicWebTwain1_OnPostTransfer();
//-->
</script>
<script language="javascript" type="text/javascript" event="OnMouseClick(index)"
for="DynamicWebTwain1">
<!--
logPage_DynamicWebTwain1_OnMouseClick(index);
//-->
</script>
<telerik:RadCodeBlock ID="RadCodeBlock1" runat="server">
<script language="javascript" type="text/javascript">
var td = document.getElementById('tdThumbNails');
// wyeager - 09/21/2010
// Tab to next tab depending on last field selected
// Once all required fields have been entered, enable the Save button
function CheckForCompletedReqFlds(currentTab) {
var tabStrip = $find("<%= tsPatientDemographics.ClientID %>");
if (currentTab == "Patient") {
var tab = tabStrip.findTabByText("Guarantor");
tab.select();
var GuarRelToPat = document.getElementById("GuarRelToPat");
GuarRelToPat.focus();
}
else if (currentTab == "Guarantor") {
var tab = tabStrip.findTabByText("Pri Ins");
tab.select();
var priInsCode = document.getElementById("priInsCode");
priInsCode.focus();
}
else if (currentTab == "Pri Ins") {
var tab = tabStrip.findTabByText("Sec Ins");
tab.enable();
tab.select();
var secInsCode = document.getElementById("secInsCode");
secInsCode.focus();
}
else if (currentTab == "Sec Ins") {
var tab = tabStrip.findTabByText("Ter Ins");
tab.enable();
tab.select();
var terInsCode = document.getElementById("terInsCode");
terInsCode.focus();
}
else if (currentTab == "Ter Ins") {
var tab = tabStrip.findTabByText("Patient");
tab.select();
var HospAcctno = document.getElementById("HospAcctno");
HospAcctno.focus();
}
if ((document.getElementById("HospAcctno").value != "") && (document.getElementById("MRN").value != "") && (document.getElementById("PatLName").value != "") && (document.getElementById("PatFName").value != "") && (document.getElementById("PatAddress1").value != "") && (document.getElementById("PatCity").value != "") && (document.getElementById("PatState").value != "Select") && (document.getElementById("PatDOB").value != "") && (document.getElementById("PatMaritalStatus").value != "Select") && (document.getElementById("PatSex").value != "Select") && (document.getElementById("GuarRelToPat").value != "Select") && (document.getElementById("GuarLName").value != "") && (document.getElementById("GuarFName").value != "") && (document.getElementById("GuarAddress1").value != "") && (document.getElementById("GuarCity").value != "") && (document.getElementById("GuarState").value != "Select") && (document.getElementById("ddlGuarArrivalMode").value != "Select") && (document.getElementById("radAdmitDate").value != "") && (document.getElementById("radAdmitTime").value != "") && (document.getElementById("GuarSex").value != "Select") && (document.getElementById("radDischargeDate").value != "") && (document.getElementById("radDischargeTime").value != "") && (document.getElementById("ddlGuarMaritalStatus").value != "Select") && (document.getElementById("radGuarDOB").value != "") && (document.getElementById("priInsCode").value != "") && (document.getElementById("priInsName").value != "") && (document.getElementById("priInsAddress1").value != "") && (document.getElementById("priInsCity").value != "") && (document.getElementById("priInsState").value != "") && (document.getElementById("priInsZip").value != "") && (document.getElementById("priInsPolicyNum").value != "") && (document.getElementById("priInsPolicyNumVer").value != "") && (document.getElementById("priInsGrpNum").value != ""))
document.getElementById("btnSaveLogEntry").disabled = false;
else
document.getElementById("btnSaveLogEntry").disabled = true;
}
</script>
<script language="javascript" type="text/javascript">
// wyeager - 10/06/2010
// Check if user has secondary or tertiary insurance as a reminder to fill in.
function CheckForOtherIns() {
var tabStrip = $find("<%= tsPatientDemographics.ClientID %>");
var selectedTab = tabStrip.get_selectedTab();
var hdnOtherIns = document.getElementById("hdnOtherIns");
var secInsCode = document.getElementById("secInsCode");
var terInsCode = document.getElementById("terInsCode");
hdnOtherIns.value = "0";
if (selectedTab != null) {
var selectedTabValue = selectedTab.get_text();
if (selectedTabValue == "Pri Ins") {
if (confirm("Is there Secondary or Tertiary Insurance information available?" + '\n' + "Press OK if Yes or CANCEL if No.")) {
selectSecTab();
hdnOtherIns.value = "1";
return false;
}
else {
return true;
}
}
else if ((selectedTabValue == "Sec Ins") && (secInsCode.value == ""))
if (confirm("Is there Secondary Insurance information available?" + '\n' + "Press OK if Yes or CANCEL if No.")) {
selectSecTab();
hdnOtherIns.value = "2";
return false;
}
else {
return true;
}
else if ((selectedTabValue == "Sec Ins") && (secInsCode.value != ""))
if (confirm("Is there Tertiary Insurance information available?" + '\n' + "Press OK if Yes or CANCEL if No.")) {
selectTerTab();
hdnOtherIns.value = "2";
return false;
}
else {
return true;
}
else if ((selectedTabValue == "Ter Ins") && (terInsCode.value == ""))
if (confirm("Is there Tertiary Insurance information available?" + '\n' + "Press OK if Yes or CANCEL if No.")) {
selectTerTab();
hdnOtherIns.value = "3";
return false;
}
else {
return true;
}
}
}
// wyeager - 10/13/2010
function selectSecTab() {
var tabStrip = $find("<%= tsPatientDemographics.ClientID %>");
var tab = tabStrip.findTabByText("Sec Ins");
tab.enable();
tab.select();
}
// wyeager - 10/13/2010
function selectTerTab() {
var tabStrip = $find("<%= tsPatientDemographics.ClientID %>");
var tab = tabStrip.findTabByText("Ter Ins");
tab.enable();
tab.select();
}
// wyeager - 10/13/2010
// Gets the Relation to Patient for the Guarantor.
function getGuarSelectedValue() {
var index = document.getElementById("GuarRelToPat").selectedIndex;
if (document.getElementById("GuarRelToPat").options[index].text == "Self") {
var GuarRelToPat = document.getElementById("GuarRelToPat");
GuarRelToPat.options[index].text = 'Self';
var GuarLName = document.getElementById("GuarLName");
var PatLName = document.getElementById("PatLName");
GuarLName.value = PatLName.value;
var GuarFName = document.getElementById("GuarFName");
var PatFName = document.getElementById("PatFName");
GuarFName.value = PatFName.value;
var GuarInitial = document.getElementById("GuarInitial");
var PatInitial = document.getElementById("PatInitial");
GuarInitial.value = PatInitial.value;
var GuarAddress1 = document.getElementById("GuarAddress1");
var PatAddress1 = document.getElementById("PatAddress1");
GuarAddress1.value = PatAddress1.value;
var GuarAddress2 = document.getElementById("GuarAddress2");
var PatAddress2 = document.getElementById("PatAddress2");
GuarAddress2.value = PatAddress2.value;
var GuarCity = document.getElementById("GuarCity");
var PatCity = document.getElementById("PatCity");
GuarCity.value = PatCity.value;
var GuarState = document.getElementById("GuarState");
var PatState = document.getElementById("PatState");
GuarState.value = PatState.value;
var GuarZip = $find("<%= GuarZip.ClientID %>");
var PatZip = $find("<%= PatZip.ClientID %>");
GuarZip.set_value(PatZip.get_value());
var GuarSex = document.getElementById("GuarSex");
var PatSex = document.getElementById("PatSex");
GuarSex.value = PatSex.value;
var GuarSSN = $find("<%= GuarSSN.ClientID %>");
var PatSSN = $find("<%= PatSSN.ClientID %>");
GuarSSN.set_value(PatSSN.get_value());
var radGuarDOB = $find("<%= radGuarDOB.ClientID %>");
var PatDOB = $find("<%= PatDOB.ClientID %>");
var PatDOBDate = PatDOB.get_selectedDate();
radGuarDOB.set_selectedDate(PatDOBDate);
var ddlGuarMaritalStatus = document.getElementById("ddlGuarMaritalStatus");
var PatMaritalStatus = document.getElementById("PatMaritalStatus");
ddlGuarMaritalStatus.value = PatMaritalStatus.value;
var GuarHomePhone = $find("<%= GuarHomePhone.ClientID %>");
var PatHomePhone = $find("<%= PatHomePhone.ClientID %>");
GuarHomePhone.set_value(PatHomePhone.get_value());
var GuarWorkPhone = $find("<%= GuarWorkPhone.ClientID %>");
var PatWorkPhone = $find("<%= PatWorkPhone.ClientID %>");
GuarWorkPhone.set_value(PatWorkPhone.get_value());
var GuarCellPhone = $find("<%= GuarCellPhone.ClientID %>");
var PatCellPhone = $find("<%= PatCellPhone.ClientID %>");
GuarCellPhone.set_value(PatCellPhone.get_value());
}
}
// wyeager - 10/13/2010
// Gets the Relation to Patient for the Primary Insurance.
function getPriSelectedValue() {
var index = document.getElementById("priSubRelToPat").selectedIndex;
if (document.getElementById("priSubRelToPat").options[index].text == "Self") {
var priSubRelToPat = document.getElementById("priSubRelToPat");
priSubRelToPat.options[index].text = 'Self';
var priSubLName = document.getElementById("priSubLName");
var PatLName = document.getElementById("PatLName");
priSubLName.value = PatLName.value;
var priSubFName = document.getElementById("priSubFName");
var PatFName = document.getElementById("PatFName");
priSubFName.value = PatFName.value;
var priSubInitial = document.getElementById("priSubInitial");
var PatInitial = document.getElementById("PatInitial");
priSubInitial.value = PatInitial.value;
var priSubAddress1 = document.getElementById("priSubAddress1");
var PatAddress1 = document.getElementById("PatAddress1");
priSubAddress1.value = PatAddress1.value;
var priSubAddress2 = document.getElementById("priSubAddress2");
var PatAddress2 = document.getElementById("PatAddress2");
priSubAddress2.value = PatAddress2.value;
var priSubCity = document.getElementById("priSubCity");
var PatCity = document.getElementById("PatCity");
priSubCity.value = PatCity.value;
var priSubState = document.getElementById("priSubState");
var PatState = document.getElementById("PatState");
priSubState.value = PatState.value;
var priSubZip = $find("<%= priSubZip.ClientID %>");
var PatZip = $find("<%= PatZip.ClientID %>");
priSubZip.set_value(PatZip.get_value());
var priSubSex = document.getElementById("priSubSex");
var PatSex = document.getElementById("PatSex");
priSubSex.value = PatSex.value;
var priSubSSN = $find("<%= priSubSSN.ClientID %>");
var PatSSN = $find("<%= PatSSN.ClientID %>");
priSubSSN.set_value(PatSSN.get_value());
var priSubDOB = $find("<%= priSubDOB.ClientID %>");
var PatDOB = $find("<%= PatDOB.ClientID %>");
var PatDOBDate = PatDOB.get_selectedDate();
priSubDOB.set_selectedDate(PatDOBDate);
}
}
// wyeager - 10/13/2010
// Gets the Relation to Patient for the Secondary Insurance.
function getSecSelectedValue() {
var index = document.getElementById("secSubRelToPat").selectedIndex;
if (document.getElementById("secSubRelToPat").options[index].text == "Self") {
var secSubRelToPat = document.getElementById("secSubRelToPat");
secSubRelToPat.options[index].text = 'Self';
var secSubLName = document.getElementById("secSubLName");
var PatLName = document.getElementById("PatLName");
secSubLName.value = PatLName.value;
var secSubFName = document.getElementById("secSubFName");
var PatFName = document.getElementById("PatFName");
secSubFName.value = PatFName.value;
var secSubInitial = document.getElementById("secSubInitial");
var PatInitial = document.getElementById("PatInitial");
secSubInitial.value = PatInitial.value;
var secSubAddress1 = document.getElementById("secSubAddress1");
var PatAddress1 = document.getElementById("PatAddress1");
secSubAddress1.value = PatAddress1.value;
var secSubAddress2 = document.getElementById("secSubAddress2");
var PatAddress2 = document.getElementById("PatAddress2");
secSubAddress2.value = PatAddress2.value;
var secSubCity = document.getElementById("secSubCity");
var PatCity = document.getElementById("PatCity");
secSubCity.value = PatCity.value;
var secSubState = document.getElementById("secSubState");
var PatState = document.getElementById("PatState");
secSubState.value = PatState.value;
var secSubZip = $find("<%= secSubZip.ClientID %>");
var PatZip = $find("<%= PatZip.ClientID %>");
secSubZip.set_value(PatZip.get_value());
var secSubSex = document.getElementById("secSubSex");
var PatSex = document.getElementById("PatSex");
secSubSex.value = PatSex.value;
var secSubSSN = $find("<%= secSubSSN.ClientID %>");
var PatSSN = $find("<%= PatSSN.ClientID %>");
secSubSSN.set_value(PatSSN.get_value());
var secSubDOB = $find("<%= secSubDOB.ClientID %>");
var PatDOB = $find("<%= PatDOB.ClientID %>");
var PatDOBDate = PatDOB.get_selectedDate();
secSubDOB.set_selectedDate(PatDOBDate);
}
}
// wyeager - 10/13/2010
// Gets the Relation to Patient for the Tertiary Insurance.
function getTerSelectedValue() {
var index = document.getElementById("terSubRelToPat").selectedIndex;
if (document.getElementById("terSubRelToPat").options[index].text == "Self") {
var terSubRelToPat = document.getElementById("terSubRelToPat");
terSubRelToPat.options[index].text = 'Self';
var terSubLName = document.getElementById("terSubLName");
var PatLName = document.getElementById("PatLName");
terSubLName.value = PatLName.value;
var terSubFName = document.getElementById("terSubFName");
var PatFName = document.getElementById("PatFName");
terSubFName.value = PatFName.value;
var terSubInitial = document.getElementById("terSubInitial");
var PatInitial = document.getElementById("PatInitial");
terSubInitial.value = PatInitial.value;
var terSubAddress1 = document.getElementById("terSubAddress1");
var PatAddress1 = document.getElementById("PatAddress1");
terSubAddress1.value = PatAddress1.value;
var terSubAddress2 = document.getElementById("terSubAddress2");
var PatAddress2 = document.getElementById("PatAddress2");
terSubAddress2.value = PatAddress2.value;
var terSubCity = document.getElementById("terSubCity");
var PatCity = document.getElementById("PatCity");
terSubCity.value = PatCity.value;
var terSubState = document.getElementById("terSubState");
var PatState = document.getElementById("PatState");
terSubState.value = PatState.value;
var terSubZip = $find("<%= terSubZip.ClientID %>");
var PatZip = $find("<%= PatZip.ClientID %>");
terSubZip.set_value(PatZip.get_value());
var terSubSex = document.getElementById("terSubSex");
var PatSex = document.getElementById("PatSex");
terSubSex.value = PatSex.value;
var terSubSSN = $find("<%= terSubSSN.ClientID %>");
var PatSSN = $find("<%= PatSSN.ClientID %>");
terSubSSN.set_value(PatSSN.get_value());
var terSubDOB = $find("<%= terSubDOB.ClientID %>");
var PatDOB = $find("<%= PatDOB.ClientID %>");
var PatDOBDate = PatDOB.get_selectedDate();
terSubDOB.set_selectedDate(PatDOBDate);
}
}
</script>
</telerik:RadCodeBlock>
</head>
<body onkeydown="checkImage_onclick(event);" text="#000000" link="#165492" bgcolor="#ffffff"
leftmargin="0" topmargin="0" marginheight="0" marginwidth="0">
<form id="frmPatientDemo" runat="server">
<telerik:RadScriptManager ID="RadScriptManager1" runat="server">
</telerik:RadScriptManager>
<telerik:RadWindowManager ID="RadWindowManager1" ShowContentDuringLoad="false" VisibleStatusbar="false"
ReloadOnShow="true" runat="server">
<Windows>
<telerik:RadWindow ID="RadWindow1" Behaviors="Close" Title="Primary Institution Search"
Modal="true" runat="server" OnClientClose="OnPriClientClose">
</telerik:RadWindow>
<telerik:RadWindow ID="RadWindow2" Behaviors="Close" Title="Secondary Institution Search"
Modal="true" runat="server" OnClientClose="OnSecClientClose">
</telerik:RadWindow>
<telerik:RadWindow ID="RadWindow3" Behaviors="Close" Title="Tertiary Institution Search"
Modal="true" runat="server" OnClientClose="OnTerClientClose">
</telerik:RadWindow>
</Windows>
</telerik:RadWindowManager>
<div>
<input type="hidden" id="hdnImageURL" name="hdnImageURL" value="" runat="server" />
<input type="hidden" id="hdnImageName" name="hdnImageName" value="" runat="server" />
<input type="hidden" id="hdnPendFlag" name="hdnPendFlag" value="" runat="server" />
<input type="hidden" id="hdnVoidFlag" name="hdnVoidFlag" value="" runat="server" />
<input type="hidden" id="hdnDefFlag" name="hdnDefFlag" value="" runat="server" />
<input type="hidden" id="hdnbfiPriCount" name="hdnbfiPriCount" value="" runat="server" />
<input type="hidden" id="hdnbfiSecCount" name="hdnbfiSecCount" value="" runat="server" />
<input type="hidden" id="hdnbfiTerCount" name="hdnbfiTerCount" value="" runat="server" />
<input type="hidden" id="hdnpriInsID" name="hdnpriInsID" value="" runat="server" />
<input type="hidden" id="hdnsecInsID" name="hdnsecInsID" value="" runat="server" />
<input type="hidden" id="hdnterInsID" name="hdnterInsID" value="" runat="server" />
<input type="hidden" id="hdnPageName" name="hdnPageName" value="Demographics" runat="server" />
<input type="hidden" id="hdnOtherIns" name="hdnOtherIns" value="0" runat="server" />
<telerik:RadAjaxManager ID="RadAjaxManager1" runat="server">
<AjaxSettings>
<telerik:AjaxSetting AjaxControlID="btnPriSearch">
<UpdatedControls>
<telerik:AjaxUpdatedControl ControlID="priInsCode" />
<telerik:AjaxUpdatedControl ControlID="priInsName" />
<telerik:AjaxUpdatedControl ControlID="priInsAddress1" />
<telerik:AjaxUpdatedControl ControlID="priInsAddress2" />
<telerik:AjaxUpdatedControl ControlID="priInsCity" />
<telerik:AjaxUpdatedControl ControlID="priInsState" />
<telerik:AjaxUpdatedControl ControlID="priInsZip" />
</UpdatedControls>
</telerik:AjaxSetting>
<telerik:AjaxSetting AjaxControlID="btnSecSearch">
<UpdatedControls>
<telerik:AjaxUpdatedControl ControlID="secInsCode" />
<telerik:AjaxUpdatedControl ControlID="secInsName" />
<telerik:AjaxUpdatedControl ControlID="secInsAddress1" />
<telerik:AjaxUpdatedControl ControlID="secInsAddress2" />
<telerik:AjaxUpdatedControl ControlID="secInsCity" />
<telerik:AjaxUpdatedControl ControlID="secInsState" />
<telerik:AjaxUpdatedControl ControlID="secInsZip" />
</UpdatedControls>
</telerik:AjaxSetting>
<telerik:AjaxSetting AjaxControlID="btnTerSearch">
<UpdatedControls>
<telerik:AjaxUpdatedControl ControlID="terInsCode" />
<telerik:AjaxUpdatedControl ControlID="terInsName" />
<telerik:AjaxUpdatedControl ControlID="terInsAddress1" />
<telerik:AjaxUpdatedControl ControlID="terInsAddress2" />
<telerik:AjaxUpdatedControl ControlID="terInsCity" />
<telerik:AjaxUpdatedControl ControlID="terInsState" />
<telerik:AjaxUpdatedControl ControlID="terInsZip" />
</UpdatedControls>
</telerik:AjaxSetting>
<telerik:AjaxSetting AjaxControlID="btnSaveLogEntry">
<UpdatedControls>
<telerik:AjaxUpdatedControl ControlID="tsPatientDemographics" />
<telerik:AjaxUpdatedControl ControlID="RadMultiPage1" />
<telerik:AjaxUpdatedControl ControlID="hdnImageName" />
<telerik:AjaxUpdatedControl ControlID="hdnImageURL" />
</UpdatedControls>
</telerik:AjaxSetting>
<telerik:AjaxSetting AjaxControlID="btnVoid">
<UpdatedControls>
<telerik:AjaxUpdatedControl ControlID="tsPatientDemographics" />
<telerik:AjaxUpdatedControl ControlID="RadMultiPage1" />
<telerik:AjaxUpdatedControl ControlID="hdnVoidFlag" />
<telerik:AjaxUpdatedControl ControlID="hdnImageName" />
<telerik:AjaxUpdatedControl ControlID="hdnImageURL" />
</UpdatedControls>
</telerik:AjaxSetting>
<telerik:AjaxSetting AjaxControlID="btnPend">
<UpdatedControls>
<telerik:AjaxUpdatedControl ControlID="tsPatientDemographics" />
<telerik:AjaxUpdatedControl ControlID="RadMultiPage1" />
<telerik:AjaxUpdatedControl ControlID="hdnPendFlag" />
<telerik:AjaxUpdatedControl ControlID="hdnImageName" />
<telerik:AjaxUpdatedControl ControlID="hdnImageURL" />
</UpdatedControls>
</telerik:AjaxSetting>
<telerik:AjaxSetting AjaxControlID="btnDEF">
<UpdatedControls>
<telerik:AjaxUpdatedControl ControlID="tsPatientDemographics" />
<telerik:AjaxUpdatedControl ControlID="RadMultiPage1" />
<telerik:AjaxUpdatedControl ControlID="hdnDefFlag" />
<telerik:AjaxUpdatedControl ControlID="hdnImageName" />
<telerik:AjaxUpdatedControl ControlID="hdnImageURL" />
</UpdatedControls>
</telerik:AjaxSetting>
<telerik:AjaxSetting AjaxControlID="priInsCode">
<UpdatedControls>
<telerik:AjaxUpdatedControl ControlID="priInsName" />
<telerik:AjaxUpdatedControl ControlID="priInsAddress1" />
<telerik:AjaxUpdatedControl ControlID="priInsAddress2" />
<telerik:AjaxUpdatedControl ControlID="priInsCity" />
<telerik:AjaxUpdatedControl ControlID="priInsState" />
<telerik:AjaxUpdatedControl ControlID="priInsZip" />
<telerik:AjaxUpdatedControl ControlID="hdnpriInsID" />
</UpdatedControls>
</telerik:AjaxSetting>
<telerik:AjaxSetting AjaxControlID="secInsCode">
<UpdatedControls>
<telerik:AjaxUpdatedControl ControlID="secInsName" />
<telerik:AjaxUpdatedControl ControlID="secInsAddress1" />
<telerik:AjaxUpdatedControl ControlID="secInsAddress2" />
<telerik:AjaxUpdatedControl ControlID="secInsCity" />
<telerik:AjaxUpdatedControl ControlID="secInsState" />
<telerik:AjaxUpdatedControl ControlID="secInsZip" />
<telerik:AjaxUpdatedControl ControlID="hdnsecInsID" />
</UpdatedControls>
</telerik:AjaxSetting>
<telerik:AjaxSetting AjaxControlID="terInsCode">
<UpdatedControls>
<telerik:AjaxUpdatedControl ControlID="terInsName" />
<telerik:AjaxUpdatedControl ControlID="terInsAddress1" />
<telerik:AjaxUpdatedControl ControlID="terInsAddress2" />
<telerik:AjaxUpdatedControl ControlID="terInsCity" />
<telerik:AjaxUpdatedControl ControlID="terInsState" />
<telerik:AjaxUpdatedControl ControlID="terInsZip" />
<telerik:AjaxUpdatedControl ControlID="hdnterInsID" />
</UpdatedControls>
</telerik:AjaxSetting>
</AjaxSettings>
</telerik:RadAjaxManager>
</div>
<table cellpadding="0" cellspacing="0" border="1" style="border: thin solid #004990;
width: 100%; height: 100%" frame="box">
<tr valign="top" style="height: 100%">
<td width="100%">
<fieldset>
<legend><font color="blue" size="1"><b>Patient Demographics ==> Data Entry</b></font></legend>
<table cellpadding="0" cellspacing="0" border="0" width="100%">
<tr valign="top">
<td width="100%">
<input onclick="rd_onclick();" type="hidden" value=".bmp" name="ImageType">
<object classid="clsid:5220cb21-c88d-11cf-b347-00aa00a28331">
<param name="LPKPath" value="../DynamicWebTwain.lpk" />
</object>
<table cellspacing="1" cellpadding="1" width="100%" border="0">
<tbody>
<tr height="300">
<td valign="top" width="10%" height="280" align="center" bgcolor="f0f0f0" id="tdThumbNails">
<table cellpadding="1" cellspacing="1" width="100%">
<tr>
<td height="300">
<div align="left">
<font color="darkblue"><b> Thumbnails<br>
</b></font>
</div>
<object classid="clsid:E7DA7F8D-27AB-4EE9-8FC0-3FEC9ECFE758" id="DynamicWebTwain1"
height="70%" width="90%" codebase="../DynamicWebTWAIN.cab#version=5,2">
<param name="_cx" value="847" />
<param name="_cy" value="847" />
<param name="JpgQuality" value="80" />
<param name="Manufacturer" value="Dynamsoft Corporation" />
<param name="ProductFamily" value="Dynamic Web TWAIN" />
<param name="ProductName" value="Dynamic Web TWAIN" />
<param name="VersionInfo" value="Dynamic Web TWAIN 5.2" />
<param name="TransferMode" value="0" />
<param name="BorderStyle" value="0" />
<param name="FTPUserName" value="" />
<param name="FTPPassword" value="" />
<param name="FTPPort" value="21" />
<param name="HTTPUserName" value="" />
<param name="HTTPPassword" value="" />
<param name="HTTPPort" value="80" />
<param name="ProxyServer" value="" />
<param name="IfDisableSourceAfterAcquire" value="0" />
<param name="IfShowUI" value="1" />
<param name="IfModalUI" value="1" />
<param name="IfTiffMultiPage" value="0" />
<param name="IfThrowException" value="0" />
<param name="MaxImagesInBuffer" value="1" />
<param name="TIFFCompressionType" value="0" />
</object>
</td>
</tr>
<tr>
<td>
<table cellpadding="1" cellspacing="1" width="100%">
<tr>
<td colspan="2" bgcolor="#f0f0f0" align="left">
<font color="darkblue"><b>Edit Image</b></font>
</td>
</tr>
<tr>
<td bgcolor="#f0f0f0" colspan="2" align="left">
<input id="btnRotateRight" onclick="return btnRotateRight_onclick()" style="font-size: xx-small;
font-weight: bold; width: 90px;" type="button" value="Rotate Right">
<input id="btnRotateLeft" onclick="return btnRotateLeft_onclick()" type="button"
style="font-size: xx-small; font-weight: bold; width: 80px;" value="Rotate Left">
</td>
</tr>
<tr>
<td bgcolor="#f0f0f0" colspan="2" align="left">
<input id="btnFirstImage" onclick="return btnFirstImage_onclick()" type="button"
style="font-size: xx-small; font-weight: bold; width: 25px;" value="|<">
<input id="btnPreImage" onclick="return btnPreImage_onclick()" style="font-size: xx-small;
font-weight: bold; width: 25px;" type="button" value="<">
<input id="CurrentImage" readonly size="2" name="CurrentImage" style="font-size: xx-small;
font-weight: bold; width: 25px;">/
<input id="TotalImage" readonly size="2" value="0" name="TotalImage" style="font-size: xx-small;
font-weight: bold; width: 25px;">
<input id="btnNextImage" onclick="return btnNextImage_onclick()" style="font-size: xx-small;
font-weight: bold; width: 25px;" type="button" value=">">
<input id="btnLastImage" onclick="return btnLastImage_onclick()" style="font-size: xx-small;
font-weight: bold; width: 25px;" type="button" value=">|">
</td>
</tr>
<tr>
<td bgcolor="#f0f0f0" colspan="2" align="left">
<input id="btnFit" onclick="return btnFit_onclick()" type="button" value="Fit Window"
style="font-size: xx-small; font-weight: bold; width: 80px;" />
<input id="btnFact" onclick="return btnFact_onclick()" type="button" value="1:1"
style="font-size: xx-small; font-weight: bold; width: 25px;" />
<input id="btnZoomIn" onclick="return btnZoomIn_onclick()" type="button" value="+"
style="font-size: xx-small; font-weight: bold; width: 25px;">
<input id="btnZoomOut" onclick="return btnZoomOut_onclick()" type="button" value="-"
style="font-size: xx-small; font-weight: bold; width: 25px;">
</td>
</tr>
<tr>
<td bgcolor="#f0f0f0" colspan="2" align="left">
<input id="btnPointer" onclick="return btnPointer_onclick()" type="button" value="Pointer"
style="font-size: xx-small; font-weight: bold; width: 90px;" />
<input id="btnHand" onclick="return btnHand_onclick()" type="button" value="Hand"
style="font-size: xx-small; font-weight: bold; width: 90px;" />
<br />
<br />
<div align="left">
Message:<br />
</div>
<center>
<textarea name="emessage" rows="4" readonly cols="10"></textarea></center>
</td>
</tr>
</table>
</td>
</tr>
</table>
</td>
<td valign="top" width="65%">
<object classid="clsid:E7DA7F8D-27AB-4EE9-8FC0-3FEC9ECFE758" id="DynamicWebTwain2"
width="100%" height="900px" codebase="../DynamicWebTWAIN.cab#version=5,1" style="z-index: -10000">
<param name="_cx" value="847" />
<param name="_cy" value="847" />
<param name="JpgQuality" value="80" />
<param name="Manufacturer" value="Dynamsoft Corporation" />
<param name="ProductFamily" value="Dynamic Web TWAIN" />
<param name="ProductName" value="Dynamic Web TWAIN" />
<param name="VersionInfo" value="Dynamic Web TWAIN 5.1" />
<param name="TransferMode" value="0" />
<param name="BorderStyle" value="0" />
<param name="FTPUserName" value="" />
<param name="FTPPassword" value="" />
<param name="FTPPort" value="21" />
<param name="HTTPUserName" value="" />
<param name="HTTPPassword" value="" />
<param name="HTTPPort" value="80" />
<param name="ProxyServer" value="" />
<param name="IfDisableSourceAfterAcquire" value="0" />
<param name="IfShowUI" value="1" />
<param name="IfModalUI" value="1" />
<param name="IfTiffMultiPage" value="0" />
<param name="IfThrowException" value="0" />
<param name="MaxImagesInBuffer" value="1" />
<param name="TIFFCompressionType" value="0" />
</object>
</td>
<td valign="top" width="25%">
<table cellspacing="0" cellpadding="0" width="100%" border="0">
<tbody style="font-size: 8pt;">
<tr>
<td colspan="3">
<table cellpadding="0" cellspacing="0" width="100%">
<tr>
<td class="td_AEVNoBold">
<b>FACILITY: </b>
<asp:Label ID="lblFacility" runat="server" Font-Bold="true" ForeColor="Blue"></asp:Label>
<b>DOS: </b>
<asp:Label ID="lblDOS" runat="server" Font-Bold="true" ForeColor="Blue"></asp:Label>
</td>
</tr>
<tr>
<td>
<div>
<telerik:RadTabStrip ID="tsPatientDemographics" runat="server" AutoPostBack="false"
ScrollButtonsPosition="Right" MultiPageID="RadMultiPage1" BackColor="Gray" CausesValidation="False"
Align="Left" Width="100%">
<Tabs>
<telerik:RadTab Text="P<u>a</u>tient" AccessKey="A" Width="60px">
</telerik:RadTab>
<telerik:RadTab Text="G<u>u</u>arantor" AccessKey="U" Width="80px">
</telerik:RadTab>
<telerik:RadTab Text="<u>P</u>ri Ins" AccessKey="P" Width="60px">
</telerik:RadTab>
<telerik:RadTab Text="<u>S</u>ec Ins" AccessKey="S" Value="Sec Ins" Width="60px"
Enabled="false">
</telerik:RadTab>
<telerik:RadTab Text="<u>T</u>er Ins" AccessKey="T" Value="Ter Ins" Width="70px"
Enabled="false">
</telerik:RadTab>
</Tabs>
</telerik:RadTabStrip>
<telerik:RadMultiPage ID="RadMultiPage1" runat="server" SelectedIndex="0" ScrollBars="None">
<telerik:RadPageView ID="RadPatientInfoView" runat="server" Width="100%" BackColor="LightGray">
<table width="100%" bgcolor="#F6F6F6" cellpadding="0" cellspacing="0">
<tr>
<td>
<fieldset>
<legend><b><font style="font-size: x-small;">Patient Info</font></b></legend>
<table width="100%" bordercolor="white" border="1" cellpadding="0" cellspacing="0">
<tr>
<td class="td_AEV" width="35%">
Hosp Acct# *:
</td>
<td class="td_AEVNoBold">
<asp:TextBox ID="HospAcctno" runat="server" onblur="CheckForCompletedReqFlds();"
MaxLength="25"></asp:TextBox>
<asp:RequiredFieldValidator ID="RequiredFieldValidator1" ControlToValidate="HospAcctno"
Display="Dynamic" ErrorMessage="Patient Info: Hosp Acct#" Text="*" runat="server" />
</td>
</tr>
<tr>
<td class="td_AEV">
MRN # *:
</td>
<td class="td_AEVNoBold">
<asp:TextBox ID="MRN" runat="server" onblur="CheckForCompletedReqFlds();" MaxLength="25"></asp:TextBox>
<asp:RequiredFieldValidator ID="RequiredFieldValidator2" ControlToValidate="MRN"
Display="Dynamic" ErrorMessage="Patient Info: MRN #" Text="*" runat="server" />
</td>
</tr>
<tr>
<td class="td_AEV">
Admit Date *:
</td>
<td class="td_AEVNoBold">
<telerik:RadDatePicker ID="radAdmitDate" runat="server" onblur="CheckForCompletedReqFlds();"
Font-Size="8pt">
<Calendar UseColumnHeadersAsSelectors="False" UseRowHeadersAsSelectors="False" ViewSelectorText="x">
</Calendar>
<DatePopupButton HoverImageUrl="" ImageUrl="" />
<DateInput ID="DateInput4" DateFormat="M/d/yyyy" DisplayDateFormat="M/d/yyyy" runat="server">
</DateInput>
</telerik:RadDatePicker>
<asp:RequiredFieldValidator ID="RequiredFieldValidator17" ControlToValidate="radAdmitDate"
Display="Dynamic" ErrorMessage="Patient Info: Admit Date" Text="*" runat="server" />
</td>
</tr>
<tr>
<td class="td_AEV">
Admit Time *:
</td>
<td class="td_AEVNoBold">
<telerik:RadTimePicker ID="radAdmitTime" runat="server" onblur="CheckForCompletedReqFlds();"
Font-Size="8pt">
<Calendar UseColumnHeadersAsSelectors="False" UseRowHeadersAsSelectors="False" ViewSelectorText="x">
</Calendar>
<TimeView CellSpacing="-1">
</TimeView>
<TimePopupButton CssClass="" HoverImageUrl="" ImageUrl="" />
<DatePopupButton CssClass="" HoverImageUrl="" ImageUrl="" Visible="False" />
<DateInput ID="DateInput5" DateFormat="h:mm tt" DisplayDateFormat="h:mm tt" runat="server">
</DateInput>
</telerik:RadTimePicker>
<asp:RequiredFieldValidator ID="RequiredFieldValidator18" ControlToValidate="radAdmitTime"
Display="Dynamic" ErrorMessage="Patient Info: Admit Time" Text="*" runat="server" />
</td>
</tr>
<tr>
<td class="td_AEV">
Discharge Date *:
</td>
<td class="td_AEVNoBold">
<telerik:RadDatePicker ID="radDischargeDate" runat="server" onblur="CheckForCompletedReqFlds();"
Font-Size="8pt">
<Calendar UseColumnHeadersAsSelectors="False" UseRowHeadersAsSelectors="False" ViewSelectorText="x">
</Calendar>
<DatePopupButton HoverImageUrl="" ImageUrl="" />
<DateInput ID="DateInput6" DateFormat="M/d/yyyy" DisplayDateFormat="M/d/yyyy" runat="server">
</DateInput>
</telerik:RadDatePicker>
<asp:CompareValidator ID="cvAdmitDischargeDates" runat="server" ErrorMessage="Patient Info: Discharge Date cannot be less than Admit Date!"
Display="Dynamic" Text="*" ControlToValidate="radAdmitDate" ControlToCompare="radDischargeDate"
Operator="LessThanEqual" Type="Date"></asp:CompareValidator>
</td>
</tr>
<tr>
<td class="td_AEV">
Discharge Time *:
</td>
<td class="td_AEVNoBold">
<telerik:RadTimePicker ID="radDischargeTime" runat="server" onblur="CheckForCompletedReqFlds();"
Font-Size="8pt">
<Calendar UseColumnHeadersAsSelectors="False" UseRowHeadersAsSelectors="False" ViewSelectorText="x">
</Calendar>
<TimeView CellSpacing="-1">
</TimeView>
<TimePopupButton CssClass="" HoverImageUrl="" ImageUrl="" />
<DatePopupButton CssClass="" HoverImageUrl="" ImageUrl="" Visible="False" />
<DateInput ID="DateInput7" DateFormat="h:mm tt" DisplayDateFormat="h:mm tt" runat="server">
</DateInput>
</telerik:RadTimePicker>
<asp:CustomValidator ID="cvDischargeDateTime" runat="server" ErrorMessage="Patient Info: Discharge Date & Time cannot be less than Admit Date & Time!"
Display="Dynamic" EnableClientScript="true" Text="Patient Info: Discharge Date & Time cannot be less than Admit Date & Time!"
ControlToValidate="radDischargeTime" OnServerValidate="cvAdmitDischargeDateTime_OnServerValidate"></asp:CustomValidator>
</td>
</tr>
<tr>
<td class="td_AEV">
Last Name *:
</td>
<td class="td_AEVNoBold">
<asp:TextBox ID="PatLName" runat="server" onblur="CheckForCompletedReqFlds();" MaxLength="50"></asp:TextBox>
<asp:RequiredFieldValidator ID="RequiredFieldValidator3" ControlToValidate="PatLName"
Display="Dynamic" ErrorMessage="Patient Info: Last Name" Text="*" runat="server" />
</td>
</tr>
<tr>
<td class="td_AEV">
First Name *:
</td>
<td class="td_AEVNoBold">
<asp:TextBox ID="PatFName" runat="server" onblur="CheckForCompletedReqFlds();" MaxLength="50"></asp:TextBox>
<asp:RequiredFieldValidator ID="RequiredFieldValidator4" ControlToValidate="PatFName"
Display="Dynamic" ErrorMessage="Patient Info: First Name" Text="*" runat="server" />
</td>
</tr>
<tr>
<td class="td_AEV">
Initial:
</td>
<td class="td_AEVNoBold">
<asp:TextBox ID="PatInitial" runat="server" MaxLength="25"></asp:TextBox>
</td>
</tr>
<tr>
<td class="td_AEV">
Address1 *:
</td>
<td class="td_AEVNoBold">
<asp:TextBox ID="PatAddress1" runat="server" onblur="CheckForCompletedReqFlds();"
MaxLength="50"></asp:TextBox>
<asp:RequiredFieldValidator ID="RequiredFieldValidator5" ControlToValidate="PatAddress1"
Display="Dynamic" ErrorMessage="Patient Info: Address1" Text="*" runat="server" />
</td>
</tr>
<tr>
<td class="td_AEV">
Address2:
</td>
<td class="td_AEVNoBold">
<asp:TextBox ID="PatAddress2" runat="server" MaxLength="50"></asp:TextBox>
</td>
</tr>
<tr>
<td class="td_AEV">
City *:
</td>
<td class="td_AEVNoBold">
<asp:TextBox ID="PatCity" runat="server" onblur="CheckForCompletedReqFlds();" MaxLength="50"></asp:TextBox>
<asp:RequiredFieldValidator ID="RequiredFieldValidator6" ControlToValidate="PatCity"
Display="Dynamic" ErrorMessage="Patient Info: City" Text="*" runat="server" />
</td>
</tr>
<tr>
<td class="td_AEV">
State *:
</td>
<td class="td_AEVNoBold">
<asp:DropDownList ID="PatState" runat="server" Font-Size="8pt" />
<asp:RequiredFieldValidator ID="RequiredFieldValidator7" ControlToValidate="PatState"
Display="Dynamic" ErrorMessage="Patient Info: State" Text="*" runat="server" />
</td>
</tr>
<tr>
<td class="td_AEV">
Zip:
</td>
<td class="td_AEVNoBold">
<telerik:RadMaskedTextBox ID="PatZip" runat="server" Mask="#####-####" Width="70px"
Font-Size="8pt">
</telerik:RadMaskedTextBox>
<asp:RegularExpressionValidator ID="RegularExpressionValidator5" runat="server" ErrorMessage="Patient Info: Zip Invalid!"
Display="Dynamic" ValidationExpression="^((\d{5}-_{0,4})|(|(\d{5}-\d{4})))$"
ControlToValidate="PatZip"></asp:RegularExpressionValidator>
</td>
</tr>
<tr>
<td class="td_AEV">
SSN:
</td>
<td class="td_AEVNoBold">
<telerik:RadMaskedTextBox ID="PatSSN" runat="server" Mask="###-##-####" Width="92px"
Font-Size="8pt">
</telerik:RadMaskedTextBox>
<asp:RegularExpressionValidator ID="RegularExpressionValidator6" runat="server" ErrorMessage="Patient Info: SSN Invalid!"
Display="Dynamic" ValidationExpression="^\d{3}-\d{2}-\d{4}$" ControlToValidate="PatSSN"></asp:RegularExpressionValidator>
</td>
</tr>
<tr>
<td class="td_AEV">
DOB *:
</td>
<td class="td_AEVNoBold">
<telerik:RadDatePicker ID="PatDOB" runat="server" onblur="CheckForCompletedReqFlds();"
Font-Size="8pt">
<Calendar UseColumnHeadersAsSelectors="False" UseRowHeadersAsSelectors="False" ViewSelectorText="x">
</Calendar>
<DatePopupButton HoverImageUrl="" ImageUrl="" />
<DateInput ID="DateInput0" DateFormat="M/d/yyyy" DisplayDateFormat="M/d/yyyy" runat="server">
</DateInput>
</telerik:RadDatePicker>
<asp:RequiredFieldValidator ID="RequiredFieldValidator8" ControlToValidate="PatDOB"
Display="Dynamic" ErrorMessage="Patient Info: DOB" Text="*" runat="server" />
<asp:CompareValidator ID="cvPatDOB" runat="server" ErrorMessage="Admit Date cannot be less than Patient DOB!"
ControlToValidate="PatDOB" ControlToCompare="radAdmitDate" Operator="LessThanEqual"
Display="Dynamic" Type="Date"></asp:CompareValidator>
<asp:CompareValidator ID="cvDOB2" runat="server" ErrorMessage="Discharge Date cannot be less than Patient DOB!"
Display="Dynamic" ControlToValidate="PatDOB" ControlToCompare="radDischargeDate"
Operator="LessThanEqual" Type="Date"></asp:CompareValidator>
</td>
</tr>
<tr>
<td class="td_AEV">
Home Phone:
</td>
<td class="td_AEVNoBold">
<telerik:RadMaskedTextBox ID="PatHomePhone" runat="server" Mask="(###) ###-####"
Width="80px" Font-Size="8pt">
</telerik:RadMaskedTextBox>
<asp:RegularExpressionValidator ID="RegularExpressionValidator8" runat="server" ErrorMessage="Patient Info: Home Phone Invalid!"
Display="Dynamic" ControlToValidate="PatHomePhone" ValidationExpression="^([\(]{1}[0-9]{3}[\)]{1}[ ]{1}[0-9]{3}[\-]{1}[0-9]{4})$"></asp:RegularExpressionValidator>
</td>
</tr>
<tr>
<td class="td_AEV">
Work Phone:
</td>
<td class="td_AEVNoBold">
<telerik:RadMaskedTextBox ID="PatWorkPhone" runat="server" Mask="(###) ###-####"
Width="80px" Font-Size="8pt">
</telerik:RadMaskedTextBox>
<asp:RegularExpressionValidator ID="RegularExpressionValidator9" runat="server" ErrorMessage="Patient Info: Work Phone Invalid!"
Display="Dynamic" ControlToValidate="PatWorkPhone" ValidationExpression="^([\(]{1}[0-9]{3}[\)]{1}[ ]{1}[0-9]{3}[\-]{1}[0-9]{4})$"></asp:RegularExpressionValidator>
</td>
</tr>
<tr>
<td class="td_AEV">
Cell Phone:
</td>
<td class="td_AEVNoBold">
<telerik:RadMaskedTextBox ID="PatCellPhone" runat="server" Mask="(###) ###-####"
Width="80px" Font-Size="8pt">
</telerik:RadMaskedTextBox>
<asp:RegularExpressionValidator ID="RegularExpressionValidator10" runat="server"
Display="Dynamic" ErrorMessage="Patient Info: Cell Phone Invalid!" ControlToValidate="PatCellPhone"
ValidationExpression="^([\(]{1}[0-9]{3}[\)]{1}[ ]{1}[0-9]{3}[\-]{1}[0-9]{4})$"></asp:RegularExpressionValidator>
</td>
</tr>
<tr>
<td class="td_AEV">
Marital status *:
</td>
<td class="td_AEVNoBold">
<asp:DropDownList ID="PatMaritalStatus" runat="server" onblur="CheckForCompletedReqFlds();"
Font-Size="8pt" />
<asp:RequiredFieldValidator ID="RequiredFieldValidator9" ControlToValidate="PatMaritalStatus"
Display="Dynamic" ErrorMessage="Patient Info: Marital status" Text="*" runat="server" />
</td>
</tr>
<tr>
<td class="td_AEV">
Sex *:
</td>
<td class="td_AEVNoBold">
<asp:DropDownList ID="PatSex" runat="server" onblur="CheckForCompletedReqFlds('Patient');"
Font-Size="8pt">
<asp:ListItem Selected="True" Text="Select" Value=""></asp:ListItem>
<asp:ListItem Text="Male" Value="M"></asp:ListItem>
<asp:ListItem Text="Female" Value="F"></asp:ListItem>
</asp:DropDownList>
<asp:RequiredFieldValidator ID="RequiredFieldValidator10" ControlToValidate="PatSex"
Display="Dynamic" ErrorMessage="Patient Info: Sex" Text="*" runat="server" />
</td>
</tr>
</table>
</fieldset>
</td>
</tr>
</table>
</telerik:RadPageView>
<telerik:RadPageView ID="RadGuarView" runat="server" Width="100%">
<table width="100%" bgcolor="#F6F6F6" cellpadding="0" cellspacing="0">
<tr>
<td>
<fieldset>
<legend><b><font style="font-size: x-small;">Guarantor Info</font></b></legend>
<table width="100%" bordercolor="white" border="1" cellpadding="0" cellspacing="0">
<tr>
<td class="td_AEV">
Rel to Patient *:
</td>
<td class="td_AEVNoBold">
<asp:DropDownList ID="GuarRelToPat" runat="server" onblur="CheckForCompletedReqFlds();"
onchange="getGuarSelectedValue();" Font-Size="8pt" />
<asp:RequiredFieldValidator ID="RequiredFieldValidator11" ControlToValidate="GuarRelToPat"
Display="Dynamic" ErrorMessage="Guarantor Info: Rel to Patient" Text="*" runat="server" />
</td>
</tr>
<tr>
<td class="td_AEV">
Last Name *:
</td>
<td class="td_AEVNoBold">
<asp:TextBox ID="GuarLName" runat="server" onblur="CheckForCompletedReqFlds();" MaxLength="50"></asp:TextBox>
<asp:RequiredFieldValidator ID="RequiredFieldValidator12" ControlToValidate="GuarLName"
Display="Dynamic" ErrorMessage="Guarantor Info: Last Name" Text="*" runat="server" />
</td>
</tr>
<tr>
<td class="td_AEV">
First Name *:
</td>
<td class="td_AEVNoBold">
<asp:TextBox ID="GuarFName" runat="server" onblur="CheckForCompletedReqFlds();" MaxLength="50"></asp:TextBox>
<asp:RequiredFieldValidator ID="RequiredFieldValidator13" ControlToValidate="GuarFName"
Display="Dynamic" ErrorMessage="Guarantor Info: First Name" Text="*" runat="server" />
</td>
</tr>
<tr>
<td class="td_AEV">
Initial:
</td>
<td class="td_AEVNoBold">
<asp:TextBox ID="GuarInitial" runat="server" MaxLength="25"></asp:TextBox>
</td>
</tr>
<tr>
<td class="td_AEV">
Address1 *:
</td>
<td class="td_AEVNoBold">
<asp:TextBox ID="GuarAddress1" runat="server" onblur="CheckForCompletedReqFlds();"
MaxLength="50"></asp:TextBox>
<asp:RequiredFieldValidator ID="RequiredFieldValidator14" ControlToValidate="GuarAddress1"
Display="Dynamic" ErrorMessage="Guarantor Info: Address1" Text="*" runat="server" />
</td>
</tr>
<tr>
<td class="td_AEV">
Address2:
</td>
<td class="td_AEVNoBold">
<asp:TextBox ID="GuarAddress2" runat="server" MaxLength="50"></asp:TextBox>
</td>
</tr>
<tr>
<td class="td_AEV">
City *:
</td>
<td class="td_AEVNoBold">
<asp:TextBox ID="GuarCity" runat="server" onblur="CheckForCompletedReqFlds();" MaxLength="50"></asp:TextBox>
<asp:RequiredFieldValidator ID="RequiredFieldValidator15" ControlToValidate="GuarCity"
Display="Dynamic" ErrorMessage="Guarantor Info: City" Text="*" runat="server" />
</td>
</tr>
<tr>
<td class="td_AEV">
State *:
</td>
<td class="td_AEVNoBold">
<asp:DropDownList ID="GuarState" runat="server" Font-Size="8pt" />
<asp:RequiredFieldValidator ID="RequiredFieldValidator16" ControlToValidate="GuarState"
Display="Dynamic" ErrorMessage="Guarantor Info: State" Text="*" runat="server" />
</td>
</tr>
<tr>
<td class="td_AEV">
Zip:
</td>
<td class="td_AEVNoBold">
<telerik:RadMaskedTextBox ID="GuarZip" runat="server" Mask="#####-####" Width="70px">
</telerik:RadMaskedTextBox>
<asp:RegularExpressionValidator ID="RegularExpressionValidator11" runat="server"
ErrorMessage="Guarantor Info: Home Phone Invalid!" ControlToValidate="GuarZip"
Display="Dynamic" ValidationExpression="^((\d{5}-_{0,4})|(|(\d{5}-\d{4})))$"></asp:RegularExpressionValidator>
</td>
</tr>
<tr>
<td class="td_AEV">
Home Phone:
</td>
<td class="td_AEVNoBold">
<telerik:RadMaskedTextBox ID="GuarHomePhone" runat="server" Mask="(###) ###-####"
Width="80px" Font-Size="8pt">
</telerik:RadMaskedTextBox>
<asp:RegularExpressionValidator ID="RegularExpressionValidator12" runat="server"
ErrorMessage="Guarantor Info: Home Phone Invalid!" ControlToValidate="GuarHomePhone"
Display="Dynamic" ValidationExpression="^([\(]{1}[0-9]{3}[\)]{1}[ ]{1}[0-9]{3}[\-]{1}[0-9]{4})$"></asp:RegularExpressionValidator>
</td>
</tr>
<tr>
<td class="td_AEV">
Work Phone:
</td>
<td class="td_AEVNoBold">
<telerik:RadMaskedTextBox ID="GuarWorkPhone" runat="server" Mask="(###) ###-####"
Width="80px" Font-Size="8pt">
</telerik:RadMaskedTextBox>
<asp:RegularExpressionValidator ID="RegularExpressionValidator13" runat="server"
ErrorMessage="Guarantor Info: Work Phone Invalid!" ControlToValidate="GuarWorkPhone"
Display="Dynamic" ValidationExpression="^([\(]{1}[0-9]{3}[\)]{1}[ ]{1}[0-9]{3}[\-]{1}[0-9]{4})$"></asp:RegularExpressionValidator>
</td>
</tr>
<tr>
<td class="td_AEV">
Cell Phone:
</td>
<td class="td_AEVNoBold">
<telerik:RadMaskedTextBox ID="GuarCellPhone" runat="server" Mask="(###) ###-####"
Width="80px" Font-Size="8pt">
</telerik:RadMaskedTextBox>
<asp:RegularExpressionValidator ID="RegularExpressionValidator14" runat="server"
ErrorMessage="Guarantor Info: Cell Phone Invalid!" ControlToValidate="GuarCellPhone"
Display="Dynamic" ValidationExpression="^([\(]{1}[0-9]{3}[\)]{1}[ ]{1}[0-9]{3}[\-]{1}[0-9]{4})$"></asp:RegularExpressionValidator>
</td>
</tr>
<tr>
<td class="td_AEV">
SSN:
</td>
<td class="td_AEVNoBold">
<telerik:RadMaskedTextBox ID="GuarSSN" runat="server" Mask="###-##-####" Width="92px"
Font-Size="8pt">
</telerik:RadMaskedTextBox>
<asp:RegularExpressionValidator ID="RegularExpressionValidator15" runat="server"
ErrorMessage="Guarantor Info: SSN Invalid!" ValidationExpression="^\d{3}-\d{2}-\d{4}$"
Display="Dynamic" ControlToValidate="GuarSSN"></asp:RegularExpressionValidator>
</td>
</tr>
<tr>
<td class="td_AEV">
Sex *:
</td>
<td class="td_AEVNoBold">
<asp:DropDownList ID="GuarSex" runat="server" onblur="CheckForCompletedReqFlds();"
Font-Size="8pt">
<asp:ListItem Selected="True" Text="Select" Value=""></asp:ListItem>
<asp:ListItem Text="Male" Value="M"></asp:ListItem>
<asp:ListItem Text="Female" Value="F"></asp:ListItem>
</asp:DropDownList>
<asp:RequiredFieldValidator ID="RequiredFieldValidator22" ControlToValidate="GuarSex"
Display="Dynamic" ErrorMessage="Guarantor Info: Sex" Text="*" runat="server" />
</td>
</tr>
<tr>
<td class="td_AEV">
Marital status *:
</td>
<td class="td_AEVNoBold">
<asp:DropDownList ID="ddlGuarMaritalStatus" runat="server" onblur="CheckForCompletedReqFlds();"
Font-Size="8pt" />
<asp:RequiredFieldValidator ID="RequiredFieldValidator21" ControlToValidate="ddlGuarMaritalStatus"
Display="Dynamic" ErrorMessage="Guarantor Info: Marital status" Text="*" runat="server" />
</td>
</tr>
<tr>
<td class="td_AEV" valign="top">
DOB *:
</td>
<td class="td_AEVNoBold">
<telerik:RadDatePicker ID="radGuarDOB" runat="server" onblur="CheckForCompletedReqFlds();"
Font-Size="8pt">
<Calendar UseColumnHeadersAsSelectors="False" UseRowHeadersAsSelectors="False" ViewSelectorText="x">
</Calendar>
<DatePopupButton HoverImageUrl="" ImageUrl="" />
<DateInput ID="DateInput8" DateFormat="M/d/yyyy" DisplayDateFormat="M/d/yyyy" runat="server">
</DateInput>
</telerik:RadDatePicker>
<asp:RequiredFieldValidator ID="RequiredFieldValidator23" ControlToValidate="radGuarDOB"
Display="Dynamic" ErrorMessage="Guarantor Info: DOB" Text="*" runat="server" />
<asp:CompareValidator ID="CompareValidator1" runat="server" ErrorMessage="Admit Date cannot be less than Guarantor DOB!"
ControlToValidate="radGuarDOB" ControlToCompare="radAdmitDate" Operator="LessThanEqual"
Display="Dynamic" Type="Date"></asp:CompareValidator>
<asp:CompareValidator ID="CompareValidator2" runat="server" ErrorMessage="Discharge Date cannot be less than Guarantor DOB!"
ControlToValidate="radGuarDOB" ControlToCompare="radDischargeDate" Operator="LessThanEqual"
Display="Dynamic" Type="Date"></asp:CompareValidator>
</td>
</tr>
<tr>
<td class="td_AEV">
Arrival Mode *:
</td>
<td class="td_AEVNoBold">
<asp:DropDownList ID="ddlGuarArrivalMode" runat="server" onblur="CheckForCompletedReqFlds();"
Font-Size="8pt" />
<asp:RequiredFieldValidator ID="RequiredFieldValidator25" ControlToValidate="ddlGuarArrivalMode"
Display="Dynamic" ErrorMessage="Guarantor Info: Arrival Mode" Text="*" runat="server" />
</td>
</tr>
</table>
</fieldset>
</td>
</tr>
<tr>
<td>
<fieldset>
<legend><b><font style="font-size: x-small;">Employer Info</font></b></legend>
<table width="100%" bordercolor="white" border="1" cellpadding="0" cellspacing="0">
<tr>
<td class="td_AEV" width="35%">
Employer:
</td>
<td class="td_AEVNoBold">
<asp:TextBox ID="GuarEmployer" runat="server" MaxLength="100"></asp:TextBox>
</td>
</tr>
<tr>
<td class="td_AEV">
Address1:
</td>
<td class="td_AEVNoBold">
<asp:TextBox ID="GuarEmpAddress1" runat="server" MaxLength="50"></asp:TextBox>
</td>
</tr>
<tr>
<td class="td_AEV">
Address2:
</td>
<td class="td_AEVNoBold">
<asp:TextBox ID="GuarEmpAddress2" runat="server" MaxLength="50"></asp:TextBox>
</td>
</tr>
<tr>
<td class="td_AEV">
City:
</td>
<td class="td_AEVNoBold">
<asp:TextBox ID="GuarEmpCity" runat="server" MaxLength="50"></asp:TextBox>
</td>
</tr>
<tr>
<td class="td_AEV">
State:
</td>
<td class="td_AEVNoBold">
<asp:DropDownList ID="GuarEmpState" runat="server" Font-Size="8pt" />
</td>
</tr>
<tr>
<td class="td_AEV">
Zip:
</td>
<td class="td_AEVNoBold">
<telerik:RadMaskedTextBox ID="GuarEmpZip" runat="server" Mask="#####-####" Width="70px"
Font-Size="8pt">
</telerik:RadMaskedTextBox>
<asp:RegularExpressionValidator ID="RegularExpressionValidator17" runat="server"
ErrorMessage="Guarantor Employer Info: Zip Invalid!" ControlToValidate="GuarEmpZip"
Display="Dynamic" ValidationExpression="^((\d{5}-_{0,4})|(|(\d{5}-\d{4})))$"></asp:RegularExpressionValidator>
</td>
</tr>
<tr>
<td class="td_AEV">
Phone:
</td>
<td class="td_AEVNoBold">
<telerik:RadMaskedTextBox ID="GuarEmpPhone" runat="server" Mask="(###) ###-####"
Width="80px" onblur="CheckForCompletedReqFlds('Guarantor');" Font-Size="8pt">
</telerik:RadMaskedTextBox>
<asp:RegularExpressionValidator ID="RegularExpressionValidator18" runat="server"
ErrorMessage="Guarantor Employer Info: Phone Invalid!" ControlToValidate="GuarEmpPhone"
Display="Dynamic" ValidationExpression="^([\(]{1}[0-9]{3}[\)]{1}[ ]{1}[0-9]{3}[\-]{1}[0-9]{4})$"></asp:RegularExpressionValidator>
</td>
</tr>
</table>
</fieldset>
</td>
</tr>
</table>
</telerik:RadPageView>
<telerik:RadPageView ID="RadPriView" runat="server" Width="100%">
<table width="100%" bgcolor="#F6F6F6" cellpadding="0" cellspacing="0">
<tr>
<td>
<fieldset>
<legend><b><font style="font-size: x-small;">Primary Insurance</font></b></legend>
<table width="100%" bordercolor="white" border="1" cellpadding="0" cellspacing="0">
<tr>
<td class="td_AEV" width="30%">
Ins Code *:
</td>
<td class="td_AEVNoBold">
<asp:TextBox ID="priInsCode" runat="server" AutoPostBack="true" OnTextChanged="priInsCode_OnTextChanged"
MaxLength="10"></asp:TextBox>
<asp:Button ID="btnPriSearch" runat="server" Text="Search" CausesValidation="false"
AccessKey="1" />
<asp:RequiredFieldValidator ID="rfvpriInsCode" ControlToValidate="priInsCode" ErrorMessage="Primary Insurance: Pri Ins Code"
Display="Dynamic" Text="*" runat="server" Enabled="false" />
</td>
</tr>
<tr>
<td class="td_AEV">
Ins Name *:
</td>
<td class="td_AEVNoBold">
<asp:TextBox ID="priInsName" runat="server" ReadOnly="true" Width="225px"></asp:TextBox>
</td>
</tr>
<tr>
<td class="td_AEV">
Ins Address1 *:
</td>
<td class="td_AEVNoBold">
<asp:TextBox ID="priInsAddress1" runat="server" ReadOnly="true"></asp:TextBox>
</td>
</tr>
<tr>
<td class="td_AEV">
Ins Address2:
</td>
<td class="td_AEVNoBold">
<asp:TextBox ID="priInsAddress2" runat="server" ReadOnly="true"></asp:TextBox>
</td>
</tr>
<tr>
<td class="td_AEV">
City *:
</td>
<td class="td_AEVNoBold">
<asp:TextBox ID="priInsCity" runat="server" ReadOnly="true"></asp:TextBox>
</td>
</tr>
<tr>
<td class="td_AEV">
State *:
</td>
<td class="td_AEVNoBold">
<asp:TextBox ID="priInsState" runat="server" onblur="CheckForCompletedReqFlds();"
ReadOnly="true"></asp:TextBox>
</td>
</tr>
<tr>
<td class="td_AEV">
Zip *:
</td>
<td class="td_AEVNoBold">
<asp:TextBox ID="priInsZip" runat="server" ReadOnly="true" Width="70px">
</asp:TextBox>
</td>
</tr>
<tr>
<td>
</td>
</tr>
<tr>
<td class="td_AEV">
Policy # *:
</td>
<td class="td_AEVNoBold">
<asp:TextBox ID="priInsPolicyNum" runat="server" MaxLength="50" onblur="CheckForCompletedReqFlds();"></asp:TextBox>
<asp:RequiredFieldValidator ID="rfvpriInsPolicyNum" ControlToValidate="priInsPolicyNum"
Display="Dynamic" ErrorMessage="Primary Insurance: Policy #" Text="*" runat="server"
Enabled="false" />
</td>
</tr>
<tr>
<td class="td_AEV" valign="top">
Retype Policy #:
</td>
<td>
<asp:TextBox ID="priInsPolicyNumVer" runat="server" MaxLength="50" onblur="CheckForCompletedReqFlds();"></asp:TextBox>
<asp:CompareValidator ID="CompareValidator9" runat="server" ErrorMessage="Primary Insurance: Confirmation Primary Policy Numbers NOT equal!"
ControlToValidate="priInsPolicyNumVer" ControlToCompare="priInsPolicyNum" Operator="Equal"
Display="Dynamic" Type="String"></asp:CompareValidator>
</td>
</tr>
<tr>
<td class="td_AEV">
Group # *:
</td>
<td class="td_AEVNoBold">
<asp:TextBox ID="priInsGrpNum" runat="server" MaxLength="25" onblur="CheckForCompletedReqFlds();"></asp:TextBox>
<asp:RequiredFieldValidator ID="rfvpriInsGrpNum" ControlToValidate="priInsGrpNum"
Display="Dynamic" ErrorMessage="Primary Insurance: Group #" Text="*" runat="server"
Enabled="false" />
</td>
</tr>
</table>
</fieldset>
</td>
</tr>
<tr>
<td>
<fieldset>
<legend><b><font style="font-size: x-small;">Primary Subscriber Info</font></b></legend>
<table width="100%" bordercolor="white" border="1" cellpadding="0" cellspacing="0">
<tr>
<td class="td_AEV" width="30%">
Rel to Patient *:
</td>
<td class="td_AEVNoBold">
<asp:DropDownList ID="priSubRelToPat" runat="server" onchange="getPriSelectedValue();"
Font-Size="8pt" />
<asp:RequiredFieldValidator ID="rfvpriSubRelToPat" ControlToValidate="priSubRelToPat"
Enabled="false" Display="Dynamic" ErrorMessage="Primary Subscriber Info: Rel to Patient"
Text="*" runat="server" />
</td>
</tr>
<tr>
<td class="td_AEV">
Last Name *:
</td>
<td class="td_AEVNoBold">
<asp:TextBox ID="priSubLName" runat="server" MaxLength="100"></asp:TextBox>
<asp:RequiredFieldValidator ID="rfvpriSubLName" ControlToValidate="priSubLName" Enabled="false"
Display="Dynamic" ErrorMessage="Primary Subscriber Info: Last Name" Text="*"
runat="server" />
</td>
</tr>
<tr>
<td class="td_AEV">
First Name *:
</td>
<td class="td_AEVNoBold">
<asp:TextBox ID="priSubFName" runat="server" MaxLength="100"></asp:TextBox>
<asp:RequiredFieldValidator ID="rfvpriSubFName" ControlToValidate="priSubFName" Enabled="false"
Display="Dynamic" ErrorMessage="Primary Subscriber Info: First Name" Text="*"
runat="server" />
</td>
</tr>
<tr>
<td class="td_AEV">
Initial:
</td>
<td class="td_AEVNoBold">
<asp:TextBox ID="priSubInitial" runat="server" MaxLength="50"></asp:TextBox>
</td>
</tr>
<tr>
<td class="td_AEV">
Address1 *:
</td>
<td class="td_AEVNoBold">
<asp:TextBox ID="priSubAddress1" runat="server" MaxLength="100"></asp:TextBox>
<asp:RequiredFieldValidator ID="rfvpriSubAddress1" ControlToValidate="priSubAddress1"
Enabled="false" Display="Dynamic" ErrorMessage="Primary Subscriber Info: Address1"
Text="*" runat="server" />
</td>
</tr>
<tr>
<td class="td_AEV">
Address2:
</td>
<td class="td_AEVNoBold">
<asp:TextBox ID="priSubAddress2" runat="server" MaxLength="100"></asp:TextBox>
</td>
</tr>
<tr>
<td class="td_AEV">
City *:
</td>
<td class="td_AEVNoBold">
<asp:TextBox ID="priSubCity" runat="server" MaxLength="100"></asp:TextBox>
<asp:RequiredFieldValidator ID="rfvpriSubCity" ControlToValidate="priSubCity" Enabled="false"
Display="Dynamic" ErrorMessage="Primary Subscriber Info: City" Text="*" runat="server" />
</td>
</tr>
<tr>
<td class="td_AEV">
State *:
</td>
<td class="td_AEVNoBold">
<asp:DropDownList ID="priSubState" runat="server" Font-Size="8pt" />
<asp:RequiredFieldValidator ID="rfvpriSubState" ControlToValidate="priSubState" Enabled="false"
Display="Dynamic" ErrorMessage="Primary Subscriber Info: State" Text="*" runat="server" />
</td>
</tr>
<tr>
<td class="td_AEV">
Zip:
</td>
<td class="td_AEVNoBold">
<telerik:RadMaskedTextBox ID="priSubZip" runat="server" Mask="#####-####" Width="70px"
Font-Size="8pt">
</telerik:RadMaskedTextBox>
<asp:RegularExpressionValidator ID="RegularExpressionValidator19" runat="server"
ErrorMessage="Primary Insurance: Zip Invalid!" ControlToValidate="priSubZip"
Display="Dynamic" ValidationExpression="^((\d{5}-_{0,4})|(|(\d{5}-\d{4})))$"></asp:RegularExpressionValidator>
</td>
</tr>
<tr>
<td class="td_AEV">
SSN:
</td>
<td class="td_AEVNoBold">
<telerik:RadMaskedTextBox ID="priSubSSN" runat="server" Mask="###-##-####" Width="92px"
Font-Size="8pt">
</telerik:RadMaskedTextBox>
<asp:RegularExpressionValidator ID="RegularExpressionValidator20" runat="server"
ErrorMessage="Primary Insurance: SSN Invalid!" ValidationExpression="^\d{3}-\d{2}-\d{4}$"
Display="Dynamic" ControlToValidate="priSubSSN"></asp:RegularExpressionValidator>
</td>
</tr>
<tr>
<td class="td_AEV" valign="top">
DOB:
</td>
<td class="td_AEVNoBold">
<telerik:RadDatePicker ID="priSubDOB" runat="server" Font-Size="8pt">
<Calendar UseColumnHeadersAsSelectors="False" UseRowHeadersAsSelectors="False" ViewSelectorText="x">
</Calendar>
<DatePopupButton HoverImageUrl="" ImageUrl="" />
<DateInput ID="DateInput1" DateFormat="M/d/yyyy" DisplayDateFormat="M/d/yyyy" runat="server">
</DateInput>
</telerik:RadDatePicker>
<asp:CompareValidator ID="CompareValidator3" runat="server" ErrorMessage="Admit Date cannot be less than Primary Subscriber DOB!"
ControlToValidate="priSubDOB" ControlToCompare="radAdmitDate" Operator="LessThanEqual"
Display="Dynamic" Type="Date"></asp:CompareValidator>
<asp:CompareValidator ID="CompareValidator4" runat="server" ErrorMessage="Discharge Date cannot be less than Primary Subscriber DOB!"
ControlToValidate="priSubDOB" ControlToCompare="radDischargeDate" Operator="LessThanEqual"
Display="Dynamic" Type="Date"></asp:CompareValidator>
</td>
</tr>
<tr>
<td class="td_AEV">
Sex:
</td>
<td class="td_AEVNoBold">
<asp:DropDownList ID="priSubSex" runat="server" Font-Size="8pt">
<asp:ListItem Selected="True" Text="Select" Value=""></asp:ListItem>
<asp:ListItem Text="Male" Value="M"></asp:ListItem>
<asp:ListItem Text="Female" Value="F"></asp:ListItem>
</asp:DropDownList>
</td>
</tr>
<tr>
<td class="td_AEV">
Authorization:
</td>
<td class="td_AEVNoBold">
<asp:TextBox ID="priAuthorization" runat="server" MaxLength="50" onblur="CheckForCompletedReqFlds('Pri Ins');"></asp:TextBox>
</td>
</tr>
</table>
</fieldset>
</td>
</tr>
</table>
</telerik:RadPageView>
<telerik:RadPageView ID="RadSecView" runat="server" Width="100%">
<table width="100%" bgcolor="#F6F6F6" cellpadding="0" cellspacing="0">
<tr>
<td>
<fieldset>
<legend><b><font style="font-size: x-small;">Secondary Insurance</font></b></legend>
<table width="100%" bordercolor="white" border="1" cellpadding="0" cellspacing="0">
<tr>
<td class="td_AEV" width="35%">
Ins Code *:
</td>
<td class="td_AEVNoBold">
<asp:TextBox ID="secInsCode" runat="server" AutoPostBack="true" OnTextChanged="secInsCode_OnTextChanged"
MaxLength="10"></asp:TextBox>
<asp:RequiredFieldValidator ID="rfvsecInsCode" ControlToValidate="secInsCode" ErrorMessage="Secondary Insurance: Sec Ins Code"
Display="Dynamic" Text="*" runat="server" Enabled="false" />
<asp:Button ID="btnSecSearch" runat="server" Text="Search" CausesValidation="false"
AccessKey="2" />
</td>
</tr>
<tr>
<td class="td_AEV">
Ins Name *:
</td>
<td class="td_AEVNoBold">
<asp:TextBox ID="secInsName" runat="server" ReadOnly="true" Width="225px"></asp:TextBox>
</td>
</tr>
<tr>
<td class="td_AEV">
Ins Address1 *:
</td>
<td class="td_AEVNoBold">
<asp:TextBox ID="secInsAddress1" runat="server" ReadOnly="true"></asp:TextBox>
</td>
</tr>
<tr>
<td class="td_AEV">
Ins Address2:
</td>
<td class="td_AEVNoBold">
<asp:TextBox ID="secInsAddress2" runat="server" ReadOnly="true" MaxLength="100"></asp:TextBox>
</td>
</tr>
<tr>
<td class="td_AEV">
City *:
</td>
<td class="td_AEVNoBold">
<asp:TextBox ID="secInsCity" runat="server" ReadOnly="true"></asp:TextBox>
</td>
</tr>
<tr>
<td class="td_AEV">
State *:
</td>
<td class="td_AEVNoBold">
<asp:TextBox ID="secInsState" runat="server" ReadOnly="true"></asp:TextBox>
</td>
</tr>
<tr>
<td class="td_AEV">
Zip *:
</td>
<td class="td_AEVNoBold">
<asp:TextBox ID="secInsZip" runat="server" Height="21px" ReadOnly="true" Width="70px">
</asp:TextBox>
</td>
</tr>
<tr>
<td>
</td>
</tr>
<tr>
<td class="td_AEV">
Policy # *:
</td>
<td class="td_AEVNoBold">
<asp:TextBox ID="secInsPolicyNum" runat="server" MaxLength="50"></asp:TextBox>
<asp:RequiredFieldValidator ID="rfvsecInsPolicyNum" ControlToValidate="secInsPolicyNum"
Display="Dynamic" ErrorMessage="Secondary Insurance: Policy #" Text="*" runat="server"
Enabled="false" />
</td>
</tr>
<tr>
<td class="td_AEV" valign="top">
Retype Policy #:
</td>
<td>
<asp:TextBox ID="secInsPolicyNumVer" runat="server" MaxLength="50"></asp:TextBox>
<asp:CompareValidator ID="CompareValidator10" runat="server" ErrorMessage="Secondary Insurance: Confirmation Secondary Policy Numbers NOT equal!"
Display="Dynamic" ControlToValidate="secInsPolicyNumVer" ControlToCompare="secInsPolicyNum"
Operator="Equal" Type="String"></asp:CompareValidator>
</td>
</tr>
<tr>
<td class="td_AEV">
Group # *:
</td>
<td class="td_AEVNoBold">
<asp:TextBox ID="secInsGrpNum" runat="server" MaxLength="25"></asp:TextBox>
<asp:RequiredFieldValidator ID="rfvsecInsGrpNum" ControlToValidate="secInsGrpNum"
Display="Dynamic" ErrorMessage="Secondary Insurance: Group #" Text="*" runat="server"
Enabled="false" />
</td>
</tr>
</table>
</fieldset>
</td>
</tr>
<tr>
<td>
<fieldset>
<legend><b><font style="font-size: x-small;">Secondary Subscriber Info</font></b></legend>
<table width="100%" bordercolor="white" border="1" cellpadding="0" cellspacing="0">
<tr>
<td class="td_AEV" width="35%">
Rel to Patient *:
</td>
<td class="td_AEVNoBold">
<asp:DropDownList ID="secSubRelToPat" runat="server" onchange="getSecSelectedValue();"
Font-Size="8pt" />
<asp:RequiredFieldValidator ID="rfvsecSubRelToPat" ControlToValidate="secSubRelToPat"
Enabled="false" Display="Dynamic" ErrorMessage="Secondary Subscriber Info: Rel to Patient"
Text="*" runat="server" />
</td>
</tr>
<tr>
<td class="td_AEV">
Last Name *:
</td>
<td class="td_AEVNoBold">
<asp:TextBox ID="secSubLName" runat="server" MaxLength="100"></asp:TextBox>
<asp:RequiredFieldValidator ID="rfvsecSubLName" ControlToValidate="secSubLName" Enabled="false"
Display="Dynamic" ErrorMessage="Secondary Subscriber Info: Last Name" Text="*"
runat="server" />
</td>
</tr>
<tr>
<td class="td_AEV">
First Name *:
</td>
<td class="td_AEVNoBold">
<asp:TextBox ID="secSubFName" runat="server" MaxLength="100"></asp:TextBox>
<asp:RequiredFieldValidator ID="rfvsecSubFName" ControlToValidate="secSubFName" Enabled="false"
Display="Dynamic" ErrorMessage="Secondary Subscriber Info: First Name" Text="*"
runat="server" />
</td>
</tr>
<tr>
<td class="td_AEV">
Initial:
</td>
<td class="td_AEVNoBold">
<asp:TextBox ID="secSubInitial" runat="server" MaxLength="50"></asp:TextBox>
</td>
</tr>
<tr>
<td class="td_AEV">
Address1 *:
</td>
<td class="td_AEVNoBold">
<asp:TextBox ID="secSubAddress1" runat="server" MaxLength="100"></asp:TextBox>
<asp:RequiredFieldValidator ID="rfvsecSubAddress1" ControlToValidate="secSubAddress1"
Enabled="false" Display="Dynamic" ErrorMessage="Secondary Subscriber Info: Address1"
Text="*" runat="server" />
</td>
</tr>
<tr>
<td class="td_AEV">
Address2:
</td>
<td class="td_AEVNoBold">
<asp:TextBox ID="secSubAddress2" runat="server" MaxLength="100"></asp:TextBox>
</td>
</tr>
<tr>
<td class="td_AEV">
City *:
</td>
<td class="td_AEVNoBold">
<asp:TextBox ID="secSubCity" runat="server" MaxLength="100"></asp:TextBox>
<asp:RequiredFieldValidator ID="rfvsecSubCity" ControlToValidate="secSubCity" Enabled="false"
Display="Dynamic" ErrorMessage="Secondary Subscriber Info: City" Text="*" runat="server" />
</td>
</tr>
<tr>
<td class="td_AEV">
State *:
</td>
<td class="td_AEVNoBold">
<asp:DropDownList ID="secSubState" runat="server" />
<asp:RequiredFieldValidator ID="rfvsecSubState" ControlToValidate="secSubState" Enabled="false"
Display="Dynamic" ErrorMessage="Secondary Subscriber Info: State" Text="*" runat="server" />
</td>
</tr>
<tr>
<td class="td_AEV">
Zip:
</td>
<td class="td_AEVNoBold">
<telerik:RadMaskedTextBox ID="secSubZip" runat="server" Height="21px" Mask="#####-####"
Width="70px">
</telerik:RadMaskedTextBox>
<asp:RegularExpressionValidator ID="RegularExpressionValidator22" runat="server"
ErrorMessage="Secondary Insurance: Zip Invalid!" ControlToValidate="secSubZip"
Display="Dynamic" ValidationExpression="^((\d{5}-_{0,4})|(|(\d{5}-\d{4})))$"></asp:RegularExpressionValidator>
</td>
</tr>
<tr>
<td class="td_AEV">
SSN:
</td>
<td class="td_AEVNoBold">
<telerik:RadMaskedTextBox ID="secSubSSN" runat="server" Height="20px" Mask="###-##-####"
Width="92px">
</telerik:RadMaskedTextBox>
<asp:RegularExpressionValidator ID="RegularExpressionValidator23" runat="server"
Display="Dynamic" ErrorMessage="Secondary Insurance: SSN Invalid!" ValidationExpression="^\d{3}-\d{2}-\d{4}$"
ControlToValidate="secSubSSN"></asp:RegularExpressionValidator>
</td>
</tr>
<tr>
<td class="td_AEV" valign="top">
DOB:
</td>
<td class="td_AEVNoBold">
<telerik:RadDatePicker ID="secSubDOB" runat="server">
<DateInput ID="DateInput2" DateFormat="M/d/yyyy" DisplayDateFormat="M/d/yyyy" runat="server">
</DateInput>
</telerik:RadDatePicker>
<asp:CompareValidator ID="CompareValidator5" runat="server" ErrorMessage="Admit Date cannot be less than Secondary Subscriber DOB!"
ControlToValidate="secSubDOB" ControlToCompare="radAdmitDate" Operator="LessThanEqual"
Display="Dynamic" Type="Date"></asp:CompareValidator>
<asp:CompareValidator ID="CompareValidator6" runat="server" ErrorMessage="Discharge Date cannot be less than Secondary Subscriber DOB!"
ControlToValidate="secSubDOB" ControlToCompare="radDischargeDate" Operator="LessThanEqual"
Display="Dynamic" Type="Date"></asp:CompareValidator>
</td>
</tr>
<tr>
<td class="td_AEV">
Sex:
</td>
<td class="td_AEVNoBold">
<asp:DropDownList ID="secSubSex" runat="server">
<asp:ListItem Selected="True" Text="Select" Value=""></asp:ListItem>
<asp:ListItem Text="Male" Value="M"></asp:ListItem>
<asp:ListItem Text="Female" Value="F"></asp:ListItem>
</asp:DropDownList>
</td>
</tr>
<tr>
<td class="td_AEV">
Authorization:
</td>
<td class="td_AEVNoBold">
<asp:TextBox ID="secAuthorization" runat="server" MaxLength="50" onblur="CheckForCompletedReqFlds('Sec Ins');"></asp:TextBox>
</td>
</tr>
</table>
</fieldset>
</td>
</tr>
</table>
</telerik:RadPageView>
<telerik:RadPageView ID="RadTerView" runat="server" Width="100%">
<table width="100%" bgcolor="#F6F6F6" cellpadding="0" cellspacing="0">
<tr>
<td>
<fieldset>
<legend><b><font style="font-size: x-small;">Tertiary Insurance</font></b></legend>
<table width="100%" bordercolor="white" border="1" cellpadding="0" cellspacing="0">
<tr>
<td class="td_AEV" width="35%">
Ins Code *:
</td>
<td class="td_AEVNoBold">
<asp:TextBox ID="terInsCode" runat="server" AutoPostBack="true" OnTextChanged="terInsCode_OnTextChanged"
MaxLength="10"></asp:TextBox>
<asp:RequiredFieldValidator ID="rfvterInsCode" ControlToValidate="terInsCode" ErrorMessage="Tertiary Insurance: Ter Ins Code"
Display="Dynamic" Text="*" runat="server" Enabled="false" />
<asp:Button ID="btnTerSearch" runat="server" Text="Search" CausesValidation="false"
AccessKey="3" />
</td>
</tr>
<tr>
<td class="td_AEV">
Ins Name *:
</td>
<td class="td_AEVNoBold">
<asp:TextBox ID="terInsName" runat="server" ReadOnly="true" Width="225px"></asp:TextBox>
</td>
</tr>
<tr>
<td class="td_AEV">
Ins Address1 *:
</td>
<td class="td_AEVNoBold">
<asp:TextBox ID="terInsAddress1" runat="server" ReadOnly="true"></asp:TextBox>
</td>
</tr>
<tr>
<td class="td_AEV">
Ins Address2:
</td>
<td class="td_AEVNoBold">
<asp:TextBox ID="terInsAddress2" runat="server" ReadOnly="true"></asp:TextBox>
</td>
</tr>
<tr>
<td class="td_AEV">
City *:
</td>
<td class="td_AEVNoBold">
<asp:TextBox ID="terInsCity" runat="server" ReadOnly="true"></asp:TextBox>
</td>
</tr>
<tr>
<td class="td_AEV">
State *:
</td>
<td class="td_AEVNoBold">
<asp:TextBox ID="terInsState" runat="server" ReadOnly="true"></asp:TextBox>
</td>
</tr>
<tr>
<td class="td_AEV">
Zip *:
</td>
<td class="td_AEVNoBold">
<asp:TextBox ID="terInsZip" runat="server" Height="21px" ReadOnly="true" Width="70px">
</asp:TextBox>
</td>
</tr>
<tr>
<td>
</td>
</tr>
<tr>
<td class="td_AEV">
Policy # *:
</td>
<td class="td_AEVNoBold">
<asp:TextBox ID="terInsPolicyNum" runat="server" MaxLength="50"></asp:TextBox>
<asp:RequiredFieldValidator ID="rfvterInsPolicyNum" ControlToValidate="terInsPolicyNum"
Display="Dynamic" ErrorMessage="Tertiary Insurance: Policy #" Text="*" runat="server"
Enabled="false" />
</td>
</tr>
<tr>
<td class="td_AEV" valign="top">
Retype Policy #:
</td>
<td>
<asp:TextBox ID="terInsPolicyNumVer" runat="server" MaxLength="50"></asp:TextBox>
<asp:CompareValidator ID="CompareValidator11" runat="server" ErrorMessage="Tertiary Insurance: Confirmation Tertiary Policy Numbers NOT equal!"
ControlToValidate="terInsPolicyNumVer" ControlToCompare="terInsPolicyNum" Operator="Equal"
Display="Dynamic" Type="String"></asp:CompareValidator>
</td>
</tr>
<tr>
<td class="td_AEV">
Group # *:
</td>
<td class="td_AEVNoBold">
<asp:TextBox ID="terInsGrpNum" runat="server" MaxLength="25"></asp:TextBox>
<asp:RequiredFieldValidator ID="rfvterInsGrpNum" ControlToValidate="terInsGrpNum"
Display="Dynamic" ErrorMessage="Tertiary Insurance: Group #" Text="*" runat="server"
Enabled="false" />
</td>
</tr>
</table>
</fieldset>
</td>
</tr>
<tr>
<td>
<fieldset>
<legend><b><font style="font-size: x-small;">Tertiary Subscriber Info</font></b></legend>
<table width="100%" bordercolor="white" border="1">
<tr>
<td class="td_AEV" width="35%">
Rel to Patient *:
</td>
<td class="td_AEVNoBold">
<asp:DropDownList ID="terSubRelToPat" runat="server" onchange="getTerSelectedValue();"
Font-Size="8pt" />
<asp:RequiredFieldValidator ID="rfvterSubRelToPat" ControlToValidate="terSubRelToPat"
Enabled="false" Display="Dynamic" ErrorMessage="Tertiary Subscriber Info: Rel to Patient"
Text="*" runat="server" />
</td>
</tr>
<tr>
<td class="td_AEV">
Last Name *:
</td>
<td class="td_AEVNoBold">
<asp:TextBox ID="terSubLName" runat="server" MaxLength="100"></asp:TextBox>
<asp:RequiredFieldValidator ID="rfvterSubLName" ControlToValidate="terSubLName" Enabled="false"
Display="Dynamic" ErrorMessage="Tertiary Subscriber Info: Last Name" Text="*"
runat="server" />
</td>
</tr>
<tr>
<td class="td_AEV">
First Name *:
</td>
<td class="td_AEVNoBold">
<asp:TextBox ID="terSubFName" runat="server" MaxLength="100"></asp:TextBox>
<asp:RequiredFieldValidator ID="rfvterSubFName" ControlToValidate="terSubFName" Enabled="false"
Display="Dynamic" ErrorMessage="Tertiary Subscriber Info: First Name" Text="*"
runat="server" />
</td>
</tr>
<tr>
<td class="td_AEV">
Initial:
</td>
<td class="td_AEVNoBold">
<asp:TextBox ID="terSubInitial" runat="server" MaxLength="50"></asp:TextBox>
</td>
</tr>
<tr>
<td class="td_AEV">
Address1 *:
</td>
<td class="td_AEVNoBold">
<asp:TextBox ID="terSubAddress1" runat="server" MaxLength="100"></asp:TextBox>
<asp:RequiredFieldValidator ID="rfvterSubAddress1" ControlToValidate="terSubAddress1"
Enabled="false" Display="Dynamic" ErrorMessage="Tertiary Subscriber Info: Address1"
Text="*" runat="server" />
</td>
</tr>
<tr>
<td class="td_AEV">
Address2:
</td>
<td class="td_AEVNoBold">
<asp:TextBox ID="terSubAddress2" runat="server" MaxLength="100"></asp:TextBox>
</td>
</tr>
<tr>
<td class="td_AEV">
City *:
</td>
<td class="td_AEVNoBold">
<asp:TextBox ID="terSubCity" runat="server" MaxLength="100"></asp:TextBox>
<asp:RequiredFieldValidator ID="rfvterSubCity" ControlToValidate="terSubCity" Enabled="false"
Display="Dynamic" ErrorMessage="Tertiary Subscriber Info: City" Text="*" runat="server" />
</td>
</tr>
<tr>
<td class="td_AEV">
State *:
</td>
<td class="td_AEVNoBold">
<asp:DropDownList ID="terSubState" runat="server" />
<asp:RequiredFieldValidator ID="rfvterSubState" ControlToValidate="terSubState" Enabled="false"
Display="Dynamic" ErrorMessage="Tertiary Subscriber Info: State" Text="*" runat="server" />
</td>
</tr>
<tr>
<td class="td_AEV">
Zip:
</td>
<td class="td_AEVNoBold">
<telerik:RadMaskedTextBox ID="terSubZip" runat="server" Height="21px" Mask="#####-####"
Width="70px">
</telerik:RadMaskedTextBox>
<asp:RegularExpressionValidator ID="RegularExpressionValidator25" runat="server"
ErrorMessage="Tertiary Insurance: Zip Invalid!" ControlToValidate="terSubZip"
Display="Dynamic" ValidationExpression="^((\d{5}-_{0,4})|(|(\d{5}-\d{4})))$"></asp:RegularExpressionValidator>
</td>
</tr>
<tr>
<td class="td_AEV">
SSN:
</td>
<td class="td_AEVNoBold">
<telerik:RadMaskedTextBox ID="terSubSSN" runat="server" Height="20px" Mask="###-##-####"
Width="92px">
</telerik:RadMaskedTextBox>
<asp:RegularExpressionValidator ID="RegularExpressionValidator26" runat="server"
Display="Dynamic" ErrorMessage="Tertiary Insurance: SSN Invalid!" ValidationExpression="^\d{3}-\d{2}-\d{4}$"
ControlToValidate="terSubSSN"></asp:RegularExpressionValidator>
</td>
</tr>
<tr>
<td class="td_AEV" valign="top">
DOB:
</td>
<td class="td_AEVNoBold">
<telerik:RadDatePicker ID="terSubDOB" runat="server">
<DateInput ID="DateInput3" DateFormat="M/d/yyyy" DisplayDateFormat="M/d/yyyy" runat="server">
</DateInput>
</telerik:RadDatePicker>
<asp:CompareValidator ID="CompareValidator7" runat="server" ErrorMessage="Admit Date cannot be less than Tertiary Subscriber DOB!"
ControlToValidate="terSubDOB" ControlToCompare="radAdmitDate" Operator="LessThanEqual"
Display="Dynamic" Type="Date"></asp:CompareValidator>
<asp:CompareValidator ID="CompareValidator8" runat="server" ErrorMessage="Discharge Date cannot be less than Tertiary Subscriber DOB!"
ControlToValidate="terSubDOB" ControlToCompare="radDischargeDate" Operator="LessThanEqual"
Display="Dynamic" Type="Date"></asp:CompareValidator>
</td>
</tr>
<tr>
<td class="td_AEV">
Sex:
</td>
<td class="td_AEVNoBold">
<asp:DropDownList ID="terSubSex" runat="server">
<asp:ListItem Selected="True" Text="Select" Value=""></asp:ListItem>
<asp:ListItem Text="Male" Value="M"></asp:ListItem>
<asp:ListItem Text="Female" Value="F"></asp:ListItem>
</asp:DropDownList>
</td>
</tr>
<tr>
<td class="td_AEV">
Authorization:
</td>
<td class="td_AEVNoBold">
<asp:TextBox ID="terAuthorization" runat="server" MaxLength="50" onblur="CheckForCompletedReqFlds('Ter Ins');"></asp:TextBox>
</td>
</tr>
</table>
</fieldset>
</td>
</tr>
</table>
</telerik:RadPageView>
</telerik:RadMultiPage>
</div>
</td>
</tr>
</table>
</td>
</tr>
<tr bgcolor="#ffffff">
<td colspan="3" align="center">
<div id="msg">
</div>
</td>
</tr>
<tr>
<td colspan="3">
<table cellpadding="1" cellspacing="1" width="100%" id="tblEntry">
<tr>
<td bgcolor="#f0f0f0" colspan="2" align="center">
<asp:Button ID="btnSaveLogEntry" runat="server" Text="Save Log Entry" Enabled="true"
AccessKey="L" Style="width: 150px; font-size: x-smaller; color: #fe8e14; font-style: italic;
font-family: Arial Black; font-weight: bold;" OnClick="btnSaveLogEntry_Click"
OnClientClick="CheckForOtherIns();" />
<asp:Button ID="btnVoid" runat="server" Text="VOID" AccessKey="V" CausesValidation="false"
Style="width: 150px; font-size: x-smaller; color: #fe8e14; font-style: italic;
font-family: Arial Black; font-weight: bold;" />
<asp:Button ID="btnPend" runat="server" Text="PEND" AccessKey="N" CausesValidation="false"
Style="width: 150px; font-size: x-smaller; color: #fe8e14; font-style: italic;
font-family: Arial Black; font-weight: bold;" />
<asp:Button ID="btnDEF" runat="server" Text="DEF" AccessKey="F" CausesValidation="false"
Style="width: 150px; font-size: x-smaller; color: #fe8e14; font-style: italic;
font-family: Arial Black; font-weight: bold;" />
<br />
<div id="testBlock" runat="server">
<input type="button" id="doIT" onclick="PatientLoad();" style="width: 1px; height: 1px" />
</div>
<asp:ValidationSummary ID="ValidationSummary1" runat="server" DisplayMode="BulletList"
ShowMessageBox="true" ShowSummary="false" EnableClientScript="true" HeaderText="You must enter a value in the following fields:" />
</td>
</tr>
</table>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
</table>
</fieldset>
</td>
</tr>
<telerik:RadAjaxLoadingPanel ID="LoadingPanel1" runat="server" BackgroundPosition="Center"
Skin="Windows7">
<asp:Image ID="Image1" runat="server" ImageUrl="~/Images/Windows7.gif"></asp:Image>
</telerik:RadAjaxLoadingPanel>
</table>
<telerik:RadCodeBlock ID="RadCodeBlock2" runat="server">
<script language="javascript">
var frmScan = document.forms['frmPatientDemo'];
document.getElementById("btnSaveLogEntry").disabled = true;
var td = document.getElementById("tdThumbNails");
var hdnImageName = document.getElementById("<%= hdnImageName.ClientID %>");
var hdnImageURL = document.getElementById("<%= hdnImageURL.ClientID %>");
function waitForPageLoad() {
while ((typeof document.getElementById("DynamicWebTwain1") == 'undefined') &&
(typeof document.getElementById("hdnImageURL") == 'undefined') &&
(typeof document.getElementById("hdnImageName") == 'undefined')) { }
document.getElementById("doIT").click();
}
setTimeout("waitForPageLoad()", 1000);
</script>
</telerik:RadCodeBlock>
</form>
</body>
</html>
Unsupported scenarios
There are several limitations that you should have in mind. They are caused by the complexity and specifics of the frozen columns feature, which is implemented by means of hiding and showing columns, instead of actually scrolling them.
Please let us know if there are any workarounds for each of the mentioned issues. We seriously need some solution about these issues, specially the ones which have comments in brackets next to it. We want to know if these issues will be addressed in the next versions. These are Bottleneck for us to use in our application
Thanks and Regards
Nabeel Faruqui