I have confirmed that the image exists in the proper path. I have a RadScriptManager on my Master page. Here is the full HTML. Scroll all the way down near the bottom in bold to see the control. I also have a RadAjaxManager in place (see bolding). Note that the page works absolutely fine; I just can't get the image to appear... What do I need to do in order for it to appear?
<%@ 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>