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general_new.html
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general_new.html
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<html>
<head>
{literal}
<style>
<!--
td {
font-size:12pt;
font-family:helvetica;
}
li{
font-size:11pt;
font-family:helvetica;
margin-left: 15px;
}
a {
font-size:11pt;
font-family:helvetica;
}
.title {
font-family: sans-serif;
font-size: 12pt;
font-weight: bold;
text-decoration: none;
color: #000000;
}
.form_text{
font-family: sans-serif;
font-size: 9pt;
text-decoration: none;
color: #000000;
}
-->
</style>
{/literal}
</head>
<body bgcolor="{$STYLE.BGCOLOR2|attr}">
<p><span class="title">Prior Authorization Form</span></p>
<form name="prior_auth" method="post" action="{$FORM_ACTION}/interface/forms/prior_auth/save.php">
<table>
<tr>
<td>Prior Authorization Number</td><td><input type="text" size="35" name="prior_auth_number" value="{$prior_auth->get_prior_auth_number()|attr}"></td>
</tr>
<tr>
<td><br /><br />Comments</td>
</tr>
<tr>
<td colspan="2"><textarea name="comments" value="{$prior_auth->get_comments()|attr}" wrap="virtual" cols="75" rows="8">{$prior_auth->get_comments()|text}</textarea></td>
</tr>
{if $VIEW != true}
<tr>
<td><br /><br /><input type="submit" name="Submit" value="Save Form"> <a href="{$DONT_SAVE_LINK}" class="link">[Don't Save]</a></td>
</tr>
{/if}
</table>
<input type="hidden" name="id" value="{$prior_auth->get_id()|attr}" />
<input type="hidden" name="activity" value="{$prior_auth->get_activity()|attr}">
<input type="hidden" name="pid" value="{$prior_auth->get_pid()|attr}">
<input type="hidden" name="process" value="true">
</form>
</body>
</html>