File: /home/imensosw/www/imenso.co/dev/prc/profile.html
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<html lang="en-US" >
<head>
<meta charset="UTF-8">
<meta name="viewport" content="width=device-width, initial-scale=1">
<link rel="profile" href="http://gmpg.org/xfn/11">
<title>Patient Portal</title>
<link rel='stylesheet' href='css/bootstrap.min.css' media='all' />
<link rel='stylesheet' href='css/style-2.css' media='all' />
<link rel='stylesheet' href='css/responsive.css' media='all' />
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<script src="js/jquery.min.js"></script>
<script src="js/bootstrap.min.js"></script>
<script src="js/popover.js"></script>
<script>
$(function(){
$("#includedContent").load("sidebar.html");
setTimeout(function(){
$('.sidebar_nav a').removeClass('active');
$('.sidebar_nav a').eq(1).addClass('active');
},100);
});
</script>
</head>
<body style="background: #F0F4F7;">
<!-- Add new insurance -->
<div class="modal fade" id="newInsurance" tabindex="-1" role="dialog" aria-labelledby="exampleModalLabel" aria-hidden="true">
<div class="modal-dialog" role="document">
<div class="modal-content">
<div class="modal-header">
<h5 class="modal-title" id="exampleModalLabel">Add New Insurance</h5>
<button type="button" class="close" data-dismiss="modal" aria-label="Close">
<span aria-hidden="true">×</span>
</button>
</div>
<div class="modal-body">
<form>
<div class="form-group">
<input type="text" class="form-control" id="" aria-describedby="emailHelp" placeholder="Carrier Name">
</div>
<div class="form-group">
<input type="text" class="form-control" id="" placeholder="Effective Date ">
</div>
<div class="form-group">
<input type="text" class="form-control" id="" placeholder="Group Number ">
</div>
<div class="form-group">
<input type="text" class="form-control" id="" placeholder="Subscriber Name">
</div>
<div class="form-group">
<input type="text" class="form-control" id="" placeholder="Identification Number ">
</div>
<div class="form-group">
<input type="text" class="form-control" id="" placeholder="Claims Address ">
</div>
<div class="form-group">
<input type="text" class="form-control" id="" placeholder="Phone ">
</div>
</form>
</div>
<div class="modal-footer">
<button type="button" class="btn btn-login">Submit</button>
</div>
</div>
</div>
</div>
<!-- Update Contact Information -->
<div class="modal fade" id="updateContact" tabindex="-1" role="dialog" aria-labelledby="exampleModalLabel" aria-hidden="true">
<div class="modal-dialog" role="document">
<div class="modal-content">
<div class="modal-header">
<h5 class="modal-title" id="exampleModalLabel">Update Contact Information</h5>
<button type="button" class="close" data-dismiss="modal" aria-label="Close">
<span aria-hidden="true">×</span>
</button>
</div>
<div class="modal-body">
<form>
<div class="form-group">
<input type="text" class="form-control" id="" aria-describedby="emailHelp" placeholder="Name" value="John Smith">
</div>
<div class="form-group">
<input type="text" class="form-control" id="" placeholder="Account No." value="5876255">
</div>
<div class="form-group">
<input type="email" class="form-control" id="" placeholder="E-mail" value="johnsmith@mps.com">
</div>
<div class="form-group">
<input type="text" class="form-control" id="" placeholder="Phone" value="999-999-9999">
</div>
<div class="form-group">
<textarea class="form-control" id="" placeholder="Address" value="">123 MAIN ST GLENDALE AZ, 85304 </textarea>
</div>
</form>
</div>
<div class="modal-footer">
<button type="button" class="btn btn-login">Update</button>
</div>
</div>
</div>
</div>
<!-- Update Password Information -->
<div class="modal fade" id="ChangePassword" tabindex="-1" role="dialog" aria-labelledby="exampleModalLabel" aria-hidden="true">
<div class="modal-dialog" role="document">
<div class="modal-content">
<div class="modal-header">
<h5 class="modal-title" id="exampleModalLabel">Reset Password</h5>
<button type="button" class="close" data-dismiss="modal" aria-label="Close">
<span aria-hidden="true">×</span>
</button>
</div>
<div class="modal-body">
<form>
<div class="form-group">
<label>Old Password</label>
<input type="Password" class="form-control" id="" placeholder="**********">
</div>
<div class="form-group">
<label>New Password</label>
<input type="Password" class="form-control" id="" placeholder="---">
</div>
<div class="form-group">
<label>Re-Enter Password</label>
<input type="Password" class="form-control" id="" placeholder="---">
</div>
</form>
</div>
<div class="modal-footer">
<button type="button" class="btn btn-login">Update Password</button>
</div>
</div>
</div>
</div>
<!-- Update insurance -->
<div class="modal fade" id="updateInsurance" tabindex="-1" role="dialog" aria-labelledby="exampleModalLabel" aria-hidden="true">
<div class="modal-dialog" role="document">
<div class="modal-content">
<div class="modal-header">
<h5 class="modal-title" id="exampleModalLabel">Update Insurance</h5>
<button type="button" class="close" data-dismiss="modal" aria-label="Close">
<span aria-hidden="true">×</span>
</button>
</div>
<div class="modal-body">
<form>
<div class="form-group">
<input type="text" class="form-control" id="" aria-describedby="emailHelp" placeholder="Carrier Name" value="Good Health">
</div>
<div class="form-group">
<input type="text" class="form-control" id="" placeholder="Effective Date" value="1/1/2018">
</div>
<div class="form-group">
<input type="text" class="form-control" id="" placeholder="Group Number " value="322">
</div>
<div class="form-group">
<input type="text" class="form-control" id="" placeholder="Subscriber Name" value="John Smith">
</div>
<div class="form-group">
<input type="text" class="form-control" id="" placeholder="Identification Number " value="7894562">
</div>
<div class="form-group">
<input type="text" class="form-control" id="" placeholder="Claims Address " value="LAS VEGAS">
</div>
<div class="form-group">
<input type="text" class="form-control" id="" placeholder="Phone " value="987-654-3210">
</div>
</form>
</div>
<div class="modal-footer">
<button type="button" class="btn btn-login">Update</button>
</div>
</div>
</div>
</div>
<div class="container-fluid">
<div id="includedContent"></div>
<div class="right right_panel animate dashboard">
<div class="m-5">
<div class="container-fluid">
<div class="row">
<div class="col-md-12 mb-3 header_area">
<div class="d-flex justify-content-between align-items-center">
<h4 calss="mb-0">Profile</h4>
<!-- <a href="javascript:;" data-toggle="modal" data-target="#newInsurance" class="btn btn btn-secondary"><i class="fa fa-plus"></i> Add New Insurance</a> -->
</div>
<hr>
</div>
</div>
<div class="row profie_edit">
<div class="col-md-12">
<div class="clear-fix"> </div>
<div class="card">
<div class="card-header green-bg-g">
<div class="d-flex justify-content-between align-items-center">
<h4>Contact Information</h4>
<a class="" data-toggle="modal" data-target="#updateContact" href="javascript:;"><i class="fa fa-pencil white-text"></i></a>
</div>
</div>
<div class="card-body">
<table class="table">
<tr>
<td><strong class="big-text">John Smith</strong><br>
<!-- <span class="opaq">Account #5876255</span> -->
<br><br>
123 MAIN ST<br>
GLENDALE AZ, 85304
</td>
<td class="text-right">
<span class="opaq">E-mail: Johnsmith@mps.com</span><br>
<span class="opaq">Phone: 999-999-9999</span><br>
<span class="opaq">Password: *******</span><br> <a class="" data-toggle="modal" data-target="#ChangePassword" href="javascript:;">Change Password</a>
<!-- <span class="badge badge-success">Subscribed</span> -->
</td>
</tr>
</table>
<div class="p-3">
<div class="outerDivFull d-flex align-items-center" >
<p class="mb-0 mr-3" > Sign up for E-Statements</p>
<div class="switchToggle">
<input type="checkbox" checked="" id="switch">
<label for="switch" class="mb-0">Toggle</label>
</div>
</div>
</div>
</div>
</div>
<!-- <div class="row">
<div class="col-md-6">
<div class="card b-r-4">
<div class="card-header" id="primary_indurance">
<div class="d-flex justify-content-between align-items-center">
<a href="javascript:;" data-toggle="collapse" data-target="#collapseOne" aria-expanded="true" aria-controls="collapseOne"> <h4>Primary Insurance</h4> </a>
<a href="javascript:;" data-toggle="modal" data-target="#updateInsurance" class="edit_field"> <i class="fa fa-pencil"></i> </a>
</div>
</div>
<div class="card-body">
<table class="table">
<tr>
<td> <span class="opaq">Carrier Name </span></td>
<td style="text-align: right;"> <strong>John Smith</strong> <input type="text" value="Good Health" name=""> </td>
</tr>
<tr>
<td><span class="opaq">Effective Date </span></td>
<td style="text-align: right;"> <strong>1/1/2019</strong> <input type="text" value="1/1/2018" name=""> </td>
</tr>
<tr>
<td><span class="opaq">Group Number </span> </td>
<td style="text-align: right;"> <strong>322</strong> <input type="text" value="322" name=""> </td>
</tr>
<tr>
<td><span class="opaq">Subscriber Name </span> </td>
<td style="text-align: right;"> <strong>John Smith</strong> <input type="text" value="SMITH JOHN" name=""> </td>
</tr>
<tr>
<td><span class="opaq">Identification Number </span> </td>
<td style="text-align: right;"> <strong>7894562</strong> <input type="text" value="7894562" name=""> </td>
</tr>
<tr>
<td><span class="opaq">Claims Address </span> </td>
<td style="text-align: right;"> <strong>LAS VEGAS</strong> <input type="text" value="LOS VEGAS" name=""> </td>
</tr>
<tr>
<td><span class="opaq">Phone </span> </td>
<td style="text-align: right;"> <strong>987-654-3210</strong> <input type="text" value="987-654-3210" name=""> </td>
</tr>
</table>
</div>
</div>
</div>
<div class="col-md-6">
<div class="card b-r-4">
<div class="card-header" id="secondary_indurance">
<div class="d-flex justify-content-between align-items-center">
<a href="javascript:;" data-toggle="collapse" data-target="#collapseTwo" aria-expanded="false" aria-controls="collapseTwo"> <h4>Secondary Insurance</h4> </a>
<a href="javascript:;" data-toggle="modal" data-target="#updateInsurance" class="edit_field"> <i class="fa fa-pencil"></i> </a>
</div>
</div>
<div class="card-body">
<table class="table">
<tr>
<td> <span class="opaq">Carrier Name </span></td>
<td style="text-align: right;"> <strong>Good Health</strong> <input type="text" value="ABC" name=""> </td>
</tr>
<tr>
<td><span class="opaq">Effective Date </span></td>
<td style="text-align: right;"> <strong>1/1/2019</strong> <input type="text" value="1/1/2018" name=""> </td>
</tr>
<tr>
<td><span class="opaq">Group Number </span> </td>
<td style="text-align: right;"> <strong>322</strong> <input type="text" value="322" name=""> </td>
</tr>
<tr>
<td><span class="opaq">Subscriber Name </span> </td>
<td style="text-align: right;"> <strong>SMITH JOHN</strong> <input type="text" value="Jane Smith" name=""> </td>
</tr>
<tr>
<td><span class="opaq">Identification Number </span> </td>
<td style="text-align: right;"> <strong>7894562</strong> <input type="text" value="7894562" name=""> </td>
</tr>
<tr>
<td><span class="opaq">Claims Address </span> </td>
<td style="text-align: right;"> <strong>LAS VEGAS</strong> <input type="text" value="LOS VEGAS" name=""> </td>
</tr>
<tr>
<td><span class="opaq">Phone </span> </td>
<td style="text-align: right;"> <strong>987-654-3210</strong> <input type="text" value="987-654-3210" name=""> </td>
</tr>
</table>
</div>
</div>
</div> -->
</div>
</div>
</div>
</div>
</div>
</div>
<script type="text/javascript">
//.edit_field
$(".edit_field").click(function(){
//alert($( this).next( ".collapse" ).html());
});
</script>
</body>
</html>