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<%@LANGUAGE="VBSCRIPT" CODEPAGE="65001"%>
<!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>
<meta http-equiv="Content-Type" content="text/html; charset=utf-8" />
<title>Attach a Document</title>
<script type="text/javascript">
function hide(id){
document.getElementById(id).style.display='none';
}
function show(id){
document.getElementById(id).style.display='';//'block'
}</script>
<style type="text/css">
<!--
#pageHeader { color: #FF9900; height: 18px; padding-top: 3px; padding-bottom: 3px; margin-top: 5px; margin-left: 5px; vertical-align: middle; text-align:left; font: bold 16px Arial, Helvetica, sans-serif; margin-bottom: 20px; }
#container ul { list-style: none; padding: 3px; margin: 0px; }
#upload table { margin-left: auto; margin-right: auto; width: 700px; }
#container { font-family: Arial, Helvetica, sans-serif; width: 900px; }
#options { width: 610px; margin-right: auto; margin-left: auto; font-weight: bold; }
#upload { width: 700px; margin-right: auto; margin-left: auto; font-weight: bold; }
#container li { display: inline; margin-right: 25px; }
/*#textfield { font-family: Arial, Helvetica, sans-serif; font-size: 11px; color: #000000; height: 15px; border: 1px solid #6699CC; }*/
.dataHeader { font-weight: bold; color: #000000; line-height: 22px; text-indent: 2px; vertical-align: middle; text-align: left; background-color: #C3DEF9; padding: 1px; }
#upload table { font-weight: normal; }
-->
</style>
<link href="../HFPM_hybrid.css" rel="stylesheet" type="text/css" />
</head>
<body>
<div id="container">
<div id="pageHeader">Attach a Document</div>
<form action="" method="post" enctype="multipart/form-data" name="form1" id="form1">
<div id="options">
<div style="margin-left:auto; margin-right:auto; width:610px; margin-bottom:20px;" class="instructions" >
<ul>
<li> <input name="radio" type="radio" id="radio" checked="checked" onclick="hide('upload');show('options')" />
Browse your computer and upload a file</li>
<li> -OR- </li>
<li> <input type="radio" name="radio" id="radio2" onclick="hide('options');show('upload')" />
Select a file from your document library </li>
</ul>
</div>
<table cellpadding="1" cellspacing="1" style="width:450px; margin-left:10px;">
<tr>
<td>File Location</td>
<td><input type="file" name="fileField" id="fileField" /></td>
</tr>
<tr>
<td>Document Type</td>
<td><select name="select" id="select" style="width:200px;">
<option>Patient Form</option>
</select>
</td>
</tr>
<tr>
<td>Title</td>
<td><input name="textfield2" type="text" class="formfield" id="textfield2" style="width:250px;" value="Family History Form" /></td>
</tr>
<tr>
<td>Document Date</td>
<td><input name="textfield3" type="text" class="formfield" id="textfield3" value="04/28/2009" />
<img src="../images/icon_calendar.png" width="18" height="16" /></td>
</tr>
<tr>
<td>Review Required</td>
<td><select name="select2" id="select2" style="width:200px;">
<option>NO REVIEW REQUIRED</option>
<option selected="selected">JOHNSON, JACK</option>
<option>SMITH, MIKE</option>
</select>
</td>
</tr>
</table>
<div style="background-color:#e5e5e5; margin-top:25px;">
<div style="margin-left:auto; margin-right:auto; width:150px; padding-top:10px; padding-bottom:10px;">
<input name="button3" type="button" class="frmButton" id="button3" value="Upload" />
<input name="button4" type="button" class="frmButton" id="button4" value="Cancel" onclick="javascript:window.close();" />
</div>
</div>
</div>
<div id="upload" style="display:none;">
<div style="margin-left:auto; margin-right:auto; width:610px; margin-bottom:20px;" class="instructions" >
<ul>
<li>
<input type="radio" name="radio2" id="radio3" onclick="hide('upload');show('options')" />
Browse your computer and upload a file</li>
<li> -OR- </li>
<li>
<input name="radio2" type="radio" id="radio4" checked="checked" onclick="hide('options');show('upload')" />
Select a file from your document library </li>
</ul>
</div>
<table cellspacing="1" cellpadding="1">
<tr>
<td colspan="7" style="text-align:right"><strong>Filter by:</strong> <select name="select3" id="select3">
<option>ALL DOCUMENT TYPES</option>
</select></td>
</tr>
<tr>
<td align="center" style="background-color:#C3DEF9"><input name="checkbox" type="checkbox" id="checkbox" /></td>
<td class="dataHeader">Title</td>
<td class="dataHeader">Document Type</td>
<td class="dataHeader">Review Required</td>
<td class="dataHeader">Document Date</td>
<td width="75" class="dataHeader">Size</td>
<td class="dataHeader">Upload Date</td>
</tr>
<tr>
<td align="center" class="datacell"><input type="checkbox" name="checkbox2" id="checkbox2" /></td>
<td class="datacell">Family History Form - 00123</td>
<td class="datacell">PATIENT FORM</td>
<td class="datacell">JOHNSON, JACK</td>
<td class="datacell">04/28/2009</td>
<td class="datacell">233 KB</td>
<td class="datacell">04/28/2009</td>
</tr>
<tr>
<td align="center" class="datacell2"><input type="checkbox" name="checkbox3" id="checkbox3" /></td>
<td class="datacell2">LABCORP_06542335987</td>
<td class="datacell2">LAB RESULT</td>
<td class="datacell2">SMITH, MIKE</td>
<td class="datacell2">04/28/2009</td>
<td class="datacell2">1.4 MB</td>
<td class="datacell2">04/28/2009</td>
</tr>
<tr>
<td align="center" class="datacell"><input type="checkbox" name="checkbox4" id="checkbox4" /></td>
<td class="datacell">Care Plan - Diabetes Type I</td>
<td class="datacell">TEMPLATE</td>
<td class="datacell">NOT REQUIRED</td>
<td class="datacell"> </td>
<td class="datacell">186 KB</td>
<td class="datacell">04/28/2009</td>
</tr>
<tr>
<td align="center" class="datacell2"><input type="checkbox" name="checkbox5" id="checkbox5" /></td>
<td class="datacell2">Family History Form - 00124</td>
<td class="datacell2">PATIENT FORM</td>
<td class="datacell2">SMITH, MIKE</td>
<td class="datacell2">04/27/2009</td>
<td class="datacell2">233 KB</td>
<td class="datacell2">04/27/2009</td>
</tr>
<tr>
<td align="center" class="datacell"><input type="checkbox" name="checkbox6" id="checkbox6" /></td>
<td class="datacell">HIPAA Consent - 006543</td>
<td class="datacell">PATIENT FORM</td>
<td class="datacell">NOT REQUIRED</td>
<td class="datacell">04/27/2009</td>
<td class="datacell">233 KB</td>
<td class="datacell">04/27/2009</td>
</tr>
<tr>
<td align="center" class="datacell2"><input type="checkbox" name="checkbox7" id="checkbox7" /></td>
<td class="datacell2">Family History Form - 00120</td>
<td class="datacell2">PATIENT FORM</td>
<td class="datacell2">JOHNSON, JACK</td>
<td class="datacell2">04/26/2009</td>
<td class="datacell2">233 KB</td>
<td class="datacell2">04/26/2009</td>
</tr>
</table>
<div style="background-color:#e5e5e5; margin-top:25px;">
<div style="margin-left:auto; margin-right:auto; width:160px; padding-top:10px; padding-bottom:10px;">
<input name="button3" type="button" class="frmButton" id="button3" value="Attach Selected" style="width:100px;" />
<input name="button4" type="button" class="frmButton" id="button4" value="Cancel" onclick="javascript:window.close();" />
</div>
</div>
</div>
</form>
</div>
</body>
</html>
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