<?php
/**
 * Default Pre-Authorization Form Fields
 * Used for insurance providers without specific templates
 */

// Prevent direct access
if (!defined('PREAUTH_FORM_INCLUDE')) {
    exit('Direct access not allowed');
}
?>

<!-- Default Insurer-Specific Fields -->
<div class="form-section insurer-specific-section" id="defaultFormFields">
    <div class="form-section-title">
        <i class="ri-file-list-3-line"></i> Additional Information
    </div>

    <div class="row">
        <div class="col-md-12">
            <div class="mb-3">
                <label class="form-label">Clinical Summary</label>
                <textarea class="form-control" name="preauth_data[clinical_summary]" rows="4"
                    placeholder="Provide a brief clinical summary of the patient's condition and the need for the requested services"></textarea>
            </div>
        </div>
    </div>

    <div class="row">
        <div class="col-md-6">
            <div class="mb-3">
                <label class="form-label">Previous Treatment History</label>
                <textarea class="form-control" name="preauth_data[previous_treatment]" rows="3"
                    placeholder="Describe any previous treatments for this condition"></textarea>
            </div>
        </div>
        <div class="col-md-6">
            <div class="mb-3">
                <label class="form-label">Current Medications</label>
                <textarea class="form-control" name="preauth_data[current_medications]" rows="3"
                    placeholder="List current medications if relevant"></textarea>
            </div>
        </div>
    </div>

    <div class="row">
        <div class="col-md-4">
            <div class="mb-3">
                <label class="form-label">Is this related to an accident?</label>
                <select class="form-select" name="preauth_data[is_accident_related]">
                    <option value="no">No</option>
                    <option value="yes">Yes</option>
                </select>
            </div>
        </div>
        <div class="col-md-4">
            <div class="mb-3">
                <label class="form-label">Is this a pre-existing condition?</label>
                <select class="form-select" name="preauth_data[is_preexisting]">
                    <option value="no">No</option>
                    <option value="yes">Yes</option>
                </select>
            </div>
        </div>
        <div class="col-md-4">
            <div class="mb-3">
                <label class="form-label">Expected Hospital Stay (days)</label>
                <input type="number" class="form-control" name="preauth_data[expected_stay_days]" min="0" placeholder="0">
            </div>
        </div>
    </div>

    <div class="row">
        <div class="col-md-12">
            <div class="mb-3">
                <label class="form-label">Additional Notes</label>
                <textarea class="form-control" name="preauth_data[additional_notes]" rows="2"
                    placeholder="Any additional information relevant to this pre-authorization request"></textarea>
            </div>
        </div>
    </div>
</div>
