<?php
/**
 * Liaison Group Pre-Authorization Form
 * Based on: NEW LIAISON NORMAL PRE-AUTHORISATION FORM.PDF
 */

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

<div class="form-section insurer-specific-section" id="liaFormFields">
    <div class="form-section-title">
        <i class="ri-shield-star-line"></i> Liaison Group Pre-Authorization
    </div>

    <!-- Part A: Member / Patient Details -->
    <div class="card mb-4">
        <div class="card-header bg-light">
            <h6 class="mb-0">Part A: Member / Patient Information</h6>
        </div>
        <div class="card-body">
            <div class="row">
                <div class="col-md-6">
                    <div class="mb-3">
                        <label class="form-label">Scheme Name / Employer</label>
                        <input type="text" class="form-control" name="preauth_data[scheme_name]"
                            placeholder="e.g. Judicial Service Commission">
                    </div>
                </div>
                <div class="col-md-6">
                    <div class="mb-3">
                        <label class="form-label">Member Number</label>
                        <input type="text" class="form-control" name="preauth_data[member_number]"
                            value="<?php echo isset($patient_data) ? htmlspecialchars($patient_data['policy_number'] ?? '') : ''; ?>">
                    </div>
                </div>
            </div>
            <div class="row">
                <div class="col-md-6">
                    <div class="mb-3">
                        <label class="form-label">Patient Name</label>
                        <input type="text" class="form-control"
                            value="<?php echo isset($patient_data) ? htmlspecialchars($patient_data['full_name'] ?? '') : ''; ?>"
                            readonly>
                    </div>
                </div>
                <div class="col-md-6">
                    <div class="mb-3">
                        <label class="form-label">Mobile Number</label>
                        <input type="text" class="form-control"
                            value="<?php echo isset($patient_data) ? htmlspecialchars($patient_data['phone_primary'] ?? '') : ''; ?>"
                            readonly>
                    </div>
                </div>
            </div>
        </div>
    </div>

    <!-- Part B: Clinical Information -->
    <div class="card mb-4">
        <div class="card-header bg-light">
            <h6 class="mb-0">Part B: Clinical Information (To be filled by Doctor)</h6>
        </div>
        <div class="card-body">
            <div class="row">
                <div class="col-md-12">
                    <div class="mb-3">
                        <label class="form-label">Chief Complaints & History</label>
                        <textarea class="form-control" name="preauth_data[history]" rows="3" required
                            placeholder="History of present illness"></textarea>
                    </div>
                </div>
            </div>
            <div class="row">
                <div class="col-md-6">
                    <div class="mb-3">
                        <label class="form-label">Provisional Diagnosis</label>
                        <textarea class="form-control" name="preauth_data[diagnosis]" rows="2"
                            placeholder="ICD10 / Description"></textarea>
                    </div>
                </div>
                <div class="col-md-6">
                    <div class="mb-3">
                        <label class="form-label">Investigation Results</label>
                        <textarea class="form-control" name="preauth_data[investigation_results]" rows="2"
                            placeholder="Relevant Lab/X-Ray Results"></textarea>
                    </div>
                </div>
            </div>
            <div class="row">
                <div class="col-md-6">
                    <div class="mb-3">
                        <label class="form-label">Proposed Procedure / Management</label>
                        <input type="text" class="form-control" name="preauth_data[procedure_name]"
                            placeholder="Procedure Name or Medical Management">
                    </div>
                </div>
                <div class="col-md-6">
                    <div class="mb-3">
                        <label class="form-label">Date of Discovery of Ailment</label>
                        <input type="date" class="form-control" name="preauth_data[ailment_date]">
                    </div>
                </div>
            </div>
        </div>
    </div>

    <!-- Part C: Admission Details -->
    <div class="card mb-4">
        <div class="card-header bg-light">
            <h6 class="mb-0">Part C: Admission / Hospitalization Details</h6>
        </div>
        <div class="card-body">
            <div class="row">
                <div class="col-md-4">
                    <div class="mb-3">
                        <label class="form-label">Date of Admission</label>
                        <input type="date" class="form-control" name="preauth_data[admission_date]"
                            value="<?php echo date('Y-m-d'); ?>">
                    </div>
                </div>
                <div class="col-md-4">
                    <div class="mb-3">
                        <label class="form-label">Expected Stay (Days)</label>
                        <input type="number" class="form-control" name="preauth_data[expected_stay]" min="1"
                            placeholder="e.g. 3">
                    </div>
                </div>
                <div class="col-md-4">
                    <div class="mb-3">
                        <label class="form-label">Ward / Room Type</label>
                        <select class="form-select" name="preauth_data[room_type]">
                            <option value="General Ward">General Ward</option>
                            <option value="Standard Private">Standard Private</option>
                            <option value="Ensuite">Ensuite</option>
                            <option value="ICU">ICU</option>
                            <option value="HDU">HDU</option>
                        </select>
                    </div>
                </div>
            </div>
        </div>
    </div>

    <!-- Part D: Financial Breakdown -->
    <div class="card mb-4">
        <div class="card-header bg-light">
            <h6 class="mb-0">Part D: Estimated Professional Fees & Hospital Costs (KES)</h6>
        </div>
        <div class="card-body">
            <div class="row g-3">
                <div class="col-md-3">
                    <label class="form-label text-muted small">Surgeon's Fee</label>
                    <input type="number" step="0.01" class="form-control fee-input" name="preauth_data[surgeon_fee]"
                        placeholder="0.00">
                </div>
                <div class="col-md-3">
                    <label class="form-label text-muted small">Anaesthetist's Fee</label>
                    <input type="number" step="0.01" class="form-control fee-input"
                        name="preauth_data[anaesthetist_fee]" placeholder="0.00">
                </div>
                <div class="col-md-3">
                    <label class="form-label text-muted small">Assist. Surgeon</label>
                    <input type="number" step="0.01" class="form-control fee-input"
                        name="preauth_data[assist_surgeon_fee]" placeholder="0.00">
                </div>
                <div class="col-md-3">
                    <label class="form-label text-muted small">Physician's Fee</label>
                    <input type="number" step="0.01" class="form-control fee-input" name="preauth_data[physician_fee]"
                        placeholder="0.00">
                </div>
                <div class="col-md-3">
                    <label class="form-label text-muted small">Hospital (Bed/Nurs)</label>
                    <input type="number" step="0.01" class="form-control fee-input" name="preauth_data[hospital_fee]"
                        placeholder="0.00">
                </div>
                <div class="col-md-3">
                    <label class="form-label text-muted small">Theatre Charges</label>
                    <input type="number" step="0.01" class="form-control fee-input" name="preauth_data[theatre_fee]"
                        placeholder="0.00">
                </div>
                <div class="col-md-3">
                    <label class="form-label text-muted small">Drugs/Laboratory</label>
                    <input type="number" step="0.01" class="form-control fee-input" name="preauth_data[lab_drugs_fee]"
                        placeholder="0.00">
                </div>
                <div class="col-md-3">
                    <label class="form-label text-muted small">Other / Misc</label>
                    <input type="number" step="0.01" class="form-control fee-input" name="preauth_data[other_fee]"
                        placeholder="0.00">
                </div>
            </div>
            <div class="row mt-4 pt-3 border-top">
                <div class="col-md-6 offset-md-6">
                    <div class="d-flex justify-content-between align-items-center">
                        <h5 class="mb-0">Total Estimate:</h5>
                        <h4 class="mb-0 text-primary" id="liaTotalDisplay">KES 0.00</h4>
                        <input type="hidden" name="preauth_data[total_breakdown]" id="liaTotal">
                    </div>
                </div>
            </div>
        </div>
    </div>

    <!-- Declaration -->
    <div class="card mb-4 mb-4">
        <div class="card-body bg-light rounded">
            <div class="form-check">
                <input class="form-check-input" type="checkbox" name="preauth_data[declaration]" id="declCheck"
                    required>
                <label class="form-check-label" for="declCheck">
                    <strong>Declaration:</strong> I certify that the information provided is correct. I authorize the
                    release of medical information to Liaison Group for claim processing.
                </label>
            </div>
        </div>
    </div>
</div>

<script>
    document.addEventListener('DOMContentLoaded', function () {
        const feeInputs = document.querySelectorAll('#liaFormFields .fee-input');
        const totalDisplay = document.getElementById('liaTotalDisplay');
        const totalInput = document.getElementById('liaTotal');

        function calculateTotal() {
            let total = 0;
            feeInputs.forEach(input => {
                total += parseFloat(input.value) || 0;
            });

            totalDisplay.textContent = 'KES ' + total.toLocaleString('en-US', { minimumFractionDigits: 2, maximumFractionDigits: 2 });
            totalInput.value = total.toFixed(2);

            const mainCostInput = document.querySelector('input[name="estimated_cost"]');
            if (mainCostInput && (mainCostInput.value === '' || mainCostInput.value == 0)) {
                mainCostInput.value = total.toFixed(2);
                mainCostInput.dispatchEvent(new Event('input'));
            }
        }

        feeInputs.forEach(input => {
            input.addEventListener('input', calculateTotal);
        });
    });
</script>