AFC URGENT CARE - 149th Street (2024)

'; InstaMed.launchInContext(); } else { Ext.isSecure = /^https/i.test(window.location.protocol);InstaMed.isNativeApplication = false;InstaMed.isConsumerApp = false;InstaMed.TitleBarMargins = '17 0 0 0';InstaMed.isMobile = true;InstaMed.isResponsive = true;InstaMed.isInContextMode = false;InstaMed.passedInMetaDataToken = '';InstaMed.isInAccessibilityMode = false;InstaMed.userAgentParameter = '';InstaMed.logoutPage = '../../Form/PaymentPortal/Logout?id=AFCURGENT149';InstaMed.isLightWeightMode = false;InstaMed.isReturnUrlUpdateParent = false;InstaMed.isClientSidePostData = false;InstaMed.isDesktop = false;InstaMed.isTablet = false;InstaMed.isDesktopOrTablet = false;InstaMed.isMobileOrTablet = true;InstaMed.isLoggedIn = false;InstaMed.useHistory = false;InstaMed.hasReturnUrl = false;InstaMed.hasCancelUrl = false;InstaMed.isNewRequiredFeild = true;InstaMed.browserTabID = '7CA4ED0294554507ABF7DD725E8E5ED0';InstaMed.sessionTimeoutUrl = '../../Form/PaymentPortal/Logout?id=AFCURGENT149';InstaMed.page = 'Form/Payments/New';Ext.SSL_SECURE_URL = Ext.isSecure && Ext.isIE ? 'javascript:""' : 'about:blank';Ext.BLANK_IMAGE_URL = 'https://cdn.instamed.com/V_2024_March/Content/Images/General/BlankImage.gif';InstaMed.UniqueClientID = 'c2340fa4a16a4c97817c4e24e0808313';Ext.scopeResetCSS=true;InstaMed.contentUrl = 'https://cdn.instamed.com/V_2024_March/';var webPropertyId = 'UA-16010902-1';InstaMed.doIdleLogout = true;InstaMed.isSSO = false;InstaMed.isSelfService = false;LogoutTimer.init();var myMask = null;InstaMed.errorMessageSummaryTitle = 'Please correct the following errors';InstaMed.requiredErrorLabel = 'Required';Ext.ns('Ext.app.REMOTING_API');Ext.app.REMOTING_API = { "id": null, "url": "../../api/Payments/New", "type": "remoting", "namespace": null, "actions": { "PatientPortalLoginController": [ { "name": "checkSession", "len": 1 }, { "name": "changeLanguage", "len": 1 }, { "name": "showBiometricLogin", "len": 1 }, { "name": "authenticateBiometricInfo", "len": 1 }, { "name": "closeAppBanner", "len": 1 }, { "name": "verifyTextEnrollment", "len": 1 }, { "name": "navigateAfterLogin", "len": 1 }, { "name": "navigateFromEStatement", "len": 1 }, { "name": "forgotPassword", "len": 1 }, { "name": "submit", "len": 1 }, { "name": "deleteBiometricInfo", "len": 1 }, { "name": "navigateBackFromTwoFactor", "len": 1 }, { "name": "patientMatchSubmit", "len": 1 }, { "name": "skipTextEnrollment", "len": 1 }, { "name": "authenticateTwoFactor", "len": 1 }, { "name": "redirectToLogin", "len": 1 }, { "name": "getBackButtonOverride", "len": 1 }, { "name": "patientPortalNavigateBack", "len": 1 }, { "name": "saveEStatementPreference", "len": 1 }, { "name": "canUserResetPassword", "len": 3 }, { "name": "redirectToLoginEmailForm", "len": 1 }, { "name": "logout", "len": 1 }, { "name": "sendMobilePhoneNumberConfirmationCode", "len": 1 }, { "name": "navigateTo", "len": 1 }, { "name": "patientPortalHeaderBack", "len": 1 }, { "name": "registerUserBiometricInfo", "len": 1 }, { "name": "dualLogin", "len": 1 } ], "QuickPayOptimizedProviderLandingController": [ { "name": "navigatePayHereLink", "len": 1 }, { "name": "paymentPlanFlow", "len": 1 }, { "name": "submitPatient", "len": 1 }, { "name": "prepopulateDigitalPayoutQuickPayCode", "len": 1 }, { "name": "navigateCollectPaymentLink", "len": 1 }, { "name": "checkQuickPayCode", "len": 1 }, { "name": "payNow", "len": 1 }, { "name": "onPatientChange", "len": 1 }, { "name": "checkQuickPayCodeOnly", "len": 1 } ], "SessionlessQuickPayReviewAndConfirmController": [ { "name": "emailReceipt", "len": 1 }, { "name": "confirm", "len": 1 }, { "name": "viewReceipt", "len": 1 }, { "name": "initializeSession", "len": 1 } ], "QuickPayPaymentSummaryController": [ { "name": "redirectToSignUp", "len": 1 }, { "name": "redirectToLogin", "len": 1 }, { "name": "redirectToPatientProfile", "len": 1 } ], "SessionlessQuickPayPaymentInfoController": [ { "name": "submitPayment", "len": 1 }, { "name": "navigateBack", "len": 1 }, { "name": "updatePaymentMethod", "len": 1 } ], "PushNotificationController": [ { "name": "navigateByPushNotification", "len": 1 } ], "PreferencesController": [ { "name": "openWindowToUpdateEmailAddress", "len": 1 }, { "name": "get_MerchantStoreTerminalAlias", "len": 0 }, { "name": "openWindowToEnterMobilePhoneNumber", "len": 1 }, { "name": "openWindowToEnterMobilePhoneNumberConfirmationCode", "len": 1 }, { "name": "updateSecurityQuestions", "len": 1 }, { "name": "disableTwoFactorAuthFromPopUp", "len": 1 }, { "name": "verifyTextEnrollment", "len": 1 }, { "name": "confirmMobilePhoneNumber", "len": 1 }, { "name": "getUserMobilePhoneNumber", "len": 0 }, { "name": "navigateToTextMsgEnroll", "len": 1 }, { "name": "removeMobilePhoneNumber", "len": 1 }, { "name": "navigateToTextMsgEnrollTwoFAOnly", "len": 1 }, { "name": "enableTwoFactorAuth", "len": 1 }, { "name": "cancelTwoFAChangeFromPopup", "len": 1 }, { "name": "isUserRequireMobilePhoneNumberUpdate", "len": 0 }, { "name": "updateEmailAndPreference", "len": 1 }, { "name": "isUserRequireEmailAndPreferenceUpdate", "len": 0 }, { "name": "loadPatientData", "len": 0 }, { "name": "saveStatementPreferences", "len": 1 }, { "name": "updateMobilePhoneNumber", "len": 1 }, { "name": "loadPatientAccountPreferences", "len": 2 }, { "name": "deleteUserBiometricInfo", "len": 1 }, { "name": "sendNewMobilePhoneNumberConfirmationCode", "len": 1 }, { "name": "saveEmailPreferences", "len": 1 }, { "name": "updateCommunicationDeliverySettings", "len": 1 } ], "PaymentActionController": [ { "name": "selectLineItem", "len": 1 }, { "name": "viewTransaction", "len": 1 }, { "name": "getNextScheduledTransaction", "len": 1 }, { "name": "getSystemWideDefault", "len": 1 }, { "name": "displayPatientInformationMutliAccount", "len": 3 }, { "name": "getAuthorization", "len": 3 }, { "name": "getVirtualCardEntityID", "len": 1 }, { "name": "getPaymentPlanStatus", "len": 1 }, { "name": "getDisclaimer", "len": 1 }, { "name": "closeSSOReceipt", "len": 1 }, { "name": "voidTransactionFromHistory", "len": 1 }, { "name": "canReturnEcheck", "len": 1 }, { "name": "eCheckRefundTransactionFromHistory", "len": 1 }, { "name": "getBasePaymentTransaction", "len": 2 }, { "name": "returnToProfile", "len": 1 }, { "name": "viewReceiptByData", "len": 5 }, { "name": "canAdjustEcheck", "len": 1 }, { "name": "cancel", "len": 1 }, { "name": "doReturnEcheck", "len": 1 }, { "name": "getNumberOfPaymentsRemaining", "len": 1 }, { "name": "printAll", "len": 1 }, { "name": "emailReceipt", "len": 1 }, { "name": "getReceiptConfigurationList", "len": 1 }, { "name": "downloadReceipt", "len": 1 }, { "name": "downloadCheckImage", "len": 1 }, { "name": "cancelVirtualCard", "len": 1 }, { "name": "downloadCouponImage", "len": 1 }, { "name": "voidTransaction", "len": 1 }, { "name": "viewCheckImage", "len": 1 }, { "name": "eCheckReturn", "len": 1 }, { "name": "populateReceiptByData", "len": 5 }, { "name": "getPayeeName", "len": 3 }, { "name": "viewRefund", "len": 1 }, { "name": "creditCardRefundTransaction", "len": 2 }, { "name": "getPaymentPlan", "len": 1 }, { "name": "emailAllReceipts", "len": 1 }, { "name": "sendEmailReceipt", "len": 3 }, { "name": "canRefund", "len": 1 }, { "name": "eCheckRefundTransaction", "len": 2 }, { "name": "getBalanceRemaining", "len": 1 }, { "name": "collectNow", "len": 1 }, { "name": "eCheckAdjustment", "len": 1 }, { "name": "viewReceiptForTransaction", "len": 5 }, { "name": "viewVoid", "len": 1 }, { "name": "returnCodes", "len": 1 }, { "name": "canVoid", "len": 2 }, { "name": "populateReceipt", "len": 3 }, { "name": "displayMultiARLine", "len": 8 }, { "name": "copyPrimaryToSecondaryTransactionFieldsCommon", "len": 2 }, { "name": "creditCardRefundTransactionFromHistory", "len": 1 }, { "name": "doeCheckAdjustment", "len": 1 }, { "name": "viewReceipt", "len": 1 }, { "name": "getTransactionByData", "len": 2 }, { "name": "multiARRefundTransaction", "len": 1 }, { "name": "getTransaction", "len": 1 }, { "name": "getMultipleAccountReceiptText", "len": 3 } ], "GridController": [ { "name": "exportDataToFile", "len": 1 }, { "name": "saveColumnSortConfiguration", "len": 1 }, { "name": "saveColumnConfiguration", "len": 1 }, { "name": "updateCharts", "len": 1 }, { "name": "export", "formHandler": true, "len": 1 } ], "QuickPayLoginController": [ { "name": "login", "len": 1 }, { "name": "forgotPassword", "len": 1 }, { "name": "navigateToQuickPayLogin", "len": 1 }, { "name": "navigateBack", "len": 1 }, { "name": "navigateToQuickPaySignup", "len": 1 } ], "FileController": [ { "name": "saveHTML", "len": 1 } ], "QuickPayPaymentInfoController": [ { "name": "submitPayment", "len": 1 }, { "name": "navigateBack", "len": 1 }, { "name": "updatePaymentMethod", "len": 1 } ], "ManageAccountsController": [ { "name": "removeAccount", "len": 1 }, { "name": "saveAccountCustom", "len": 1 }, { "name": "getDigitalCard", "len": 1 }, { "name": "removePaymentMethodFromRadioSelector", "len": 1 }, { "name": "saveAccount", "len": 1 }, { "name": "editAccount", "len": 1 } ], "PayAnyDocController": [ { "name": "validateAddress", "len": 1 }, { "name": "selectAddress", "len": 1 }, { "name": "getFullAddressFromPPPTile", "len": 1 }, { "name": "updateHCBPInviteTracking", "len": 1 }, { "name": "navigateTo", "len": 1 }, { "name": "cleanUp", "len": 0 }, { "name": "verifyAddress", "len": 1 }, { "name": "confirmAddress", "len": 1 }, { "name": "isExactMatch", "len": 1 }, { "name": "formatAddress", "len": 6 }, { "name": "closeWindowNavigateTo", "len": 1 }, { "name": "isExactMatchAndCorrection", "len": 1 }, { "name": "forgotPassword", "len": 1 }, { "name": "isHealthcareBillPaymentsAmountValid", "len": 1 }, { "name": "incrementViews", "len": 1 }, { "name": "updateHCBPInviteCloseCount", "len": 1 }, { "name": "getNumberOfUserViews", "len": 0 }, { "name": "getAlias", "len": 0 }, { "name": "getSessionKey", "len": 1 } ], "IdleTimerController": [ { "name": "setRemainingIdleTime", "len": 0 }, { "name": "submit", "len": 1 }, { "name": "getRemainingIdleTime", "len": 1 } ], "PatientAuthenticationController": [ { "name": "verifyPatientAccountByQuickPayCode", "len": 1 }, { "name": "storeEStatementPreference", "len": 1 }, { "name": "skipAddPatient", "len": 1 }, { "name": "savePatientStatementAuthentication", "len": 1 }, { "name": "onStatementPatientChange", "len": 1 }, { "name": "verifyPatientAccount", "len": 1 }, { "name": "savePatientAuthenticationWithRegCode", "len": 1 }, { "name": "findPatientAuthLinkMatch", "len": 1 }, { "name": "updatePatientModule", "len": 2 }, { "name": "loadStatementData", "len": 1 }, { "name": "onPatientAuthPatientChange", "len": 1 }, { "name": "addPatient", "len": 1 }, { "name": "redirectToHome", "len": 0 }, { "name": "savePatientAuthentication", "len": 1 }, { "name": "associatePatientRecordWithUserAccount", "len": 2 } ], "MyAccountController": [ { "name": "removeProvider", "len": 1 }, { "name": "onHealthPlanChange", "len": 1 }, { "name": "hasAutoPay", "len": 1 }, { "name": "hasPaymentPlans", "len": 1 }, { "name": "loadMyProviderFeatures", "len": 0 }, { "name": "getTriggerUpdates", "len": 2 }, { "name": "removeOffNetworkPayee", "len": 1 }, { "name": "navigateToPayeeSearch", "len": 1 }, { "name": "navigateToEditAccount", "len": 1 }, { "name": "getCommunicationSettingsArray", "len": 1 }, { "name": "getCommunicationSettingsArrayInstaMedOnline", "len": 1 }, { "name": "shouldHideViewStatements", "len": 1 }, { "name": "navigateToStep", "len": 1 }, { "name": "addPayee", "len": 1 }, { "name": "shouldHideAutomaticPaymentsButton", "len": 1 }, { "name": "hasSMSEnabled", "len": 0 }, { "name": "navigateToWalletHealthPlan", "len": 1 }, { "name": "navigateToMyPreferences", "len": 1 } ], "SessionlessQuickPayGoGreenController": [ { "name": "storeEStatementPreference", "len": 1 } ], "SessionlessQuickPayPatientEntryController": [ { "name": "submitPatient", "len": 1 }, { "name": "navigateBack", "len": 1 }, { "name": "initializeSession", "len": 1 } ], "PaymentOptionsController": [ { "name": "editSelectedPaymentPlan", "len": 1 }, { "name": "submitPaymentPlan", "len": 1 }, { "name": "navigateToCustomPaymentPlan", "len": 1 }, { "name": "navigateBack", "len": 1 }, { "name": "getPaymentPlanPaymentsBreakdownWindowDetails", "len": 1 }, { "name": "navigateNext", "len": 1 }, { "name": "setSelectedOption", "len": 1 }, { "name": "navigateBackFromCustomPaymentPlan", "len": 1 }, { "name": "calculateOptions", "len": 1 } ], "PaymentHistoryController": [ { "name": "search", "len": 1 }, { "name": "cancelVirtualCards", "len": 1 }, { "name": "getSearchData", "len": 2 }, { "name": "cancelPaymentPlan", "len": 1 }, { "name": "getAdditionalColumns", "len": 0 }, { "name": "getData", "len": 1 }, { "name": "searchPayableTransactions", "len": 1 }, { "name": "getPaymentHistoryData", "len": 1 }, { "name": "searchHealthExpenses", "len": 1 }, { "name": "getScheduledPaymentData", "len": 2 }, { "name": "searchScheduledPayments", "len": 1 }, { "name": "getPayableTransactions", "len": 2 }, { "name": "viewPaymentReceipt", "len": 1 }, { "name": "quickPayViewAccountSummary", "len": 1 } ], "SessionlessQuickPayAccountSummaryController": [ { "name": "payOverTime", "len": 1 }, { "name": "navigateBack", "len": 1 }, { "name": "payNow", "len": 1 } ], "QuickPayGoGreenController": [ { "name": "storeEStatementPreference", "len": 1 } ], "QuickPayAccountSummaryController": [ { "name": "payOverTime", "len": 1 }, { "name": "navigateBack", "len": 1 }, { "name": "payNow", "len": 1 } ], "TextMessageEnrollmentController": [ { "name": "resendEnrollmentText", "len": 1 }, { "name": "updateMobilePhoneNumberFromPopUp", "len": 1 }, { "name": "updateMobilePhoneNumber", "len": 1 }, { "name": "verifyTextEnrollment", "len": 1 }, { "name": "enableTwoStepVerification", "len": 1 }, { "name": "updateUserTextCommPreference", "len": 1 }, { "name": "sendEnrollmentText", "len": 1 }, { "name": "skipTextEnrollment", "len": 1 } ], "SessionlessPaymentOptionsController": [ { "name": "editSelectedPaymentPlan", "len": 1 }, { "name": "submitPaymentPlan", "len": 1 }, { "name": "navigateToCustomPaymentPlan", "len": 1 }, { "name": "navigateBack", "len": 1 }, { "name": "getPaymentPlanPaymentsBreakdownWindowDetails", "len": 1 }, { "name": "navigateNext", "len": 1 }, { "name": "setSelectedOption", "len": 1 }, { "name": "navigateBackFromCustomPaymentPlan", "len": 1 }, { "name": "calculateOptions", "len": 1 } ], "QuickPayPatientEntryController": [ { "name": "addPatient", "len": 1 }, { "name": "submitPatient", "len": 1 }, { "name": "enterInformationManually", "len": 1 }, { "name": "navigateBack", "len": 1 }, { "name": "updatePatient", "len": 1 }, { "name": "editPatientInformation", "len": 1 } ], "SettingsController": [ { "name": "load", "len": 1 }, { "name": "save", "len": 1 } ], "ResetPasswordController": [ { "name": "changePassword", "len": 1 }, { "name": "navigateFromEnterCode", "len": 1 }, { "name": "requestPasswordReset", "len": 1 }, { "name": "validateAnswer", "len": 3 }, { "name": "isDualLoginSignUpFlow", "len": 0 }, { "name": "sendResetText", "len": 1 }, { "name": "submit", "len": 1 }, { "name": "resendPasswordResetCode", "len": 1 }, { "name": "getUserId", "len": 0 }, { "name": "sendEmail", "len": 2 }, { "name": "navigateFromSelectMethodForm", "len": 1 }, { "name": "getUserInitials", "len": 1 }, { "name": "pPPResetPassword", "len": 1 }, { "name": "generateResetCode", "len": 0 }, { "name": "sendResetEmail", "len": 1 }, { "name": "navigateFromForgotPassword", "len": 1 } ], "PatientPaymentController": [ { "name": "submitCreditCard", "len": 4 }, { "name": "confirm", "len": 1 }, { "name": "setCommonTransactionFields", "len": 1 }, { "name": "cancelNewCardInfo", "len": 1 }, { "name": "displayPatientBalance", "len": 1 }, { "name": "editProviderInformation", "len": 1 }, { "name": "setTransactionData", "len": 1 }, { "name": "onPatientChange", "len": 1 }, { "name": "submitNewCardInfo", "len": 1 }, { "name": "submitPatient", "len": 1 }, { "name": "cleanUp", "len": 0 }, { "name": "getSaveOnFilePaymentPlan", "len": 3 }, { "name": "submitPayment", "len": 1 }, { "name": "triggerPaymentEventTracking", "len": 1 }, { "name": "setPatientPaymentConfirmHeaderMessage", "len": 5 }, { "name": "preAuth", "len": 1 }, { "name": "cardAlreadySavedOnFile", "len": 1 }, { "name": "updateChargeLimit", "len": 1 }, { "name": "get_Transaction", "len": 0 }, { "name": "handleEpicPostBack", "len": 4 }, { "name": "updatePatient", "len": 1 }, { "name": "getLineItemTransactions", "len": 1 }, { "name": "redirectToLogin", "len": 1 }, { "name": "getPatientUniqueAlias", "len": 1 }, { "name": "addPatient", "len": 1 }, { "name": "editPatientInformation", "len": 1 }, { "name": "backToPayment", "len": 1 }, { "name": "getAPCEnrollmentUpdates", "len": 3 }, { "name": "setupAutomaicPayment", "len": 2 }, { "name": "set_Transaction", "len": 1 }, { "name": "clearPayAnyDocInformation", "len": 0 }, { "name": "submitECheck", "len": 3 }, { "name": "backToNewPaymentMethod", "len": 1 }, { "name": "getPreAuthUpdateFieldInfos", "len": 1 }, { "name": "getBankAccountInfoAlreadySavedOnFile", "len": 1 }, { "name": "handleDisbursem*nt", "len": 3 }, { "name": "savePaymentPlan", "len": 3 }, { "name": "getLineItemTransaction", "len": 1 }, { "name": "getCreditCardInfoAlreadySavedOnFile", "len": 1 } ], "PaymentPlanController": [ { "name": "setTransactionFields", "len": 2 }, { "name": "reCalculate", "len": 5 }, { "name": "backToPayment", "len": 1 }, { "name": "submitPayment", "len": 1 }, { "name": "onInstallmentAmountChange", "len": 1 }, { "name": "backToPaymentPlan", "len": 1 }, { "name": "onPatientChange", "len": 1 }, { "name": "submitPaymentPlan", "len": 1 }, { "name": "onTotalAmountChange", "len": 1 }, { "name": "onStartDateChange", "len": 1 }, { "name": "get_ScheduledTransactions", "len": 0 }, { "name": "submitPayments", "len": 1 }, { "name": "submitPatient", "len": 1 }, { "name": "get_EditPaymentPlan", "len": 0 }, { "name": "confirm", "len": 1 }, { "name": "emailReceipt", "len": 1 }, { "name": "onFrequencyChange", "len": 1 }, { "name": "onInitialAmountChange", "len": 1 }, { "name": "get_IsEditing", "len": 0 } ], "QuickPayReviewAndConfirmController": [ { "name": "emailReceipt", "len": 1 }, { "name": "confirm", "len": 1 }, { "name": "viewReceipt", "len": 1 } ], "CheckInPatientInformationController": [ { "name": "selectAddress", "len": 1 }, { "name": "onPatientChange", "len": 1 }, { "name": "next", "len": 1 }, { "name": "confirmAddress", "len": 1 } ], "MobilePayController": [ { "name": "getApplePayMerchantSession", "len": 1 } ], "SignUpController": [ { "name": "navigateFromSignUp", "len": 0 }, { "name": "completeSignUp", "len": 1 }, { "name": "redirectToSignUpForm", "len": 1 }, { "name": "redirectToSignUp", "len": 1 }, { "name": "sendAccountCreatedEvent", "len": 1 }, { "name": "signUp", "len": 1 }, { "name": "isEnterPayeeManuallyFlow", "len": 0 }, { "name": "verifyTextEnrollment", "len": 1 }, { "name": "dualSignUp", "len": 1 }, { "name": "isDigitalPayoutFlow", "len": 0 }, { "name": "skipTextEnrollment", "len": 1 }, { "name": "isPatientMatchFlow", "len": 0 } ], "FindProviderController": [ { "name": "search", "len": 1 }, { "name": "getManualPayeeBadge", "len": 1 }, { "name": "payNowRedirect", "len": 1 }, { "name": "clearPayAnyDocSession", "len": 1 }, { "name": "sessionSearch", "len": 1 }, { "name": "loadMyProviders", "len": 3 }, { "name": "getStore", "len": 2 }, { "name": "getVirtualCardTrustedPayeeInformation", "len": 1 }, { "name": "processStatementImage", "len": 1 }, { "name": "isIPBlocked", "len": 1 }, { "name": "updateHCBPUsageTracking", "len": 2 }, { "name": "goToAcceptPaymentRedirect", "len": 1 }, { "name": "getManualPayeeInformation", "len": 1 }, { "name": "scanStatement", "len": 1 }, { "name": "enterPayeeManually", "len": 1 }, { "name": "getPatients", "len": 3 }, { "name": "landingPageSearch", "len": 1 }, { "name": "set_ZipCodeService", "len": 1 }, { "name": "searchForProviders", "len": 1 }, { "name": "getProvidersAutoComplete", "len": 1 }, { "name": "goToRedirect", "len": 1 }, { "name": "get_ZipCodeService", "len": 0 }, { "name": "getManualPayeeText", "len": 0 } ], "QuickPaySignUpController": [ { "name": "signUp", "len": 1 }, { "name": "skip", "len": 1 } ] }, "descriptor": "Ext.app.REMOTING_API"};Ext.app.REMOTING_API.maxRetries = 0;Ext.app.REMOTING_API.timeout = 300 * 1000;Ext.app.REMOTING_API.enableBuffer = false;Ext.Direct.addProvider(Ext.app.REMOTING_API);Ext.app.REMOTING_API.requestKey = '5003A2D07AD848E3D538CE48136B8DEDB5A2F5ACECCD00F261D73C499EF48871';Ext.app.REMOTING_API.alias = 'AFCURGENT149';Ext.app.REMOTING_API.corporateID = '';Ext.app.REMOTING_API.token = '';function headerPatientPortalBack() { var nav = InstaMed.getNavigationView(); if(!Ext.Msg.isHidden()) { Ext.Msg.close(); } else if(nav.lastForm.length > 1) { nav.back(); } else { PerformAction({}, PatientPortalLoginController.patientPortalHeaderBack); } }Ext.define('MyApp.view.amountfield', { extend: 'Ext.field.Text', alias: 'widget.amountfield', config: { maxLength: 10, }, listeners: {blur: function(field, event, opts ){ field.doFormatAmount(field,event,opts); } }, doFormatAmount: function(field, event, opts ){ var s = new String(field.getValue()); if(s != null && s != '') { s = s.replace(/,/g,''); s = s.replace(/\$/g,''); field.setValue(Ext.util.Format.usMoney(s)); } }, getValue: function() { var val = new String(Ext.field.Number.superclass.getValue.call(this)); if(val == "null"){val = null;} return val; }, getSubmitValue: function() { var val = this.getValue(); if(val != null){ val = val.replace(/\$/g,''); } return val; }, transformOriginalValue: function(v) { if(v != undefined && v != null && v != '') { var s = new String(v); s = s.replace(/,/g,''); s = s.replace(/\$/g,''); var val = Ext.util.Format.usMoney(s); if(val == '$NaN.undefined') { val = ''; } return val; } return v; }, reset: function() { var me = this; Ext.field.Number.superclass.reset.call(this); me.enteredDigits = []; me.totalDigitsEntered = 0; }, setValue: function(v) { if(v==null || v==undefined || v==''){ this.enteredDigits = []; this.totalDigitsEntered = 0; } if(!this.hasFocus) { if (v == '$') { v = ''; } else { v = this.transformOriginalValue(v); } } v = new String(v).replace(/[^\$\d\.\,]/g,''); if(v.indexOf('.')!=-1 && v.indexOf('.') == v.length-4){ v = v.substring(0, v.indexOf('.') + 3); v = this.transformOriginalValue(v); } if(!this.KeyUpMode) { this.enteredDigits = []; this.totalDigitsEntered = 0; var count = 0; if(v) { var chars = v.split(''); for(var i = 0; i < chars.length; i++) { var c = chars[i]; if(c >= '0' && c <= '9') { this.enteredDigits.push(c); this.totalDigitsEntered++; } } } } Ext.field.Text.superclass.setValue.call(this,v); this.setInputValue(v); } });Ext.define('Ext.InstaMed.FormPanel',{extend: 'Ext.form.Panel',alias: 'widget.form',config: { defaultSubmitButton: null }});Ext.define('PatientPaymentPatientInfoMultiARDataViewModel', { extend: 'Ext.data.Model', config: { fields: [ { name: 'PaymentDate' },{ name: 'Amount' },{ name: 'PatientID' },{ name: 'PatientMedicalRecordNumber' },{ name: 'PatientFirstName' },{ name: 'PatientMiddleName' },{ name: 'PatientLastName' },{ name: 'PatientBirthDate' },{ name: 'PatientPhoneNumber' },{ name: 'AccountHolderEmail' },{ name: 'PatientInvoiceNumber' },{ name: 'PatientServiceBeginDate' },{ name: 'PatientServiceEndDate' },{ name: 'PatientAddress1' },{ name: 'PatientAddress2' },{ name: 'PatientCity' },{ name: 'PatientState' },{ name: 'PatientZip' },{ name: 'PatientCountry' },{ name: 'TransactionCode' },{ name: 'AdditionalCode1' },{ name: 'AdditionalCode2' },{ name: 'AdditionalCode3' },{ name: 'AdditionalCode4' },{ name: 'AdditionalCode5' },{ name: 'AdditionalCode6' },{ name: 'AdditionalInfo1' },{ name: 'AdditionalInfo2' },{ name: 'AdditionalInfo3' },{ name: 'AdditionalInfo4' },{ name: 'AdditionalInfo5' },{ name: 'AdditionalInfo6' },{ name: 'LineItemKey' } ] } }); Ext.create('Ext.data.Store', { id:'PatientPaymentPatientInfoMultiARDataViewstore', model: 'PatientPaymentPatientInfoMultiARDataViewModel', autoLoad: true, proxy: { type: 'memory', reader: { type: 'json' }, data: [] } }); function editLineItem(lineItemKey) { var store = InstaMed.get('PatientPaymentPatientInfoMultiARDataView').getStore(); var selIndex = store.find('LineItemKey', lineItemKey); if(selIndex >= 0) { var rec = store.getAt(selIndex); Ext.Array.each(InstaMed.getNavigationView().getCurrentItem().query('field'), function(f) { var val = rec.get(f.getName()); f.setValue(val && val.code ? val.code : val); }); } InstaMed.get('btnAddPatient').hide(); InstaMed.get('btnNext').hide(); var updatePatientButton = InstaMed.get('btnUpdatePatient'); InstaMed.get('btnCancelEditPatient').show(); var fullWidthButton = InstaMed.get('footerFullWidthButton'); if(fullWidthButton != undefined && fullWidthButton.isVisible()) { fullWidthButton.primaryButton = updatePatientButton; fullWidthButton.setText(fullWidthButton.primaryButton.getText()); fullWidthButton.forcePrimaryAction = true; } else { updatePatientButton.show(); } } function cancelEditLineItem() { InstaMed.get('btnAddPatient').show(); InstaMed.get('btnUpdatePatient').hide(); InstaMed.get('btnCancelEditPatient').hide(); InstaMed.resetForm(InstaMed.getNavigationView().getCurrentItem().query('form')[0]); var nextButton = InstaMed.get('btnNext'); var fullWidthButton = InstaMed.get('footerFullWidthButton'); if(fullWidthButton != undefined && fullWidthButton.isVisible()) { fullWidthButton.primaryButton = nextButton; fullWidthButton.setText(fullWidthButton.primaryButton.getText()); fullWidthButton.forcePrimaryAction = false; } else { nextButton.show(); } } function removeLineItem(lineItemKey) { var dataView = InstaMed.get('PatientPaymentPatientInfoMultiARDataView'); var store = dataView.getStore(); var selIndex = store.find('LineItemKey', lineItemKey); if(selIndex >= 0) { store.removeAt(selIndex); dataView.refresh(); } } function NavigateToPatientInformation(lineItemKey) { var form = InstaMed.getNavigationView(); form.push('NavPatientInformation'); if(lineItemKey) { editLineItem(lineItemKey); } PerformAction({}, PatientPaymentController.editPatientInformation); }function NavigateToQuickPayPatientEntry(lineItemKey) { var form = InstaMed.getNavigationView(); form.push('NavQuickPayPatientEntry'); if(lineItemKey) { editLineItem(lineItemKey); } javascript: PerformAction({}, QuickPayPatientEntryController.editPatientInformation,null); return false; }Ext.define('MyApp.model.CodeDescriptionPatientPaymentPatientInfoMultiARDataViewstore',{extend: 'Ext.data.Model',id: 'PatientPaymentPatientInfoMultiARDataViewstore',fields: [{name:'EntityID'},{name:'PatientFirstName'},{name:'PatientLastName'},{name:'PatientID'},{name:'Amount'},{name:'LineItemKey'},{name:'PaymentDate'},{name:'PatientMedicalRecordNumber'},{name:'PatientMiddleName'},{name:'PatientBirthDate'},{name:'PatientPhoneNumber'},{name:'AccountHolderEmail'},{name:'PatientInvoiceNumber'},{name:'PatientServiceBeginDate'},{name:'PatientServiceEndDate'},{name:'PatientAddress1'},{name:'PatientAddress2'},{name:'PatientCity'},{name:'PatientState'},{name:'PatientZip'},{name:'PatientCountry'},{name:'TransactionCode'},{name:'AdditionalCode1'},{name:'AdditionalCode2'},{name:'AdditionalCode3'},{name:'AdditionalCode4'},{name:'AdditionalCode5'},{name:'AdditionalCode6'},{name:'AdditionalInfo1'},{name:'AdditionalInfo2'},{name:'AdditionalInfo3'},{name:'AdditionalInfo4'},{name:'AdditionalInfo5'},{name:'AdditionalInfo6'},{name:'EmailAddress'}]});Ext.create('Ext.data.JsonStore',{ autoDestroy: false, proxy: { type: 'memory', reader: 'json', writer: 'json' }, storeId: 'PatientPaymentPatientInfoMultiARDataViewstore', fields: [{ name: 'EntityID', type: 'string'},{ name: 'PatientFirstName', type: 'string'},{ name: 'PatientLastName', type: 'string'},{ name: 'PatientID', type: 'string'},{ name: 'Amount', type: 'string'},{ name: 'LineItemKey', type: 'string'},{ name: 'PaymentDate', type: 'string'},{ name: 'PatientMedicalRecordNumber', type: 'string'},{ name: 'PatientMiddleName', type: 'string'},{ name: 'PatientBirthDate', type: 'string'},{ name: 'PatientPhoneNumber', type: 'string'},{ name: 'AccountHolderEmail', type: 'string'},{ name: 'PatientInvoiceNumber', type: 'string'},{ name: 'PatientServiceBeginDate', type: 'string'},{ name: 'PatientServiceEndDate', type: 'string'},{ name: 'PatientAddress1', type: 'string'},{ name: 'PatientAddress2', type: 'string'},{ name: 'PatientCity', type: 'string'},{ name: 'PatientState', type: 'string'},{ name: 'PatientZip', type: 'string'},{ name: 'PatientCountry', type: 'string'},{ name: 'TransactionCode', type: 'auto'},{ name: 'AdditionalCode1', type: 'auto'},{ name: 'AdditionalCode2', type: 'auto'},{ name: 'AdditionalCode3', type: 'auto'},{ name: 'AdditionalCode4', type: 'auto'},{ name: 'AdditionalCode5', type: 'auto'},{ name: 'AdditionalCode6', type: 'auto'},{ name: 'AdditionalInfo1', type: 'string'},{ name: 'AdditionalInfo2', type: 'string'},{ name: 'AdditionalInfo3', type: 'string'},{ name: 'AdditionalInfo4', type: 'string'},{ name: 'AdditionalInfo5', type: 'string'},{ name: 'AdditionalInfo6', type: 'string'},{ name: 'EmailAddress', type: 'string'}],data: []});function focusAmount(cmp){ if(cmp){ setTimeout(function(){ cmp.selectionStart = cmp.selectionEnd = 10000; }, 0); } }function setOtherAmounts(cmp){ if(cmp){ var amount = cmp.getValue(); if (amount == '') { cmp && cmp.setValue(null); cmp && cmp.setInputValue('$0.00'); }else { if(cmp){ var hasDollarSign = cmp.getInputValue().includes('$') if(hasDollarSign){ var amountVal = cmp.getInputValue().replace('$', ''); } } } } }function isNumeric(s) { return !isNaN(s - parseFloat(s)); }Ext.create('Ext.data.ArrayStore',{ type: 'json', autoDestroy: false, storeId: 'ApplicationStateComboboxStore', fields: [ { name: 'code', type: 'string' }, { name: 'description', type: 'string' } ], data: [['AK', 'Alaska'],['AL', 'Alabama'],['AR', 'Arkansas'],['AZ', 'Arizona'],['CA', 'California'],['CO', 'Colorado'],['CT', 'Connecticut'],['DC', 'District Of Columbia'],['DE', 'Delaware'],['FL', 'Florida'],['GA', 'Georgia'],['HI', 'Hawaii'],['IA', 'Iowa'],['ID', 'Idaho'],['IL', 'Illinois'],['IN', 'Indiana'],['KS', 'Kansas'],['KY', 'Kentucky'],['LA', 'Louisiana'],['MA', 'Massachusetts'],['MD', 'Maryland'],['ME', 'Maine'],['MI', 'Michigan'],['MN', 'Minnesota'],['MO', 'Missouri'],['MS', 'Mississippi'],['MT', 'Montana'],['NC', 'North Carolina'],['ND', 'North Dakota'],['NE', 'Nebraska'],['NH', 'New Hampshire'],['NJ', 'New Jersey'],['NM', 'New Mexico'],['NV', 'Nevada'],['NY', 'New York'],['OH', 'Ohio'],['OK', 'Oklahoma'],['OR', 'Oregon'],['PA', 'Pennsylvania'],['RI', 'Rhode Island'],['SC', 'South Carolina'],['SD', 'South Dakota'],['TN', 'Tennessee'],['TX', 'Texas'],['UT', 'Utah'],['VA', 'Virginia'],['VT', 'Vermont'],['WA', 'Washington'],['WI', 'Wisconsin'],['WV', 'West Virginia'],['WY', 'Wyoming'] ]})Ext.create('Ext.data.ArrayStore',{ type: 'json', autoDestroy: false, storeId: 'CountryStoreStore', fields: [ { name: 'code', type: 'string' }, { name: 'description', type: 'string' } ], data: [['AF', 'Afghanistan'],['AL', 'Albania'],['DZ', 'Algeria'],['AS', 'American Samoa'],['AD', 'Andorra'],['AO', 'Angola'],['AI', 'Anguilla'],['AQ', 'Antarctica'],['AG', 'Antigua And Barbuda'],['AR', 'Argentina'],['AM', 'Armenia'],['AW', 'Aruba'],['AU', 'Australia'],['AT', 'Austria'],['AZ', 'Azerbaijan'],['BS', 'Bahamas'],['BH', 'Bahrain'],['BD', 'Bangladesh'],['BB', 'Barbados'],['BY', 'Belarus'],['BE', 'Belgium'],['BZ', 'Belize'],['BJ', 'Benin'],['BM', 'Bermuda'],['BT', 'Bhutan'],['BO', 'Bolivia'],['BA', 'Bosnia And Herzegovina'],['BW', 'Botswana'],['BV', 'Bouvet Island'],['BR', 'Brazil'],['IO', 'British Indian Ocean Territory'],['BN', 'Brunei Darussalam'],['BG', 'Bulgaria'],['BF', 'Burkina Faso'],['BI', 'Burundi'],['KH', 'Cambodia'],['CM', 'Cameroon'],['CA', 'Canada'],['CV', 'Cape Verde'],['KY', 'Cayman Islands'],['CF', 'Central African Republic'],['TD', 'Chad'],['CL', 'Chile'],['CN', 'China'],['CX', 'Christmas Island'],['CC', 'Cocos (keeling) Islands'],['CO', 'Colombia'],['KM', 'Comoros'],['CK', 'Cook Islands'],['CR', 'Costa Rica'],['CI', 'Cote D\'ivoire (ivory Coast)'],['HR', 'Croatia (hrvatska)'],['CU', 'Cuba'],['CY', 'Cyprus'],['CZ', 'Czech Republic'],['KP', 'Democratic People\'s Republic of Korea (North)'],['CD', 'Democratic Republic Of The Congo'],['DK', 'Denmark'],['DJ', 'Djibouti'],['DM', 'Dominica'],['DO', 'Dominican Republic'],['TP', 'East Timor'],['EC', 'Ecuador'],['EG', 'Egypt'],['SV', 'El Salvador'],['GQ', 'Equatorial Guinea'],['ER', 'Eritrea'],['EE', 'Estonia'],['ET', 'Ethiopia'],['FK', 'Falkland Islands (malvinas)'],['FO', 'Faroe Islands'],['FM', 'Federated States Of Micronesia'],['FJ', 'Fiji'],['FI', 'Finland'],['FR', 'France'],['GF', 'French Guiana'],['PF', 'French Polynesia'],['TF', 'French Southern Territories'],['GA', 'Gabon'],['GM', 'Gambia'],['GE', 'Georgia'],['DE', 'Germany'],['GH', 'Ghana'],['GI', 'Gibraltar'],['GR', 'Greece'],['GL', 'Greenland'],['GD', 'Grenada'],['GP', 'Guadeloupe'],['GU', 'Guam'],['GT', 'Guatemala'],['GN', 'Guinea'],['GW', 'Guinea-bissau'],['GY', 'Guyana'],['HT', 'Haiti'],['HM', 'Heard Island And Mcdonald Islands'],['VA', 'Holy See (Vatican City State)'],['HN', 'Honduras'],['HK', 'Hong Kong'],['HU', 'Hungary'],['IS', 'Iceland'],['IN', 'India'],['ID', 'Indonesia'],['IR', 'Iran'],['IQ', 'Iraq'],['IE', 'Ireland'],['IL', 'Israel'],['IT', 'Italy'],['JM', 'Jamaica'],['JP', 'Japan'],['JO', 'Jordan'],['KZ', 'Kazakhstan'],['KE', 'Kenya'],['KI', 'Kiribati'],['KW', 'Kuwait'],['KG', 'Kyrgyzstan'],['LA', 'Lao People\'s Democratic Republic (Laos)'],['LV', 'Latvia'],['LB', 'Lebanon'],['LS', 'Lesotho'],['LR', 'Liberia'],['LY', 'Libya'],['LI', 'Liechtenstein'],['LT', 'Lithuania'],['LU', 'Luxembourg'],['MO', 'Macau (Macao)'],['MK', 'Macedonia'],['MG', 'Madagascar'],['MW', 'Malawi'],['MY', 'Malaysia'],['MV', 'Maldives'],['ML', 'Mali'],['MT', 'Malta'],['MH', 'Marshall Islands'],['MQ', 'Martinique'],['MR', 'Mauritania'],['MU', 'Mauritius'],['YT', 'Mayotte'],['MX', 'Mexico'],['FM', 'Micronesia (Federated States of)'],['MD', 'Moldova'],['MC', 'Monaco'],['MN', 'Mongolia'],['ME', 'Montenegro'],['MS', 'Montserrat'],['MA', 'Morocco'],['MZ', 'Mozambique'],['MM', 'Myanmar'],['NA', 'Namibia'],['NR', 'Nauru'],['NP', 'Nepal'],['NL', 'Netherlands'],['AN', 'Netherlands Antilles'],['NC', 'New Caledonia'],['NZ', 'New Zealand (aotearoa)'],['NI', 'Nicaragua'],['NE', 'Niger'],['NG', 'Nigeria'],['NU', 'Niue'],['NF', 'Norfolk Island'],['MP', 'Northern Mariana Islands'],['NO', 'Norway'],['OM', 'Oman'],['PK', 'Pakistan'],['PW', 'Palau'],['PS', 'Palestinian Territory'],['PA', 'Panama'],['PG', 'Papua New Guinea'],['PY', 'Paraguay'],['PE', 'Peru'],['PH', 'Philippines'],['PN', 'Pitcairn'],['PL', 'Poland'],['PT', 'Portugal'],['PR', 'Puerto Rico'],['QA', 'Qatar'],['KR', 'Republic of Korea (South)'],['RE', 'Reunion'],['RO', 'Romania'],['RU', 'Russian Federation'],['RW', 'Rwanda'],['SH', 'Saint Helena'],['KN', 'Saint Kitts And Nevis'],['LC', 'Saint Lucia'],['PM', 'Saint Pierre And Miquelon'],['VC', 'Saint Vincent And The Grenadines'],['WS', 'Samoa'],['SM', 'San Marino'],['ST', 'Sao Tome And Principe'],['SA', 'Saudi Arabia'],['SN', 'Senegal'],['CS', 'Serbia'],['SC', 'Seychelles'],['SL', 'Sierra Leone'],['SG', 'Singapore'],['SK', 'Slovakia'],['SI', 'Slovenia'],['SB', 'Solomon Islands'],['SO', 'Somalia'],['ZA', 'South Africa'],['ES', 'Spain'],['LK', 'Sri Lanka'],['SD', 'Sudan'],['SR', 'Suriname'],['SJ', 'Svalbard And Jan Mayen'],['SZ', 'Swaziland'],['SE', 'Sweden'],['CH', 'Switzerland'],['SY', 'Syrian Arab Republic'],['TW', 'Taiwan, Province of China'],['TJ', 'Tajikistan'],['TZ', 'Tanzania, United Republic of'],['TH', 'Thailand'],['TL', 'Timor-leste'],['TG', 'Togo'],['TK', 'Tokelau'],['TO', 'Tonga'],['TT', 'Trinidad And Tobago'],['TN', 'Tunisia'],['TR', 'Turkey'],['TM', 'Turkmenistan'],['TC', 'Turks And Caicos Islands'],['TV', 'Tuvalu'],['UG', 'Uganda'],['UA', 'Ukraine'],['AE', 'United Arab Emirates'],['UK', 'United Kingdom'],['US', 'United States'],['UM', 'United States Minor Outlying Islands'],['PU', 'United States Pacific Islands'],['VI', 'United States Virgin Islands'],['XK', 'Unmik (United Nations of Kosovo)'],['UY', 'Uruguay'],['UZ', 'Uzbekistan'],['VU', 'Vanuatu'],['VE', 'Venezuela'],['VN', 'Viet Nam'],['VG', 'Virgin Islands (British)'],['WF', 'Wallis and Futuna Islands'],['EH', 'Western Sahara'],['YE', 'Yemen'],['ZM', 'Zambia'],['ZW', 'Zimbabwe'] ]})Ext.define('MyApp.model.CodeDescriptionAccountSummaryPaymentInformationStore',{extend: 'Ext.data.Model',id: 'AccountSummaryPaymentInformationStore',fields: [{name:'Angle'},{name:'Label'},{name:'Color'},{name:'IsMaxAngle'}]});Ext.create('Ext.data.JsonStore',{ autoDestroy: false, proxy: { type: 'memory', reader: 'json', writer: 'json' }, storeId: 'AccountSummaryPaymentInformationStore', fields: [{ name: 'Angle', type: 'string'},{ name: 'Label', type: 'string'},{ name: 'Color', type: 'string'},{ name: 'IsMaxAngle', type: 'string'}],data: [{"Angle":"360","Label":"Total Balance","Color":"#005596","IsMaxAngle":true,"EntityID":null}]});Ext.define('Ext.chart.theme.instamed', { extend: 'Ext.chart.theme.Base', singleton: true, alias: 'chart.theme.instamed', config: { colors: ["#1976D2","#A5D6A7","#039BE5","#4A148C","#4CAF50","#9575CD","#C51162","#FB8C00","#880E4F","#E57373","#90A4AE"] } });function removeProvider(providerAlias) { var providerName = Ext.StoreManager.get('MyAccountProvidersList-init').findRecord('ProviderAlias', providerAlias).get('ProviderName');var payeeName = providerName;if(!payeeName){payeeName = 'This Payee'}if(InstaMed.isMobileOrTablet){Ext.Msg.show({title: '

Remove

',message: 'Remove ' + payeeName + ' ?',buttons: [{text: 'Cancel',ui: 'decline',itemId: 'no'}, {text: 'Remove',ui: 'confirm',itemId: 'yes'}],fn: function(btn) {if (btn === 'yes') {PerformAction({ProviderAlias: providerAlias, ProviderName: providerName}, MyAccountController.removeProvider); }}}); }else{ Ext.Msg.buttonText.cancel = Ext.util.Format.htmlEncode('Cancel'); Ext.Msg.buttonText.ok = Ext.util.Format.htmlEncode('Ok'); Ext.Msg.show({title: '

Please Confirm

Remove

',message: 'Remove ' + payeeName + ' ?',buttons: [{text: 'Cancel',ui: 'decline',itemId: 'no'}, {text: 'Remove',ui: 'confirm',itemId: 'yes'}],fn: function(btn) {if (btn === 'yes') {PerformAction({EntityID: entityID, ProviderName: payeeName}, MyAccountController.removeOffNetworkPayee); }}}); }else{ Ext.Msg.buttonText.cancel = Ext.util.Format.htmlEncode('Cancel'); Ext.Msg.buttonText.ok = Ext.util.Format.htmlEncode('Ok'); Ext.Msg.show({title: '

Please Confirm

',msg: 'Remove ' + payeeName + '?',icon: Ext.Msg.QUESTION,buttons: Ext.Msg.OKCANCEL,iconWidth:54,iconHeight:45,fn: function(btn) {if (btn === 'ok') {PerformAction({EntityID: entityID, ProviderName: payeeName}, MyAccountController.removeOffNetworkPayee);}} });} event && event.stopPropagation();}function registerRemovePayeeTooltip(providerAlias) {Ext.tip.QuickTipManager.register({target: 'remove-payee-icon-' + providerAlias,text : 'Remove',showDelay: 125});}function registerAllRemovePayeeTooltips() { var store = Ext.StoreManager.get('MyAccountProvidersList-init'); if(store) {for(var i = 0; i < store.getTotalCount(); i++){var rec = store.getAt(i);registerRemovePayeeTooltip(rec.get('ProviderAlias')); } }} function EncodeApostropheAndURIComponent (str) { return InstaMed.encodeApostrophe(encodeURIComponent(str)); } function payeeTileRedirect(alias, visit, payment, add, select, pk, memberpay,trackingData, autoCompleteName, location) { var dataView = InstaMed.get('ProviderBadges'); if(dataView && dataView.lastStoreUpdate && (Math.floor(Date.now()) - dataView.lastStoreUpdate < 1000)){ return;}; var pageNum = 1; if(dataView) pageNum = dataView.getStore().currentPage; var navPage = Ext.get('NavFindProvider') var scrollLocation = 0; if (navPage && navPage.child) { var container = navPage.child('div', false); if(container && container.child) { var scroller = container.child('div[class*=x-scroller]', false); if(scroller && scroller.dom.scroll) { scrollLocation = scroller.dom.scrollTop; } } } PerformAction({ ProviderAlias: alias, isVisit: visit, isPayment: payment, isAdd: add, isSelect: select, isMemberPayment: memberpay, OffNetworkPK: pk,Origin:null, trackingData: trackingData, pageNumber: pageNum, scrollLocation: scrollLocation, autoCompleteName: autoCompleteName, location: location }, FindProviderController.enterPayeeManually); event && event.stopPropagation();}function handlePayNow(alias, pk) {PerformAction({ ProviderAlias: alias, OffNetworkPK: pk}, FindProviderController.payNowRedirect); event && event.stopPropagation();}function handleGoTo(alias, pk) {PerformAction({ ProviderAlias: alias, OffNetworkPK: pk}, FindProviderController.goToRedirect); event && event.stopPropagation();} function handleGoToAcceptPayment(alias) { PerformAction({ ProviderAlias: alias}, FindProviderController.goToAcceptPaymentRedirect); event && event.stopPropagation(); } function closem*nu(){ var dropdowns = document.getElementsByClassName("dropdown-content");var i;for (i = 0; i x.data.PaymentPlanID === 'NEW' && x.data.PaymentType === 'CreditCard') if(storeItems.length > 1){ store.insert(index, {PaymentType: 'GooglePay', AccountType: 'GooglePay', EditPaymentPlanID: 'GooglePay', PaymentAccount: 'GooglePay', id: 'GooglePay', PaymentPlanID: 'GooglePay', AccountNickname: 'Google Pay', IconCls:'googlePayCls', ShowAllFields: false}); } else{ store.insert(index - 1, {PaymentType: 'GooglePay', AccountType: 'GooglePay', EditPaymentPlanID: 'GooglePay', PaymentAccount: 'GooglePay', id: 'GooglePay', PaymentPlanID: 'GooglePay', AccountNickname: 'Google Pay', IconCls:'googlePayCls', ShowAllFields: false}); } } } }function getPaymentMethodDefaultOnLoad(cmp){ if(window.runPaymentMethodSelectorPaintEvent == undefined) { window.runPaymentMethodSelectorPaintEvent = true; }; if(window.runPaymentMethodSelectorPaintEvent){ var storeCmp = InstaMed.get('PaymentMethodSelectionDataViewComponent'); if(storeCmp) { var store = storeCmp.getStore(); var payments = store.data.items; var hasDefault = false; var ccContainer = InstaMed.get('creditCardInfoContainer'); var checkContainer = InstaMed.get('checkInfoContainer'); var emptyContainer = InstaMed.get('PaymentMethodSelectionEmptyContainer'); var removeBtn = InstaMed.get('btnRemove'); var paymentBankAccountDefault = InstaMed.get('PaymentBankAccountDefault'); var googlePaySupported = InstaMed.get('GooglePaySupported'); var applePaySupported = InstaMed.get('ApplePaySupported'); var startInEditMode = false; var isECheckNewPaymentMethodSelected = false; var isCreditNewPaymentMethodSelected = false; var indexRadio = null; resetPaymentMethodInfoFields(cmp); removeBtn && removeBtn.innerElement.getFirstChild().addCls('x-link-red x-button'); removeBtn && removeBtn.innerElement.addCls('zero-left-padding'); if(payments.length > 0){ payments.forEach((payment, index) => { if(InstaMed.isTrue(payment.data.IsDefaultPaymentMethod)){ if(payment.data.PaymentPlanID != 'NEW'){ InstaMed.get('PaymentMethodRadioOption').resetGroupValues(); InstaMed.get('PaymentMethodRadioOption').setGroupValue(payment.data.PaymentPlanID); var editMode = InstaMed.get('EditMode'); hasDefault = true; startInEditMode = payment.data.StartInEditMode; editMode.setValue(payment.data.IsEditable) var paymentType = payment.data.PaymentType; indexRadio = index; if (!payment.data.CardHolderCountry) { payment.data.CardHolderCountry = 'US'; } InstaMed.get('CardHolderName') && InstaMed.get('CardHolderName').setValue(payment.data.NameOnCard); InstaMed.get('CreditCardNumber') && InstaMed.get('CreditCardNumber').setValue(payment.data.CardNumber); InstaMed.get('ExpMonth') && InstaMed.get('ExpMonth').setValue(payment.data.ExpMonth); InstaMed.get('ExpYear') && InstaMed.get('ExpYear').setValue(payment.data.ExpYear); InstaMed.get('ExpDate') && InstaMed.get('ExpDate').setValue(payment.data.ExpMonth==null? null : Ext.util.Format.date(new Date(payment.data.ExpMonth+'/1/'+payment.data.ExpYear),'m/y')); InstaMed.get('CVN') && InstaMed.get('CVN').setValue(payment.data.CVN); InstaMed.get('CreditCardAccountHolderAddress1') && InstaMed.get('CreditCardAccountHolderAddress1').setValue(payment.data.CardHolderAddress1); InstaMed.get('CreditCardAccountHolderAddress2') && InstaMed.get('CreditCardAccountHolderAddress2').setValue(payment.data.CardHolderAddress2); InstaMed.get('CreditCardAccountHolderCity') && InstaMed.get('CreditCardAccountHolderCity').setValue(payment.data.CardHolderCity); InstaMed.get('CreditCardAccountHolderState') && InstaMed.get('CreditCardAccountHolderState').setValue(payment.data.CardHolderState); InstaMed.get('CreditCardAccountHolderZip') && InstaMed.get('CreditCardAccountHolderZip').setValue(payment.data.CardHolderZip); InstaMed.get('CreditCardAccountHolderCountry') && InstaMed.get('CreditCardAccountHolderCountry').setValue(payment.data.CardHolderCountry); InstaMed.get('CheckingAccountNameOnAccount') && InstaMed.get('CheckingAccountNameOnAccount').setValue( payment.data.CheckHolderLastName==null? null : Ext.String.trim(payment.data.CheckHolderName)); InstaMed.get('CheckingAccountHolderFirstName') && InstaMed.get('CheckingAccountHolderFirstName').setValue(payment.data.CheckHolderFirstName); InstaMed.get('CheckingAccountHolderLastName') && InstaMed.get('CheckingAccountHolderLastName').setValue(payment.data.CheckHolderLastName); InstaMed.get('CheckingAccountType') && InstaMed.get('CheckingAccountType').setValue(payment.data.CheckAccountType); InstaMed.get('RoutingNumber') && InstaMed.get('RoutingNumber').setValue(payment.data.RoutingNumber); InstaMed.get('CheckingAccountNumber') && InstaMed.get('CheckingAccountNumber').setValue(payment.data.AccountNumber); InstaMed.get('CheckingAccountHolderState') && InstaMed.get('CheckingAccountHolderState').setValue(payment.data.CheckHolderState); InstaMed.get('CheckingAccountHolderAddress1') && InstaMed.get('CheckingAccountHolderAddress1').setValue(payment.data.CheckHolderStreet1); InstaMed.get('CheckingAccountHolderAddress2') && InstaMed.get('CheckingAccountHolderAddress2').setValue(payment.data.CheckHolderStreet2); InstaMed.get('CheckingAccountHolderCity') && InstaMed.get('CheckingAccountHolderCity').setValue(payment.data.CheckHolderCity); InstaMed.get('CheckingAccountHolderZip') && InstaMed.get('CheckingAccountHolderZip').setValue(payment.data.CheckHolderZip); InstaMed.get('CheckingAccountHolderPhoneNumber') && InstaMed.get('CheckingAccountHolderPhoneNumber').setValue(payment.data.CheckHolderPhoneNumber); InstaMed.get('CheckingAccountHolderDriversLicense') && InstaMed.get('CheckingAccountHolderDriversLicense').setValue(payment.data.CheckHolderDriversLicense); InstaMed.get('AccountType') && InstaMed.get('AccountType').setValue(paymentType); InstaMed.get('EditPaymentPlanID') && InstaMed.get('EditPaymentPlanID').setValue(payment.data.PaymentPlanID); InstaMed.get('PaymentAccount') && InstaMed.get('PaymentAccount').setValue(payment.data.PaymentPlanID); InstaMed.get('EntityID') && InstaMed.get('EntityID').setValue(payment.data.EntityID); InstaMed.get('PaymentType') && InstaMed.get('PaymentType').setValue(payment.data.PaymentPlanID); InstaMed.get('Label') && InstaMed.get('Label').setValue(payment.data.AccountNickname); } else { if(payment.data.PaymentType == 'CreditCard'){ isCreditNewPaymentMethodSelected = true; indexRadio = index; } if(payment.data.PaymentType == 'ECheck'){ isECheckNewPaymentMethodSelected = true; indexRadio = index; } } } } ); if(hasDefault && !startInEditMode || !hasDefault){ if(checkContainer){ emptyContainer && emptyContainer.add(checkContainer); } if(ccContainer){ emptyContainer && emptyContainer.add(ccContainer); } if(removeBtn){ emptyContainer && emptyContainer.add(removeBtn); } ccContainer &&ccContainer.hide(); checkContainer && checkContainer.hide(); removeBtn && removeBtn.hide(); } if(!hasDefault){ if(payments.length == 1 && !(googlePaySupported && googlePaySupported.getValue()) && !(applePaySupported && applePaySupported.getValue()) ) { checkContainer && checkContainer.hide(); ccContainer && ccContainer.hide(); InstaMed.get('PaymentMethodRadioOption').setGroupValue(payments[0].data.PaymentPlanID); if(payments[0].data.PaymentType == 'CreditCard'){ ccContainer && ccContainer.show(); } else if(payments[0].data.PaymentType == 'ECheck'){ checkContainer && checkContainer.show(); } } } if(indexRadio !=null){ var radioOpts = document.getElementsByName('PaymentMethodRadioOption'); Ext.Array.forEach(radioOpts, function(cmpRadio, index){ if(index == indexRadio){ InstaMed.get('PaymentMethodRadioOption').resetGroupValues(); cmpRadio.click(); } }); } } } } window.runPaymentMethodSelectorPaintEvent = true; }function removePaymentMethodSuccessStoreUpdate(cmp){ window.runPaymentMethodSelectorPaintEvent = true; var entityID = InstaMed.get('EntityID').getValue(); var ccContainer = InstaMed.get('creditCardInfoContainer'); var checkContainer = InstaMed.get('checkInfoContainer'); var removeBtn = InstaMed.get('btnRemove'); var emptyContainer = InstaMed.get('PaymentMethodSelectionEmptyContainer'); emptyContainer.add(checkContainer); emptyContainer.add(ccContainer); emptyContainer.add(removeBtn); ccContainer.hide(); checkContainer.hide(); removeBtn.hide(); var storeCmp = InstaMed.get('PaymentMethodSelectionDataViewComponent'); if(storeCmp) { var store = storeCmp.getStore(); var dataFromStore = store.data; var index = dataFromStore.items.findIndex(x => x.data.EntityID === entityID); dataFromStore.removeAt(index); getPaymentMethodDefaultOnLoad(cmp); } }function resetPaymentMethodInfoFields(cmp){ InstaMed.get('CardHolderName') && InstaMed.get('CardHolderName').setValue(null); InstaMed.get('CreditCardNumber') && InstaMed.get('CreditCardNumber').setValue(null); InstaMed.get('ExpMonth') && InstaMed.get('ExpMonth').setValue(null); InstaMed.get('ExpYear') && InstaMed.get('ExpYear').setValue(null); InstaMed.get('ExpDate') && InstaMed.get('ExpDate').setValue(null); InstaMed.get('CVN') && InstaMed.get('CVN').setValue(null); InstaMed.get('CreditCardAccountHolderAddress1') && InstaMed.get('CreditCardAccountHolderAddress1').setValue(null); InstaMed.get('CreditCardAccountHolderAddress2') && InstaMed.get('CreditCardAccountHolderAddress2').setValue(null); InstaMed.get('CreditCardAccountHolderCity') && InstaMed.get('CreditCardAccountHolderCity').setValue(null); InstaMed.get('CreditCardAccountHolderState') && InstaMed.get('CreditCardAccountHolderState').setValue(null); InstaMed.get('CreditCardAccountHolderZip') && InstaMed.get('CreditCardAccountHolderZip').setValue(null); InstaMed.get('CheckingAccountNameOnAccount') && InstaMed.get('CheckingAccountNameOnAccount').setValue(null); InstaMed.get('CheckingAccountHolderFirstName') && InstaMed.get('CheckingAccountHolderFirstName').setValue(null); InstaMed.get('CheckingAccountHolderLastName') && InstaMed.get('CheckingAccountHolderLastName').setValue(null); InstaMed.get('CheckingAccountType') && InstaMed.get('CheckingAccountType').setValue(null); InstaMed.get('RoutingNumber') && InstaMed.get('RoutingNumber').setValue(null); InstaMed.get('CheckingAccountHolderAddress1') && InstaMed.get('CheckingAccountHolderAddress1').setValue(null); InstaMed.get('CheckingAccountHolderAddress2') && InstaMed.get('CheckingAccountHolderAddress2').setValue(null); InstaMed.get('CheckingAccountHolderCity') && InstaMed.get('CheckingAccountHolderCity').setValue(null); InstaMed.get('CheckingAccountHolderZip') && InstaMed.get('CheckingAccountHolderZip').setValue(null); InstaMed.get('CheckingAccountNumber') && InstaMed.get('CheckingAccountNumber').setValue(null); InstaMed.get('ConfirmCheckingAccountNumber') && InstaMed.get('ConfirmCheckingAccountNumber').setValue(null); InstaMed.get('CheckingAccountHolderState') && InstaMed.get('CheckingAccountHolderState').setValue(null); InstaMed.get('CheckingAccountHolderPhoneNumber') && InstaMed.get('CheckingAccountHolderPhoneNumber').setValue(null); InstaMed.get('CheckingAccountHolderDriversLicense') && InstaMed.get('CheckingAccountHolderDriversLicense').setValue(null); InstaMed.get('AccountType') && InstaMed.get('AccountType').setValue(null); InstaMed.get('EditPaymentPlanID') && InstaMed.get('EditPaymentPlanID').setValue(null); InstaMed.get('PaymentAccount') && InstaMed.get('PaymentAccount').setValue(null); InstaMed.get('EntityID') && InstaMed.get('EntityID').setValue(null); InstaMed.get('PaymentType') && InstaMed.get('PaymentType').setValue(null); InstaMed.get('Label') && InstaMed.get('Label').setValue(null); InstaMed.get('APCNotSupportedMessageContainer') && InstaMed.get('APCNotSupportedMessageContainer').hide(); var form = InstaMed.getActiveForm(); form.clearInvalid(); InstaMed.clearValidation(form); }function setCardTypeIconCLS() { var cardType = InstaMed.get('CardType'); var creditCardField = InstaMed.get('CreditCardNumber'); if(cardType && creditCardField) { var triggers = creditCardField.getTriggers(); if (triggers && triggers.VISATrigger) { creditCardField.removeTrigger('VISATrigger'); } if (triggers && triggers.AmexTrigger) { creditCardField.removeTrigger('AmexTrigger'); } if (triggers && triggers.DiscoveryTrigger) { creditCardField.removeTrigger('DiscoveryTrigger'); } if (triggers && triggers.MasterCardTrigger) { creditCardField.removeTrigger('MasterCardTrigger'); } if (triggers && triggers.OtherCardsTrigger) { creditCardField.removeTrigger('OtherCardsTrigger'); } if(InstaMed.isTrue('False')){ cardType.setValue(''); } var cardTypeValue = cardType.getValue(); if(cardTypeValue) { cardTypeValue = cardTypeValue.toUpperCase(); if(cardTypeValue != 'INITIAL') { if(cardTypeValue == 'MC') { if (triggers && !triggers.MasterCardTrigger) { creditCardField.addTrigger('MasterCardTrigger',{cls:'mastercardCls',type: 'cardIcon'}); } } else if(cardTypeValue == 'VISA') { if (triggers && !triggers.VISATrigger) { creditCardField.addTrigger('VISATrigger',{cls:'visaCls',type: 'cardIcon'}); } } else if(cardTypeValue == 'AMEX') { if (triggers && !triggers.AmexTrigger) { creditCardField.addTrigger('AmexTrigger',{cls:'amexCls',type: 'cardIcon'}); } } else if(cardTypeValue == 'DISCOVER') { if (triggers && !triggers.DiscoveryTrigger) { creditCardField.addTrigger('DiscoveryTrigger',{cls:'discoverCls',type: 'cardIcon'}); } } else if(cardTypeValue == 'OTHER') { if (triggers && !triggers.OtherCardsTrigger) { creditCardField.addTrigger('OtherCardsTrigger',{cls:'echeckCls',type: 'cardIcon'}); } } } else { if (triggers && !triggers.VISATrigger && true) { creditCardField.addTrigger('VISATrigger',{cls:'visaCls',type: 'cardIcon'}); } if (triggers && !triggers.DiscoveryTrigger && true) { creditCardField.addTrigger('DiscoveryTrigger',{cls:'discoverCls',type: 'cardIcon'}); } if (triggers && !triggers.MasterCardTrigger && true) { creditCardField.addTrigger('MasterCardTrigger',{cls:'mastercardCls',type: 'cardIcon'}); } if (triggers && !triggers.AmexTrigger && true) { creditCardField.addTrigger('AmexTrigger',{cls:'amexCls',type: 'cardIcon'}); } if (triggers && !triggers.OtherCardsTrigger && false) { creditCardField.addTrigger('OtherCardsTrigger',{cls:'echeckCls',type: 'cardIcon'}); } } } else { if (triggers && !triggers.VISATrigger && true) { creditCardField.addTrigger('VISATrigger',{cls:'visaCls',type: 'cardIcon'}); } if (triggers && !triggers.DiscoveryTrigger && true) { creditCardField.addTrigger('DiscoveryTrigger',{cls:'discoverCls',type: 'cardIcon'}); } if (triggers && !triggers.MasterCardTrigger && true) { creditCardField.addTrigger('MasterCardTrigger',{cls:'mastercardCls',type: 'cardIcon'}); } if (triggers && !triggers.AmexTrigger && true) { creditCardField.addTrigger('AmexTrigger',{cls:'amexCls',type: 'cardIcon'}); } if (triggers && !triggers.OtherCardsTrigger && false) { creditCardField.addTrigger('OtherCardsTrigger',{cls:'echeckCls',type: 'cardIcon'}); } } } }Ext.define('MyApp.model.CodeDescriptionpaymentMethodRadioSelectorStore',{extend: 'Ext.data.Model',id: 'paymentMethodRadioSelectorStore',fields: [{name:'IconCls'},{name:'PaymentPlanID'},{name:'AccountNickname'},{name:'PaymentType'},{name:'IsDefaultPaymentMethod'},{name:'StartInEditMode'},{name:'IsEditable'},{name:'ShowAllFields'},{name:'NameOnCard'},{name:'CardNumber'},{name:'CardHolderDriversLicense'},{name:'ExpDate'},{name:'ExpMonth'},{name:'ExpYear'},{name:'CardHolderAddress1'},{name:'CardHolderAddress2'},{name:'CardHolderCity'},{name:'CardHolderState'},{name:'CardHolderZip'},{name:'CardHolderCountry'},{name:'CardHolderPhoneNumber'},{name:'CVN'},{name:'CheckHolderFirstName'},{name:'CheckHolderLastName'},{name:'RoutingNumber'},{name:'AccountNumber'},{name:'CheckHolderStreet1'},{name:'CheckHolderStreet2'},{name:'CheckHolderCity'},{name:'CheckHolderZip'},{name:'CheckHolderState'},{name:'CheckHolderPhoneNumber'},{name:'CheckHolderName'},{name:'CheckHolderDriversLicense'},{name:'CheckAccountType'},{name:'CheckHolderCountry'},{name:'EntityID'}]});Ext.create('Ext.data.JsonStore',{ autoDestroy: false, proxy: { type: 'memory', reader: 'json', writer: 'json' }, storeId: 'paymentMethodRadioSelectorStore', fields: [{ name: 'IconCls', type: 'auto'},{ name: 'PaymentPlanID', type: 'auto'},{ name: 'AccountNickname', type: 'auto'},{ name: 'PaymentType', type: 'auto'},{ name: 'IsDefaultPaymentMethod', type: 'auto'},{ name: 'StartInEditMode', type: 'boolean'},{ name: 'IsEditable', type: 'boolean'},{ name: 'ShowAllFields', type: 'boolean'},{ name: 'NameOnCard', type: 'auto'},{ name: 'CardNumber', type: 'auto'},{ name: 'CardHolderDriversLicense', type: 'auto'},{ name: 'ExpDate', type: 'auto'},{ name: 'ExpMonth', type: 'auto'},{ name: 'ExpYear', type: 'auto'},{ name: 'CardHolderAddress1', type: 'auto'},{ name: 'CardHolderAddress2', type: 'auto'},{ name: 'CardHolderCity', type: 'auto'},{ name: 'CardHolderState', type: 'auto'},{ name: 'CardHolderZip', type: 'auto'},{ name: 'CardHolderCountry', type: 'auto'},{ name: 'CardHolderPhoneNumber', type: 'auto'},{ name: 'CVN', type: 'auto'},{ name: 'CheckHolderFirstName', type: 'auto'},{ name: 'CheckHolderLastName', type: 'auto'},{ name: 'RoutingNumber', type: 'auto'},{ name: 'AccountNumber', type: 'auto'},{ name: 'CheckHolderStreet1', type: 'auto'},{ name: 'CheckHolderStreet2', type: 'auto'},{ name: 'CheckHolderCity', type: 'auto'},{ name: 'CheckHolderZip', type: 'auto'},{ name: 'CheckHolderState', type: 'auto'},{ name: 'CheckHolderPhoneNumber', type: 'auto'},{ name: 'CheckHolderName', type: 'auto'},{ name: 'CheckHolderDriversLicense', type: 'auto'},{ name: 'CheckAccountType', type: 'auto'},{ name: 'CheckHolderCountry', type: 'auto'},{ name: 'EntityID', type: 'auto'}],data: [{IconCls:'newPaymentAccountCls',PaymentPlanID:'NEW',AccountNickname:'Add Credit/Debit Card',PaymentType:'CreditCard',IsDefaultPaymentMethod:'False',StartInEditMode:'False',IsEditable:'False',ShowAllFields:null,NameOnCard:null,CardNumber:null,CardHolderDriversLicense:null,ExpDate:null,ExpMonth:null,ExpYear:null,CardHolderAddress1:null,CardHolderAddress2:null,CardHolderCity:null,CardHolderState:null,CardHolderZip:null,CardHolderCountry:'US',CardHolderPhoneNumber:null,CVN:null,CheckHolderFirstName:null,CheckHolderLastName:null,RoutingNumber:null,AccountNumber:null,CheckHolderStreet1:null,CheckHolderStreet2:null,CheckHolderCity:null,CheckHolderZip:null,CheckHolderState:null,CheckHolderPhoneNumber:null,CheckHolderName:null,CheckHolderDriversLicense:null,CheckAccountType:null,CheckHolderCountry:null,EntityID:null},{IconCls:'echeckCls',PaymentPlanID:'NEW',AccountNickname:'Add Bank Account',PaymentType:'ECheck',IsDefaultPaymentMethod:'False',StartInEditMode:'False',IsEditable:'False',ShowAllFields:null,NameOnCard:null,CardNumber:null,CardHolderDriversLicense:null,ExpDate:null,ExpMonth:null,ExpYear:null,CardHolderAddress1:null,CardHolderAddress2:null,CardHolderCity:null,CardHolderState:null,CardHolderZip:null,CardHolderCountry:null,CardHolderPhoneNumber:null,CVN:null,CheckHolderFirstName:null,CheckHolderLastName:null,RoutingNumber:null,AccountNumber:null,CheckHolderStreet1:null,CheckHolderStreet2:null,CheckHolderCity:null,CheckHolderZip:null,CheckHolderState:null,CheckHolderPhoneNumber:null,CheckHolderName:null,CheckHolderDriversLicense:null,CheckAccountType:null,CheckHolderCountry:null,EntityID:null}]});function setAccountNicknameAndIcon(isNew) { var paymentType = InstaMed.getValue('AccountType'); var saveTheCardChkBox = InstaMed.get('SaveCardOnFile'); var iconName; if (paymentType == 'CreditCard' || (paymentType && paymentType.AccountType == 'CreditCard')) { var nickNameField = InstaMed.get('CardAccountNickName'); var nickNameLinkButton = Ext.getElementById('CardAccountNickNameLinkButton'); var cardNumber = InstaMed.getValue('CreditCardNumber'); if(cardNumber) { cardNumber = cardNumber.replace(/\D/g,''); var first = cardNumber.substr(0, 1); var firstTwo = cardNumber.substr(0, 2); var firstThree = cardNumber.substr(0, 3); var firstFour = cardNumber.substr(0, 4); var lastFour = cardNumber.substring(Math.max(cardNumber.length - 4, 0), cardNumber.length); var cardType; if(first == '4') { cardType = 'VISA'; iconName = 'PaymentIconVISA'; } else if(first == '5') { cardType = 'MasterCard'; iconName = 'PaymentIconMC'; } else if(firstTwo == '34' || firstTwo == '37') { cardType = 'AmEx'; iconName = 'PaymentIconAMEX'; } else if(firstFour == '6011' || firstTwo == '65') { cardType = 'Discover'; iconName = 'PaymentIconDISCOVER'; } else if(firstThree == '300' || firstThree == '305' || firstTwo == '36' || firstTwo == '38') { cardType = 'Diners'; } else if(first == '2') { var bin = cardNumber.length >= 6 ? parseInt(cardNumber.substr(0, 6)) : null; if (bin >= 222100 && bin <= 272099) { cardType = 'MasterCard'; iconName = 'PaymentIconMC'; } else { cardType = 'Card'; } } else { cardType = 'Card'; } if(saveTheCardChkBox) { var name =cardType + ' ****' + lastFour; nickNameField.setValue(name); nickNameLinkButton.textContent = name; nickNameLinkButton.setAttribute('aria-label','Edit '+name+' nickname'); } if(nickNameField && InstaMed.isTrue(InstaMed.getValue('AutoGenerateNickname')) && InstaMed.isFalse(InstaMed.getValue('EditMode'))) { nickNameField.setValue(cardType + ' ****' + lastFour); if (nickNameLinkButton) { if(!isNew) { var name = cardType + ' ****' + lastFour; nickNameLinkButton.textContent = name; nickNameLinkButton.setAttribute('aria-label','Edit '+name+' nickname'); } } } } if(!cardNumber && isNew) { if(nickNameField && InstaMed.isTrue(InstaMed.getValue('AutoGenerateNickname')) && InstaMed.isFalse(InstaMed.getValue('EditMode'))) { nickNameField.setValue(''); if (nickNameLinkButton) { nickNameLinkButton.textContent = ''; nickNameLinkButton.setAttribute('aria-label','Blank nickname'); } } } } else { iconName = 'PaymentIconECheck'; var accountNum = InstaMed.getValue('CheckingAccountNumber'); var nickNameField = InstaMed.get('CheckingAccountNickName'); var nickNameLinkButton = Ext.getElementById('CheckingAccountNickNameLinkButton'); if(accountNum) { var lastFour = accountNum.substring(Math.max(accountNum.length - 4, 0), accountNum.length); var checkingAccountType = 'Bank Account'; if(nickNameField && InstaMed.isTrue(InstaMed.getValue('AutoGenerateNickname')) && !InstaMed.isTrue(InstaMed.getValue('EditMode'))) { nickNameField.setValue(checkingAccountType + ' ****' + lastFour); if (nickNameLinkButton) { if (isNew == true) { nickNameLinkButton.textContent = ''; nickNameLinkButton.setAttribute('aria-label',''); } else { var name = checkingAccountType + ' ****' + lastFour; nickNameLinkButton.textContent = name ; nickNameLinkButton.setAttribute('aria-label','Edit '+name+' nickname'); } } } } if(!accountNum && isNew) { if(nickNameField && InstaMed.isTrue(InstaMed.getValue('AutoGenerateNickname')) && InstaMed.isFalse(InstaMed.getValue('EditMode'))) { nickNameField.setValue(''); if (nickNameLinkButton) { nickNameLinkButton.textContent = ''; nickNameLinkButton.setAttribute('aria-label','Blank nickname'); } } } } }Ext.define('MyApp.view.creditcardfield', { extend: 'Ext.field.Text', alias: 'widget.creditcardfield', getSubmitValue: function() { var val = Ext.field.Text.superclass.getValue.call(this); if(val) { val = val.replace(/[\-\s]/g,''); } return val; } });function HandleCVNDisplay(keyed) { var form = Ext.ComponentQuery.query('[name="FormPatientPayment"]')[0]; if(InstaMed.get('CVN',form)) { var val = InstaMed.get('CVNInitialState',form).getValue(); if(val) { var cvninitialstate = Ext.JSON.decode(val); var cvnfield = InstaMed.get('CVN',form); if(!cvninitialstate.manualCardReader) { if(!keyed) { cvnfield.setDisabled(cvninitialstate.disabled); cvnfield.setVisible(cvninitialstate.visible); } else { cvnfield.setDisabled(false); cvnfield.setVisible(cvninitialstate.formVisible); } } cvnfield.reset(); } } }Ext.create('Ext.data.ArrayStore',{ type: 'json', autoDestroy: false, storeId: 'CheckingAccountHolderStateStore', fields: [ { name: 'code', type: 'string' }, { name: 'description', type: 'string' } ], data: [['AK', 'Alaska'],['AL', 'Alabama'],['AR', 'Arkansas'],['AS', 'American Samoa'],['AZ', 'Arizona'],['CA', 'California'],['CO', 'Colorado'],['CT', 'Connecticut'],['DC', 'District Of Columbia'],['DE', 'Delaware'],['FL', 'Florida'],['FM', 'Federated States Of Micronesia'],['GA', 'Georgia'],['GU', 'Guam'],['HI', 'Hawaii'],['IA', 'Iowa'],['ID', 'Idaho'],['IL', 'Illinois'],['IN', 'Indiana'],['KS', 'Kansas'],['KY', 'Kentucky'],['LA', 'Louisiana'],['MA', 'Massachusetts'],['MD', 'Maryland'],['ME', 'Maine'],['MH', 'Marshall Islands'],['MI', 'Michigan'],['MN', 'Minnesota'],['MO', 'Missouri'],['MP', 'Northern Mariana Islands'],['MS', 'Mississippi'],['MT', 'Montana'],['NC', 'North Carolina'],['ND', 'North Dakota'],['NE', 'Nebraska'],['NH', 'New Hampshire'],['NJ', 'New Jersey'],['NM', 'New Mexico'],['NV', 'Nevada'],['NY', 'New York'],['OH', 'Ohio'],['OK', 'Oklahoma'],['OR', 'Oregon'],['PA', 'Pennsylvania'],['PR', 'Puerto Rico'],['PW', 'Palau'],['RI', 'Rhode Island'],['SC', 'South Carolina'],['SD', 'South Dakota'],['TN', 'Tennessee'],['TX', 'Texas'],['UT', 'Utah'],['VA', 'Virginia'],['VI', 'Virgin Islands'],['VT', 'Vermont'],['WA', 'Washington'],['WI', 'Wisconsin'],['WV', 'West Virginia'],['WY', 'Wyoming'] ]})function ShowEStatementInfo(e) { e.preventDefault(); var form = InstaMed.getNavigationView(); form.push('EStatementEnrollmentInfo'); }Ext.define('MyApp.model.CodeDescriptionPaymentInformationReviewAndConfirmStore',{extend: 'Ext.data.Model',id: 'PaymentInformationReviewAndConfirmStore',fields: [{name:'Index'},{name:'Duration'},{name:'InstallmentAmount'},{name:'InstallmentAmountDescription'},{name:'StartDate'},{name:'EndDate'},{name:'Frequency'},{name:'FrequencyDescription'},{name:'TotalPlanAmount'},{name:'IsRecommended'},{name:'IsSelected'},{name:'IsCustomPlan'},{name:'InitialPayment'},{name:'FrequncyTranslate'}]});Ext.create('Ext.data.JsonStore',{ autoDestroy: false, proxy: { type: 'memory', reader: 'json', writer: 'json' }, storeId: 'PaymentInformationReviewAndConfirmStore', fields: [{ name: 'Index', type: 'auto'},{ name: 'Duration', type: 'auto'},{ name: 'InstallmentAmount', type: 'auto'},{ name: 'InstallmentAmountDescription', type: 'auto'},{ name: 'StartDate', type: 'auto'},{ name: 'EndDate', type: 'auto'},{ name: 'Frequency', type: 'auto'},{ name: 'FrequencyDescription', type: 'auto'},{ name: 'TotalPlanAmount', type: 'auto'},{ name: 'IsRecommended', type: 'auto'},{ name: 'IsSelected', type: 'auto'},{ name: 'IsCustomPlan', type: 'auto'},{ name: 'InitialPayment', type: 'auto'},{ name: 'FrequncyTranslate', type: 'auto'}],data: []});Ext.define('PatientPaymentConfirmMultiARDataViewModel', { extend: 'Ext.data.Model', config: { fields: [ { name: 'PaymentDate' },{ name: 'Amount' },{ name: 'PatientID' },{ name: 'PatientMedicalRecordNumber' },{ name: 'PatientFirstName' },{ name: 'PatientMiddleName' },{ name: 'PatientLastName' },{ name: 'PatientBirthDate' },{ name: 'PatientPhoneNumber' },{ name: 'AccountHolderEmail' },{ name: 'PatientInvoiceNumber' },{ name: 'PatientServiceBeginDate' },{ name: 'PatientServiceEndDate' },{ name: 'PatientAddress1' },{ name: 'PatientAddress2' },{ name: 'PatientCity' },{ name: 'PatientState' },{ name: 'PatientZip' },{ name: 'PatientCountry' },{ name: 'TransactionCode' },{ name: 'AdditionalCode1' },{ name: 'AdditionalCode2' },{ name: 'AdditionalCode3' },{ name: 'AdditionalCode4' },{ name: 'AdditionalCode5' },{ name: 'AdditionalCode6' },{ name: 'AdditionalInfo1' },{ name: 'AdditionalInfo2' },{ name: 'AdditionalInfo3' },{ name: 'AdditionalInfo4' },{ name: 'AdditionalInfo5' },{ name: 'AdditionalInfo6' },{ name: 'LineItemKey' } ] } }); Ext.create('Ext.data.Store', { id:'PatientPaymentConfirmMultiARDataViewstore', model: 'PatientPaymentConfirmMultiARDataViewModel', autoLoad: true, proxy: { type: 'memory', reader: { type: 'json' }, data: [] } });function NavigateToPatientInformation(lineItemKey) { var form = InstaMed.getNavigationView(); form.push('NavPatientInformation'); if(lineItemKey) { editLineItem(lineItemKey); } PerformAction({}, PatientPaymentController.editPatientInformation); }function NavigateToQuickPayPatientEntry(lineItemKey) { var form = InstaMed.getNavigationView(); form.push('NavQuickPayPatientEntry'); if(lineItemKey) { editLineItem(lineItemKey); } javascript: PerformAction({}, QuickPayPatientEntryController.editPatientInformation,null); return false; }function NavigateToPaymentInformation() { var form = InstaMed.getNavigationView(); var prevFormData = form.getLastFormObject(); form.push('NavQuickPayPaymentInformation'); form.setLastFormObject(prevFormData); }Ext.define('Ext.InstaMed.FormPanel',{extend: 'Ext.form.Panel',alias: 'widget.form',config: { defaultSubmitButton: null }});function NavigateToProviderInformation() { PerformAction({}, PatientPaymentController.editProviderInformation); }function NavigateToPatientInformation(lineItemKey) { var form = InstaMed.getNavigationView(); form.push('NavPatientInformation'); if(lineItemKey) { editLineItem(lineItemKey); } PerformAction({}, PatientPaymentController.editPatientInformation); }function NavigateToQuickPayPatientEntry(lineItemKey) { var form = InstaMed.getNavigationView(); form.push('NavQuickPayPatientEntry'); if(lineItemKey) { editLineItem(lineItemKey); } javascript: PerformAction({}, QuickPayPatientEntryController.editPatientInformation,null); return false; }function NavigateToPaymentInformation() { var form = InstaMed.getNavigationView(); var prevFormData = form.getLastFormObject(); form.push('NavPaymentInformation'); form.setLastFormObject(prevFormData); }Ext.define('MyApp.model.CodeDescriptionPaymentPlanPaymentsBreakdownStore',{extend: 'Ext.data.Model',id: 'PaymentPlanPaymentsBreakdownStore',fields: [{name:'Description'},{name:'Amount'},{name:'IsTotalAmount'}]});Ext.create('Ext.data.JsonStore',{ autoDestroy: false, proxy: { type: 'memory', reader: 'json', writer: 'json' }, storeId: 'PaymentPlanPaymentsBreakdownStore', fields: [{ name: 'Description', type: 'auto'},{ name: 'Amount', type: 'auto'},{ name: 'IsTotalAmount', type: 'auto'}],data: []});InstaMed.pages = new Array();Ext.Date.monthNames = [ 'January', 'February', 'March', 'April', 'May', 'June', 'July', 'August', 'September', 'October', 'November', 'December']Ext.Date.dayNames = [ 'Sunday', 'Monday', 'Tuesday', 'Wednesday', 'Thursday', 'Friday', 'Saturday']InstaMed.pages.push('NavFindAndSearch');InstaMed.pages.push('NavQuickPayPatientEntry');InstaMed.pages.push('NavQuickPayAccountSummary');InstaMed.pages.push('NavSelectProvider');InstaMed.pages.push('NavQuickPayGoGreen');InstaMed.pages.push('APCAboutWindow');InstaMed.pages.push('NavReceiptPreview');InstaMed.pages.push('ShareReceiptWindow');InstaMed.pages.push('NavAPCTerms');InstaMed.pages.push('PaymentPlanPaymentsBreakdownWindow');InstaMed.pages.push('EStatementEnrollmentInfo');InstaMed.pages.push('EStatementEnrollmentInfo');InstaMed.pages.push('EditMobilePhoneWindow');InstaMed.pages.push('NavPageIdleTimeoutForm');InstaMed.PageMaximumSequenceNumber=50; InstaMed.PopulatePaymentPlanPaymentsBreakdownDataViewComponentFromPaymentOptionDataViewComponent = function(storeIndex){ var store = InstaMed.get("PaymentOptionDataViewComponent").getStore(); var dataObj; if(storeIndex !== null){ dataObj = store.getAt(storeIndex-1); } else { if(store.queryRecords("IsSelected",true).length>0){ dataObj = store.queryRecords("IsSelected",true)[0]; }else{ dataObj = store.getAt(0); } } PerformAction({ Duration: dataObj.get("Duration"), EndDate: dataObj.get("EndDate"), Frequency: dataObj.get("Frequency"), InstallmentAmount: dataObj.get("InstallmentAmount"), IsRecommended: dataObj.get("IsRecommended"), IsSelected: dataObj.get("IsSelected"), StartDate: dataObj.get("StartDate"), TotalPlanAmount: dataObj.get("TotalPlanAmount").substr(1), InitialAmount: dataObj.get("InitialPayment").substr(1), }, PaymentOptionsController.getPaymentPlanPaymentsBreakdownWindowDetails ); }; InstaMed.PopulatePaymentPlanPaymentsBreakdownDataViewComponentFromPaymentInformationDataView = function(storeIndex){ var store = InstaMed.get("PaymentInformationDataView").getStore(); var dataObj; if(storeIndex !== null){ dataObj = store.getAt(storeIndex-1); } else { if(store.queryRecords("IsSelected",true).length>0){ dataObj = store.queryRecords("IsSelected",true)[0]; }else{ dataObj = store.getAt(0); } } PerformAction({ Duration: dataObj.get("Duration"), EndDate: dataObj.get("EndDate"), Frequency: dataObj.get("Frequency"), InstallmentAmount: dataObj.get("InstallmentAmount"), IsRecommended: dataObj.get("IsRecommended"), IsSelected: dataObj.get("IsSelected"), StartDate: dataObj.get("StartDate"), TotalPlanAmount: dataObj.get("TotalPlanAmount").substr(1), InitialAmount: dataObj.get("InitialPayment").substr(1), }, PaymentOptionsController.getPaymentPlanPaymentsBreakdownWindowDetails ); };function setCardTypeIconCLS() { var cardType = InstaMed.get('CardType'); var creditCardField = InstaMed.get('CreditCardNumber'); if(cardType && creditCardField) { var triggers = creditCardField.getTriggers(); if (triggers && triggers.VISATrigger) { creditCardField.removeTrigger('VISATrigger'); } if (triggers && triggers.AmexTrigger) { creditCardField.removeTrigger('AmexTrigger'); } if (triggers && triggers.DiscoveryTrigger) { creditCardField.removeTrigger('DiscoveryTrigger'); } if (triggers && triggers.MasterCardTrigger) { creditCardField.removeTrigger('MasterCardTrigger'); } if (triggers && triggers.OtherCardsTrigger) { creditCardField.removeTrigger('OtherCardsTrigger'); } if(InstaMed.isTrue('False')){ cardType.setValue(''); } var cardTypeValue = cardType.getValue(); if(cardTypeValue) { cardTypeValue = cardTypeValue.toUpperCase(); if(cardTypeValue != 'INITIAL') { if(cardTypeValue == 'MC') { if (triggers && !triggers.MasterCardTrigger) { creditCardField.addTrigger('MasterCardTrigger',{cls:'mastercardCls',type: 'cardIcon'}); } } else if(cardTypeValue == 'VISA') { if (triggers && !triggers.VISATrigger) { creditCardField.addTrigger('VISATrigger',{cls:'visaCls',type: 'cardIcon'}); } } else if(cardTypeValue == 'AMEX') { if (triggers && !triggers.AmexTrigger) { creditCardField.addTrigger('AmexTrigger',{cls:'amexCls',type: 'cardIcon'}); } } else if(cardTypeValue == 'DISCOVER') { if (triggers && !triggers.DiscoveryTrigger) { creditCardField.addTrigger('DiscoveryTrigger',{cls:'discoverCls',type: 'cardIcon'}); } } else if(cardTypeValue == 'OTHER') { if (triggers && !triggers.OtherCardsTrigger) { creditCardField.addTrigger('OtherCardsTrigger',{cls:'echeckCls',type: 'cardIcon'}); } } } else { if (triggers && !triggers.VISATrigger && true) { creditCardField.addTrigger('VISATrigger',{cls:'visaCls',type: 'cardIcon'}); } if (triggers && !triggers.DiscoveryTrigger && true) { creditCardField.addTrigger('DiscoveryTrigger',{cls:'discoverCls',type: 'cardIcon'}); } if (triggers && !triggers.MasterCardTrigger && true) { creditCardField.addTrigger('MasterCardTrigger',{cls:'mastercardCls',type: 'cardIcon'}); } if (triggers && !triggers.AmexTrigger && true) { creditCardField.addTrigger('AmexTrigger',{cls:'amexCls',type: 'cardIcon'}); } if (triggers && !triggers.OtherCardsTrigger && false) { creditCardField.addTrigger('OtherCardsTrigger',{cls:'echeckCls',type: 'cardIcon'}); } } } else { if (triggers && !triggers.VISATrigger && true) { creditCardField.addTrigger('VISATrigger',{cls:'visaCls',type: 'cardIcon'}); } if (triggers && !triggers.DiscoveryTrigger && true) { creditCardField.addTrigger('DiscoveryTrigger',{cls:'discoverCls',type: 'cardIcon'}); } if (triggers && !triggers.MasterCardTrigger && true) { creditCardField.addTrigger('MasterCardTrigger',{cls:'mastercardCls',type: 'cardIcon'}); } if (triggers && !triggers.AmexTrigger && true) { creditCardField.addTrigger('AmexTrigger',{cls:'amexCls',type: 'cardIcon'}); } if (triggers && !triggers.OtherCardsTrigger && false) { creditCardField.addTrigger('OtherCardsTrigger',{cls:'echeckCls',type: 'cardIcon'}); } } } }function handleNickName(promptMessageValue) { var maxLength = 100; if (window.message) { var promptObj = window.message.getPrompt(); promptObj.setValue(promptMessageValue); window.message.show(); } else { Ext.Msg.setStandardButtons({ ok: { text: 'Ok', weight: Ext.platformTags.ios || Ext.platformTags.mac ? 120 : 10 }, abort: { text: 'Abort', weight: Ext.platformTags.ios || Ext.platformTags.mac ? 110 : 20 }, retry: { text: 'Retry', weight: Ext.platformTags.ios || Ext.platformTags.mac ? 100 : 30 }, ignore: { text: 'Ignore', weight: Ext.platformTags.ios || Ext.platformTags.mac ? 90 : 40 }, yes: { text: 'Yes', weight: Ext.platformTags.ios || Ext.platformTags.mac ? 80 : 50 }, no: { text: 'No', weight: Ext.platformTags.ios || Ext.platformTags.mac ? 70 : 60 }, cancel: { text: 'Cancel', weight: Ext.platformTags.ios || Ext.platformTags.mac ? 60 : 70 }, apply: { text: 'Apply', weight: Ext.platformTags.ios || Ext.platformTags.mac ? 50 : 80 }, save: { text: 'Save', weight: Ext.platformTags.ios || Ext.platformTags.mac ? 40 : 90 }, submit: { text: 'Submit', weight: Ext.platformTags.ios || Ext.platformTags.mac ? 30 : 100 }, help: { text: 'Help', weight: Ext.platformTags.ios || Ext.platformTags.mac ? 10 : 110 }, close: { text: 'Close', weight: Ext.platformTags.ios || Ext.platformTags.mac ? 20 : 120 }}); window.message = Ext.Msg.prompt('

Add Nickname

', 'Nickname', function (btn, value) { if(btn == 'ok') { setNickName(value)} },null,false,promptMessageValue,this); if (typeof(maxLength) == 'number') { var promptObj = window.message.getPrompt(); promptObj.setMaxLength(maxLength); promptObj.setInputAttribute('aria-label','Nickname'); promptObj.setInputAttribute('aria-required',true); } } }function setNickName(name) { if (!Ext.isEmpty(name)) { var accountType; var accountTypeCmp = InstaMed.get('AccountType'); if (accountTypeCmp) { accountType = accountTypeCmp.getValue(); } if (accountType == 'CreditCard') { var nickNameField = InstaMed.get('CardAccountNickName'); var nickNameLinkButton = Ext.getElementById('CardAccountNickNameLinkButton'); if (nickNameField) { nickNameField.setValue(name); nickNameLinkButton.textContent = name; nickNameLinkButton.setAttribute('aria-label','Edit '+name+' nickname'); } } else if (accountType == 'ECheck') { var nickNameField = InstaMed.get('CheckingAccountNickName'); var nickNameLinkButton = Ext.getElementById('CheckingAccountNickNameLinkButton'); if (nickNameField) { nickNameField.setValue(name); nickNameLinkButton.textContent = name; nickNameLinkButton.setAttribute('aria-label','Edit '+name+' nickname'); } } else { var nickNameField = InstaMed.get('BlindPaymentAccountNickName'); var nickNameLinkButton = Ext.getElementById('BlindPaymentAccountNickNameLinkButton'); if(nickNameField) { nickNameField.setValue(name); nickNameLinkButton.textContent = name; nickNameLinkButton.setAttribute('aria-label','Edit '+name+' nickname'); } } } } function setBlindPaymentNickName(value) { var nickNameLinkButton = Ext.getElementById('BlindPaymentAccountNickNameLinkButton'); if (nickNameLinkButton) { nickNameLinkButton.textContent = value; } } function apcVisibility(prefix, checkboxName){ var APcontrol = InstaMed.get('AutomaticPaymentContainer'); var APcheckbox = InstaMed.get('EnrollAutomaticPayment'); var APAuth = InstaMed.getValue('IsPatientAuthenticated'); var paymentMethodDisclaimer = InstaMed.get('prefixSavePaymentMethodDislaimer'); var whatIsAPC = document.getElementById('WhatIsAPC'); if(APcontrol !=null && APcheckbox!=null){ if(InstaMed.get(checkboxName)){ if(InstaMed.get(checkboxName).getChecked()) { if(APAuth == true) { APcontrol.show(); APcheckbox.enable(); APcontrol.removeCls('im-apc-container-disabled'); whatIsAPC && whatIsAPC.setAttribute('tabIndex','0'); APcheckbox.ariaEl.dom.tabIndex=0; } else { APcontrol.hide(); APcheckbox.setChecked && APcheckbox.setChecked(false); APcheckbox.setValue && APcheckbox.setValue(false); } if (paymentMethodDisclaimer) { paymentMethodDisclaimer.hide(); } } else { APcheckbox.disable(); APcontrol.addCls('im-apc-container-disabled'); whatIsAPC && whatIsAPC.setAttribute('tabIndex','-1'); APcheckbox.ariaEl.dom.tabIndex=-1; APcheckbox.setChecked && APcheckbox.setChecked(false); APcheckbox.setValue && APcheckbox.setValue(false); if (paymentMethodDisclaimer) { paymentMethodDisclaimer.show(); } } } } } InstaMed.PopulatePaymentPlanPaymentsBreakdownDataViewComponentFromPaymentInformationReviewAndConfirmDataView = function(storeIndex){ var store = InstaMed.get("PaymentInformationReviewAndConfirmDataView").getStore(); var dataObj; if(storeIndex !== null){ dataObj = store.getAt(storeIndex-1); } else { if(store.queryRecords("IsSelected",true).length>0){ dataObj = store.queryRecords("IsSelected",true)[0]; }else{ dataObj = store.getAt(0); } } PerformAction({ Duration: dataObj.get("Duration"), EndDate: dataObj.get("EndDate"), Frequency: dataObj.get("Frequency"), InstallmentAmount: dataObj.get("InstallmentAmount"), IsRecommended: dataObj.get("IsRecommended"), IsSelected: dataObj.get("IsSelected"), StartDate: dataObj.get("StartDate"), TotalPlanAmount: dataObj.get("TotalPlanAmount").substr(1), InitialAmount: dataObj.get("InitialPayment").substr(1), }, PaymentOptionsController.getPaymentPlanPaymentsBreakdownWindowDetails ); };Ext.define('MyApp.view.NavigationView',{extend: 'InstaMed.navigation.View',alias: 'widget.mynavigationview',config: { name: 'NavigationView', useLogo: true, configInnerStates:[0], configActiveItem:0, configLastForm:[new Object()], mobilePrimaryActionButtonInTitleBar: false, mobileSecondaryActionButtonInTitleBar: false, navigationBar: false, items: [ {xtype: 'container', name: 'NavFindAndSearch', layout: {type: 'vbox', pack: 'start'}, showBackButton: true, scrollable: 'true', id: 'NavFindAndSearch', items: [ {xtype: 'container', docked: 'top', scrollable: null, id: 'NavFindAndSearch_container', items: [ {xtype: 'instamedNavigationBar', name: 'headerBar', layout: {type: 'hbox'}, hidden: false, cls: 'im-ignore-custom-colors im-ignore-background', scrollable: null, id: 'NavFindAndSearch_headerBar', items: [ {xtype: 'spacer', id: 'NavFindAndSearch_spacer', plugins: 'responsive', responsiveConfig: {'width > 1272':{flex : 1,},'width <= 1272':{flex :0,},} }, {xtype: 'titlebar', maxWidth: 1272, cls: 'largeTwelveColumn mediumTwelveColumn smallTwelveColumn xsmallTwelveColumn im-ignore-custom-colors im-ignore-background', scrollable: null, id: 'NavFindAndSearch_titlebar', plugins: 'responsive', responsiveConfig: {'width >= 1272':{title :'',},'width < 1272':{title : ' ',},}, items: [ {xtype: 'button', accessibleText: 'Back', iconCls: 'x-ma ma-arrow-back', align: 'left', name: 'TitleBarNavigationViewBack', margin: '', hidden: false, ariaRole: 'button', cls: 'x-button-icon-link-style white hiddenlg noprint', id: 'NavFindAndSearch_TitleBarNavigationViewBack', plugins: 'responsive', responsiveConfig: {'width > 1272':{iconCls :'',},'width <= 1272':{iconCls : 'x-ma ma-arrow-back',},}, listeners: {tap: function(){ headerPatientPortalBack(); }} }, {xtype: 'container', html: ' ', align: 'left', scrollable: null, id: 'NavFindAndSearch_container_1', plugins: 'responsive', responsiveConfig: {'width >= 1272':{hidden : false,},'width < 1272':{hidden :true,},} }, {xtype: 'button', name: 'HeaderTitlebarButton', ui: 'white', margin: '', hidden: true, ariaRole: 'button', cls: 'x-button-link-style im-center-header-button white noprint', id: 'NavFindAndSearch_HeaderTitlebarButton' }, {xtype: 'button', text: 'Pay Any Healthcare Bill', align: 'right', name: 'PayAnyHealthcareBillButton', ui: 'white', margin: '', ariaRole: 'button', cls: 'x-button-link-style x-border hiddenxs hiddensm white noprint', id: 'NavFindAndSearch_button_PayAnyHealthcareBill', listeners: {tap: function() { if(InstaMed.isLoggedIn) { window.location.href ='../../Form/PaymentPortal/Dashboard?id=AFCURGENT149&pageStep=NavFindProvider'; } else { window.location.href ='../../Form/PaymentPortal/Start?pageStep=NavFindProvider'; }}} }, {xtype: 'button', text: 'Pay Bills', iconCls: 'x-ma ma-search', iconAlign: 'top', align: 'right', name: 'PayAnyHealthcareBillIcon', margin: '', ariaRole: 'button', cls: 'x-button-icon-ontop-link-style white hiddenmd hiddenlg noprint', id: 'NavFindAndSearch_button_PayBills', listeners: {tap: function() { if(InstaMed.isLoggedIn) { window.location.href ='../../Form/PaymentPortal/Dashboard?pageStep=NavFindProvider'; } else { window.location.href ='../../Form/PaymentPortal/Start?pageStep=NavFindProvider'; }}} }, {xtype: 'button', accessibleText: 'Log In or Sign Up', iconCls: 'x-ma ma-account-circle', align: 'right',menu:[{xtype: 'menuitem', text: 'Log In', handler: function() { PerformAction({}, PatientPortalLoginController.redirectToLogin,null); }, id: 'menuitem_LogIn'},{xtype: 'menuitem', text: 'Sign Up', handler: function() { PerformAction({}, SignUpController.redirectToSignUp,null); }, id: 'menuitem_SignUp'},], name: 'LoginOrSignUpProfileIcon', margin: '', ariaRole: 'button', cls: 'x-button-icon-link-style white noprint', id: 'NavFindAndSearch_button_LoginOrSignUpProfileIcon', plugins: 'responsive', responsiveConfig: {'!InstaMed.isLoggedIn & width > 960':{hidden: true,},'!InstaMed.isLoggedIn && width <= 960':{hidden: false,},}, listeners: {hiddenchange: function() { Ext.ComponentQuery.query('[name=LoginOrSignUpProfileIcon]')[0].getMenu().hide(); }} }, {xtype: 'button', text: '', align: 'right',menu:[{xtype: 'menuitem', text: 'Dashboard', handler: function(){ window.location.href='../../Form/PaymentPortal/Dashboard'; }, id: 'menuitem_Dashboard'},{xtype: 'menuitem', text: 'Help', handler: function() { window.open('https://help.instamed.com/patients/s/?dc_label=Patients')}, id: 'menuitem_Help'},{xtype: 'menuitem', text: 'Log Out', handler: function(){ window.location.href='../../Form/PaymentPortal/Logout?id=AFCURGENT149'; }, id: 'menuitem_LogOut'},], name: 'Profile', ui: 'white', margin: '', hidden: true, ariaRole: 'button', cls: 'x-button-link-style white noprint', id: 'NavFindAndSearch_button_Profile', plugins: 'responsive', responsiveConfig: {'InstaMed.isLoggedIn & width > 960':{hidden: false,},'InstaMed.isLoggedIn && width <= 960':{hidden: true,},}, listeners: {hiddenchange: function() { Ext.ComponentQuery.query('[name=Profile]')[0].getMenu().hide(); }} }, {xtype: 'container', align: 'right', name: 'LoginOrSignUpContainer', layout: {type: 'hbox'}, scrollable: null, id: 'NavFindAndSearch_LoginOrSignUpContainer', plugins: 'responsive', responsiveConfig: {'!InstaMed.isLoggedIn & width > 960':{hidden: false,},'!InstaMed.isLoggedIn && width <= 960':{hidden: true,},}, items: [ {xtype: 'button', text: 'Log In', align: 'right', name: 'LoginForDualLogin', ui: 'white', margin: '', hidden: false, ariaRole: 'button', cls: 'x-button-link-style hiddenxs hiddensm white noprint', id: 'NavFindAndSearch_button_LoginForDualLogin', listeners: {tap: function() { PerformAction({}, PatientPortalLoginController.redirectToLogin,null); }} }, {xtype: 'label', html: 'or', align: 'right', name: 'Or', ui: 'body1-white', cls: 'hiddenxs hiddensm body1-white', id: 'NavFindAndSearch_Or' }, {xtype: 'button', text: 'Sign Up', align: 'right', name: 'SignUpForDualLogin', ui: 'white', margin: '', ariaRole: 'button', cls: 'x-button-link-style hiddenxs hiddensm white noprint', id: 'NavFindAndSearch_button_SignUpForDualLogin', listeners: {tap: function() { PerformAction({}, SignUpController.redirectToSignUp,null); }} }] }, {xtype: 'button', accessibleText: 'Profile', iconCls: 'x-ma ma-account-circle', align: 'right',menu:[{xtype: 'menuitem', text: 'Dashboard', handler: function(){ window.location.href='../../Form/PaymentPortal/Dashboard'; }, id: 'menuitem_Dashboard_1'},{xtype: 'menuitem', text: 'Help', handler: function() { window.open('https://help.instamed.com/patients/s/?dc_label=Patients')}, id: 'menuitem_Help_1'},{xtype: 'menuitem', text: 'Log Out', handler: function(){ window.location.href='../../Form/PaymentPortal/Logout?id=AFCURGENT149'; }, id: 'menuitem_LogOut_1'},], name: 'ProfileIcon', margin: '', hidden: true, ariaRole: 'button', cls: 'x-button-icon-link-style white noprint', id: 'NavFindAndSearch_button_ProfileIcon', plugins: 'responsive', responsiveConfig: {'InstaMed.isLoggedIn & width > 960':{hidden: true,},'InstaMed.isLoggedIn && width <= 960':{hidden: false,},}, listeners: {hiddenchange: function() { Ext.ComponentQuery.query('[name=ProfileIcon]')[0].getMenu().hide(); }} }] }, {xtype: 'spacer', id: 'NavFindAndSearch_spacer_1', plugins: 'responsive', responsiveConfig: {'width > 1272':{flex : 1,},'width <= 1272':{flex :0,},} }] }] }, {xtype: 'container', layout: {type: 'hbox'}, cls: 'x-subheader-container', scrollable: null, id: 'NavFindAndSearch_container_2', items: [ {xtype: 'spacer', id: 'NavFindAndSearch_spacer_2', plugins: 'responsive', responsiveConfig: {'width > 1272':{flex : 1,},'width <= 1272':{flex :0,},} }, {xtype: 'container', maxWidth: 1272, layout: {type: 'hbox'}, cls: 'largeTwelveColumn mediumTwelveColumn smallTwelveColumn xsmallTwelveColumn x-subheader-panel ', scrollable: null, id: 'NavFindAndSearch_container_3', items: [ {xtype: 'image', src: '../../ContentHandler.aspx?URL=/Images/Database/326332D5-86DA-4881-BE6F-8DE62B1DD7E0&id=AFCURGENT149&crop=true&maxWidth=150&maxHeight=64', hidden: false, cls: 'x-clickable x-button-provider-img', id: 'NavFindAndSearch_image', listeners: {painted: function() { var cmp = this; cmp.el.dom.setAttribute('aria-label', 'AFC URGENT CARE - 149th Street logo'); cmp.el.dom.setAttribute('role', 'img'); cmp.el.dom.setAttribute('title', ''); },tap: function(){ window.location.href='../../Form/PaymentPortal/Default?id=AFCURGENT149'; }} }, {xtype: 'container', layout: {type: 'vbox', pack: 'center', align: 'left'}, cls: 'im-provider-header-buttons', scrollable: null, id: 'NavFindAndSearch_container_4', items: [ {xtype: 'label', html: 'AFC URGENT CARE - 149th Street', name: 'SubheaderProviderName', ui: 'subheading-primary', cls: 'initial-caps font-400 im-bold-button subheading-primary', id: 'NavFindAndSearch_SubheaderProviderName' }, {xtype: 'container', layout: {type: 'hbox'}, scrollable: null, id: 'NavFindAndSearch_container_5', items: [ {xtype: 'container', html: '', hidden: true, cls: 'im-address-verification-icon', scrollable: null, id: 'NavFindAndSearch_container_6' }, {xtype: 'label', html: '332 East 149th Street, Bronx, NY 10451', ui: 'body1-secondary', cls: 'line-height-20 body1-secondary', id: 'NavFindAndSearch_label' }] }, {xtype: 'container', layout: {type: 'hbox'}, hidden: false, scrollable: null, id: 'NavFindAndSearch_container_7', items: [ {xtype: 'label', html: '(347) 329-4010', ui: 'body1-primary', cls: 'body1-primary', id: 'NavFindAndSearch_label_1' }] }] }] }, {xtype: 'spacer', id: 'NavFindAndSearch_spacer_3', plugins: 'responsive', responsiveConfig: {'width > 1272':{flex : 1,},'width <= 1272':{flex :0,},} }] }, { xtype: 'panel', dock: 'top', frame: false, scrollable: 'true', id: 'panel', items: [ {xtype: 'container', maxWidth: 1272, layout: {type: 'hbox'}, cls: 'mainContent MainContentWithHeaerAndSubheader ', scrollable: null, id: 'container', items: [ {xtype: 'container', flex: 1, scrollable: null, id: 'container_1', items: [ { xtype: 'form', preventHeader: true, bodyCls: 'mypanel', api: { }, defaultSubmitButton: 'PayNow', name: 'formSearchPayment', itemId: 'formSearchPayment', cls: 'col-large-offSet-3 col-medium-offSet-3 col-small-offSet-1 smallTenColumn xsmallTwelveColumn mediumSixColumn largeSixColumn ', scrollable: null, id: 'formSearchPayment', items: [ {xtype: 'errorbox', name: 'ValidationSummary', ui: 'ErrorBox', hidden: true, cls: 'ErrorBox', id: 'ValidationSummary' }, {xtype: 'instamedHeading1', text: 'Make a Payment', id: 'formSearchPayment_instamedHeading1' }, {xtype: 'combobox', queryMode: 'local', triggerAction: 'all', typeAheadDelay: 300, itemId: 'Patient', displayField: 'description', store: Ext.create('Ext.data.ArrayStore',{ type: 'json', autoDestroy: false, storeId: 'PatientStore5', fields: [ { name: 'code', type: 'string' }, { name: 'description', type: 'string' } ], data: [['AB8FE4DC-3341-418D-AD03-A9A149595F4A', 'Add New'] ]}), valueField: 'code', forceSelection: true, picker: 'floated', clearable: true, editable: true, selectOnFocus: true, itemTpl: '{description}', displayTpl: '{description}', autoExpandOnFocus: true, validateOnBlank: false,listConfig: { id: 'formSearchPayment_Patient-boundlist', resizable: false }, fieldLabel: 'Select Patient', label: 'Select Patient', hidden: true, labelSeparator: ' ', placeholder: 'Select One', value: 'AB8FE4DC-3341-418D-AD03-A9A149595F4A', required: false, labelWrap: true, labelAlign: 'placeholder', errorTarget: 'under', clearable: false, requiredMessage: 'Select Patient is required', autoComplete: 'off', name: 'Patient', margin: '', ariaRole: 'combobox', cls: 'x-trigger-field', id: 'formSearchPayment_Patient', listeners: {focus: function (cmp) { Ext.Function.defer(function (cmp) { if (!cmp.expanded && !cmp.readOnly && !cmp.isDisabled() && cmp.hasFocus) { cmp.onExpandTap(); } }, 250, this, [cmp]);},blur: function(cmp){if(cmp.validate){cmp.validate();}},select: function(cmp, newValue, oldValue, eOpts) {if (cmp.isRendered()) {myForm = InstaMed.findParentForm(cmp);PerformAction(myForm.getValues(),QuickPayOptimizedProviderLandingController.onPatientChange,cmp);}}} }, {xtype: 'container', name: 'PatientMatchFieldsContainer', scrollable: null, id: 'formSearchPayment_PatientMatchFieldsContainer', items: [ {xtype: 'textfield', allowBlank: false, allowOnlyWhitespace: false, maxLength: 200, maxLength: 200, enforceMaxLength: true, minLength: 1, selectOnFocus: true, autoCorrect: false, fieldLabel: 'Email', label: 'Email', component: {"type":"email","pattern":null}, inputType: 'email', hidden: false, labelSeparator: ' ', required: true, labelWrap: true, labelAlign: 'placeholder', errorTarget: 'under', clearable: false, requiredMessage: 'Email is required', autoComplete: 'on', name: 'EmailAddress', margin: '', id: 'formSearchPayment_EmailAddress', listeners: {action: submitOnEnter,blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'textfield', allowBlank: false, allowOnlyWhitespace: false, maxLength: 80, maxLength: 80, enforceMaxLength: true, minLength: 1, selectOnFocus: true, autoCorrect: false, fieldLabel: 'Patient ID', label: 'Patient ID', hidden: false, labelSeparator: ' ', required: true, labelWrap: true, labelAlign: 'placeholder', errorTarget: 'under', clearable: false, requiredMessage: 'Patient ID is required', autoComplete: 'on', name: 'QuickPayComboID', margin: '', id: 'formSearchPayment_QuickPayComboID', listeners: {action: submitOnEnter,blur: function() { var listenerArgs = arguments; Ext.Array.each([function(cmp){if(cmp.validate){cmp.validate();}},function() { PerformAction({QuickPayCode:InstaMed.get('QuickPayComboID').getValue(),ProviderAlias:InstaMed.get('ProviderAlias').getValue()}, QuickPayOptimizedProviderLandingController.checkQuickPayCode,null); }], function(func) { func.apply(this, listenerArgs); }); },change: function(cmp){ var value = cmp.getValue(); var queryLength = [7,8,9]; if(queryLength.indexOf(value.length)!=-1){ PerformAction({QuickPayCode:InstaMed.get('QuickPayComboID').getValue(),ProviderAlias:InstaMed.get('ProviderAlias').getValue()}, QuickPayOptimizedProviderLandingController.checkQuickPayCode,this,null,null,true,null,null,true); } }} }, {xtype: 'textfield', maxLength: 80, maxLength: 80, enforceMaxLength: true, minLength: 1, selectOnFocus: true, autoCorrect: false, fieldLabel: 'Medical Record Number', label: 'Medical Record Number', hidden: true, labelSeparator: ' ', required: false, labelWrap: true, labelAlign: 'placeholder', errorTarget: 'under', clearable: false, requiredMessage: 'Medical Record Number is required', autoComplete: 'on', name: 'PatientMedicalRecordNumber', margin: '', id: 'formSearchPayment_PatientMedicalRecordNumber', listeners: {action: submitOnEnter,blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'textfield', maxLength: 80, maxLength: 80, enforceMaxLength: true, minLength: 1, selectOnFocus: true, autoCorrect: false, fieldLabel: 'Guarantor ID', label: 'Guarantor ID', hidden: true, labelSeparator: ' ', required: false, labelWrap: true, labelAlign: 'placeholder', errorTarget: 'under', clearable: false, requiredMessage: 'Guarantor ID is required', autoComplete: 'on', name: 'GuarantorID', margin: '', id: 'formSearchPayment_GuarantorID', listeners: {action: submitOnEnter,blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'textfield', maxLength: 35, maxLength: 35, enforceMaxLength: true, minLength: 1, selectOnFocus: true, autoCorrect: false, fieldLabel: 'Guarantor First Name', label: 'Guarantor First Name', hidden: true, labelSeparator: ' ', required: false, labelWrap: true, labelAlign: 'placeholder', errorTarget: 'under', clearable: false, requiredMessage: 'Guarantor First Name is required', autoComplete: 'on', name: 'GuarantorFirstName', margin: '', id: 'formSearchPayment_GuarantorFirstName', listeners: {action: submitOnEnter,blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'textfield', maxLength: 60, maxLength: 60, enforceMaxLength: true, minLength: 1, selectOnFocus: true, autoCorrect: false, fieldLabel: 'Guarantor Last Name', label: 'Guarantor Last Name', hidden: true, labelSeparator: ' ', required: false, labelWrap: true, labelAlign: 'placeholder', errorTarget: 'under', clearable: false, requiredMessage: 'Guarantor Last Name is required', autoComplete: 'on', name: 'GuarantorLastName', margin: '', id: 'formSearchPayment_GuarantorLastName', listeners: {action: submitOnEnter,blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'textfield', maxLength: 35, maxLength: 35, enforceMaxLength: true, minLength: 1, selectOnFocus: true, autoCorrect: false, fieldLabel: 'First Name', label: 'First Name', hidden: true, labelSeparator: ' ', required: false, labelWrap: true, labelAlign: 'placeholder', errorTarget: 'under', clearable: false, requiredMessage: 'First Name is required', autoComplete: 'on', name: 'PatientFirstName', margin: '', id: 'formSearchPayment_PatientFirstName', listeners: {action: submitOnEnter,blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'textfield', allowBlank: false, allowOnlyWhitespace: false, maxLength: 60, maxLength: 60, enforceMaxLength: true, minLength: 1, selectOnFocus: true, autoCorrect: false, fieldLabel: 'Last Name', label: 'Last Name', hidden: false, labelSeparator: ' ', required: true, labelWrap: true, labelAlign: 'placeholder', errorTarget: 'under', clearable: false, requiredMessage: 'Last Name is required', autoComplete: 'on', name: 'PatientLastName', margin: '', id: 'formSearchPayment_PatientLastName', listeners: {action: submitOnEnter,blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'textfield', maxLength: 25, maxLength: 25, enforceMaxLength: true, minLength: 1, selectOnFocus: true, autoCorrect: false, fieldLabel: 'Middle', label: 'Middle', hidden: true, labelSeparator: ' ', required: false, labelWrap: true, labelAlign: 'placeholder', errorTarget: 'under', clearable: false, requiredMessage: 'Middle is required', autoComplete: 'on', name: 'PatientMiddleName', margin: '', id: 'formSearchPayment_PatientMiddleName', listeners: {action: submitOnEnter,blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'datepickerfield', picker: { cancelButton: false, toolbar : { items : [ { text : 'Clear', align : 'left', handler : function(btn) { var picker = btn.up('datepicker'); picker.fireEvent('change', picker, null); picker.setValue(picker.config.value); picker.hide(); } } ] } , value: new Date(), yearFrom: 1900, yearTo: 2030 }, floatedPicker: { xtype: 'datepanel', minDate: new Date('1/1/1900 12:00:00 AM'), maxDate: new Date('12/31/2030 12:00:00 AM'), yearPicker: { start: 1900, end: 2030, } }, minDate: new Date('1/1/1900 12:00:00 AM'), maxDate: new Date('12/31/2030 12:00:00 AM'), submitFormat: 'm/d/Y', showToday: true, badFormatMessage: 'Date of Birth format is MM/DD/YYYY', validateOnBlank: false, fieldLabel: 'Date of Birth', label: 'Date of Birth', hidden: true, labelSeparator: ' ', placeholder: 'MM/DD/YYYY', required: false, labelWrap: true, labelAlign: 'placeholder', errorTarget: 'under', clearable: false, requiredMessage: 'Date of Birth is required', autoComplete: 'on', name: 'PatientBirthDate', margin: '', dynamicToolTipText: 'Patient\'s date of birth (MM/DD/YYYY).', id: 'formSearchPayment_PatientBirthDate', tooltip: {html:"Patient\'s date of birth (MM/DD/YYYY).", trackMouse:"True"}, listeners: {blur: function() { var listenerArgs = arguments; Ext.Array.each([function(cmp){ var value = cmp.getValue(); if(value && typeof value == 'string') { value = new Date(value); } cmp.setValue(value); if(InstaMed.isResponsive){ cmp.setInputValue(value); } },function(cmp){if(cmp.validate){cmp.validate();}}], function(func) { func.apply(this, listenerArgs); }); }} }, {xtype: 'textfield', maxLength: 14, maxLength: 14, enforceMaxLength: true, minLength: 10, selectOnFocus: true, autoCorrect: false, fieldLabel: 'Phone Number', label: 'Phone Number', component: {"type":"tel","pattern":null}, inputType: 'tel', hidden: true, labelSeparator: ' ', placeholder: '(215) 555-5555', required: false, labelWrap: true, labelAlign: 'placeholder', errorTarget: 'under', clearable: false, requiredMessage: 'Phone Number is required', autoComplete: 'on', name: 'PatientPhoneNumber', margin: '', id: 'formSearchPayment_PatientPhoneNumber', listeners: {action: submitOnEnter,blur: function(cmp){if(cmp.validate){cmp.validate();}},change: function(field, event, opts ){ var s = new String(field.getValue()); if(s != null && s != '') { s = s.replace(/[-,()\s]/g,'');var newValue='(';newValue+=s.substring(0,3);if(s.length>3){newValue+=') ';}newValue+=s.substring(3,6);if(s.length>6){newValue+='-';}newValue+=s.substring(6,10); if(isNaN(parseInt(newValue.substring(1,3)))){ newValue = ''; } field.setValue(newValue); if(InstaMed.isResponsive){ field.setInputValue(newValue); } } }} }, {xtype: 'textfield', allowBlank: false, allowOnlyWhitespace: false, maxLength: 10, maxLength: 10, enforceMaxLength: true, minLength: 3, selectOnFocus: true, autoCorrect: false, fieldLabel: 'ZIP Code', label: 'ZIP Code', hidden: false, labelSeparator: ' ', required: true, labelWrap: true, labelAlign: 'placeholder', errorTarget: 'under', clearable: false, requiredMessage: 'ZIP Code is required', autoComplete: 'on', name: 'PatientZip', margin: '', id: 'formSearchPayment_PatientZip', listeners: {action: submitOnEnter,blur: function(cmp){if(cmp.validate){cmp.validate();}},change: function(field, event, opts ){ var s = new String(field.getValue()); if(s != null && s != '') { s = s.replace(/[^0-9]/g,'');if(s.length>5){s = [s.slice(0,5),'-',s.slice(5,9)].join('');}field.setValue(s); if(InstaMed.isResponsive){ field.setInputValue(s); } } }} }, {xtype: 'textfield', maxLength: 100, maxLength: 100, enforceMaxLength: true, minLength: 0, selectOnFocus: true, autoCorrect: false, fieldLabel: 'Statement Number', label: 'Statement Number', hidden: true, labelSeparator: ' ', required: false, labelWrap: true, labelAlign: 'placeholder', errorTarget: 'under', clearable: false, requiredMessage: 'Statement Number is required', autoComplete: 'off', name: 'StatementNumber', margin: '', id: 'formSearchPayment_StatementNumber', listeners: {action: submitOnEnter,blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'datepickerfield', picker: { cancelButton: false, toolbar : { items : [ { text : 'Clear', align : 'left', handler : function(btn) { var picker = btn.up('datepicker'); picker.fireEvent('change', picker, null); picker.setValue(picker.config.value); picker.hide(); } } ] } , value: new Date(), yearFrom: 1900, yearTo: 2030 }, floatedPicker: { xtype: 'datepanel', minDate: new Date('1/1/1900 12:00:00 AM'), maxDate: new Date('12/31/2030 12:00:00 AM'), yearPicker: { start: 1900, end: 2030, } }, minDate: new Date('1/1/1900 12:00:00 AM'), maxDate: new Date('12/31/2030 12:00:00 AM'), submitFormat: 'm/d/Y', showToday: true, badFormatMessage: 'Statement Date format is MM/DD/YYYY', validateOnBlank: false, fieldLabel: 'Statement Date', label: 'Statement Date', hidden: true, labelSeparator: ' ', placeholder: 'MM/DD/YYYY', required: false, labelWrap: true, labelAlign: 'placeholder', errorTarget: 'under', clearable: false, requiredMessage: 'Statement Date is required', autoComplete: 'off', name: 'StatementDate', margin: '', id: 'formSearchPayment_StatementDate', listeners: {blur: function() { var listenerArgs = arguments; Ext.Array.each([function(cmp){ var value = cmp.getValue(); if(value && typeof value == 'string') { value = new Date(value); } cmp.setValue(value); if(InstaMed.isResponsive){ cmp.setInputValue(value); } },function(cmp){if(cmp.validate){cmp.validate();}}], function(func) { func.apply(this, listenerArgs); }); }} }, {xtype: 'amountfield', regex: /^[\$]?\d{1,3}(\,?\d{3,3})*(\.(\d|\d\d))?$/i, regexText: 'Please enter a valid dollar amount.', maxLength: 12, maxLength: 12, enforceMaxLength: true, minLength: 0, selectOnFocus: true, autoCorrect: false, maskRe: /[\$\d\.\,]/i, fieldLabel: 'Amount Due', label: 'Amount Due', hidden: true, labelSeparator: ' ', required: false, labelWrap: true, labelAlign: 'placeholder', errorTarget: 'under', clearable: false, requiredMessage: 'Amount Due is required', autoComplete: 'off', name: 'AmountDue', margin: '', id: 'formSearchPayment_AmountDue', listeners: {action: submitOnEnter,blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'textfield', maxLength: 100, maxLength: 100, enforceMaxLength: true, minLength: 0, selectOnFocus: true, autoCorrect: false, fieldLabel: 'Dynamic Field 1', label: 'Dynamic Field 1', hidden: true, labelSeparator: ' ', required: false, labelWrap: true, labelAlign: 'placeholder', errorTarget: 'under', clearable: false, requiredMessage: 'Dynamic Field 1 is required', autoComplete: 'off', name: 'DynamicField1', margin: '', id: 'formSearchPayment_DynamicField1', listeners: {action: submitOnEnter,blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'textfield', maxLength: 100, maxLength: 100, enforceMaxLength: true, minLength: 0, selectOnFocus: true, autoCorrect: false, fieldLabel: 'Dynamic Field 2', label: 'Dynamic Field 2', hidden: true, labelSeparator: ' ', required: false, labelWrap: true, labelAlign: 'placeholder', errorTarget: 'under', clearable: false, requiredMessage: 'Dynamic Field 2 is required', autoComplete: 'off', name: 'DynamicField2', margin: '', id: 'formSearchPayment_DynamicField2', listeners: {action: submitOnEnter,blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'textfield', maxLength: 100, maxLength: 100, enforceMaxLength: true, minLength: 0, selectOnFocus: true, autoCorrect: false, fieldLabel: 'Dynamic Field 3', label: 'Dynamic Field 3', hidden: true, labelSeparator: ' ', required: false, labelWrap: true, labelAlign: 'placeholder', errorTarget: 'under', clearable: false, requiredMessage: 'Dynamic Field 3 is required', autoComplete: 'off', name: 'DynamicField3', margin: '', id: 'formSearchPayment_DynamicField3', listeners: {action: submitOnEnter,blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'textfield', maxLength: 80, maxLength: 80, enforceMaxLength: true, minLength: 1, selectOnFocus: true, autoCorrect: false, fieldLabel: 'Dynamic Field 4', label: 'Dynamic Field 4', hidden: true, labelSeparator: ' ', required: false, labelWrap: true, labelAlign: 'placeholder', errorTarget: 'under', clearable: false, requiredMessage: 'Dynamic Field 4 is required', autoComplete: 'off', name: 'DynamicField4', margin: '', id: 'formSearchPayment_DynamicField4', listeners: {action: submitOnEnter,blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'hiddenfield', fieldLabel: 'ProviderAlias', label: 'ProviderAlias', labelSeparator: ' ', required: false, labelWrap: true, errorTarget: 'under', clearable: false, requiredMessage: 'ProviderAlias is required', autoComplete: 'on', name: 'ProviderAlias', margin: '', id: 'formSearchPayment_ProviderAlias', listeners: {blur: function(cmp){if(cmp.validate){cmp.validate();}}} }] }, {xtype: 'hiddenfield', fieldLabel: 'QuickPayFlowFromPaymentPage', label: 'QuickPayFlowFromPaymentPage', labelSeparator: ' ', value: true, required: false, labelWrap: true, errorTarget: 'under', clearable: false, requiredMessage: 'QuickPayFlowFromPaymentPage is required', autoComplete: 'on', name: 'QuickPayFlowFromPaymentPage', margin: '', id: 'formSearchPayment_QuickPayFlowFromPaymentPage', listeners: {blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'container', margin: '16 0 16 0', scrollable: null, id: 'formSearchPayment_container', items: [ {xtype: 'button', text: 'Pay Now', name: 'PayNow', ui: 'wide', margin: '', hidden: true, ariaRole: 'button', cls: 'x-button-action wide noprint', id: 'formSearchPayment_button_PayNow', listeners: {tap: function(cmp, newValue, oldValue, eOpts) { myForm = InstaMed.findParentForm(cmp); PerformAction(myForm.getValues(),QuickPayOptimizedProviderLandingController.payNow,cmp,undefined,undefined,undefined,undefined,undefined); }} }] }, {xtype: 'container', layout: {type: 'hbox', pack: 'start', align: 'bottom'}, cls: 'buttonContainer', scrollable: null, id: 'formSearchPayment_container_1', items: [ {xtype: 'spacer', id: 'formSearchPayment_spacer' }, {xtype: 'button', text: 'Next', ui: 'action', margin: '', ariaRole: 'button', cls: 'action noprint', id: 'formSearchPayment_button_Next', listeners: {tap: function(cmp, newValue, oldValue, eOpts) { myForm = InstaMed.findParentForm(cmp); PerformAction(myForm.getValues(),QuickPayOptimizedProviderLandingController.payNow,cmp,undefined,undefined,undefined,undefined,undefined); }} }] }, {xtype: 'container', html: 'Don\'t have the information above? Pay Here', cls: 'donthaveinformation', scrollable: null, id: 'formSearchPayment_container_2' }] }] }] }] }, {xtype: 'spacer', flex: 1, id: 'spacer' }, {xtype: 'container', layout: {type: 'hbox'}, hidden: false, cls: 'x-panel-footer im-powered-by', scrollable: null, id: 'container_2', items: [ {xtype: 'spacer', id: 'spacer_1' }, {xtype: 'container', maxWidth: 1272, layout: {type: 'hbox'}, cls: 'largeTwelveColumn mediumTwelveColumn ', scrollable: null, id: 'NavFindAndSearch_container_8', items: [ {xtype: 'container', name: 'poweredbylogo', cls: 'hidden hiddenxs hiddensm', scrollable: null, id: 'NavFindAndSearch_poweredbylogo' }, {xtype: 'container', cls: 'copyrightContainer hiddenxs hiddensm', scrollable: null, id: 'NavFindAndSearch_container_9', items: [ {xtype: 'spacer', cls: 'hiddenmd hiddenlg', id: 'NavFindAndSearch_spacer_4' }, {xtype: 'label', html: '© 2024 InstaMed. All Rights Reserved.', name: 'copyrightFooter', ui: 'body1-primary', cls: 'margin-bottom-10 body1-primary', id: 'NavFindAndSearch_copyrightFooter' }, {xtype: 'spacer', cls: 'hiddenmd hiddenlg', id: 'NavFindAndSearch_spacer_5' }] }, {xtype: 'spacer', cls: 'hiddenxs hiddensm', id: 'NavFindAndSearch_spacer_6' }, {xtype: 'container', cls: 'linkButtonContainer hiddenxs hiddensm', scrollable: null, id: 'NavFindAndSearch_container_10', items: [ {xtype: 'button', text: 'Security', iconCls: 'x-ma ma-lock-outline', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavFindAndSearch_button_Security', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/security/','open-window');}} }, {xtype: 'button', text: 'Privacy', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavFindAndSearch_button_Privacy', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/privacy-statement/','open-window');}} }, {xtype: 'button', text: 'Terms', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavFindAndSearch_button_Terms', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/terms-of-use/','open-window');}} }, {xtype: 'button', text: 'Help', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavFindAndSearch_button_Help', listeners: {tap: function() { InstaMed.popupNewWindow('../../Form/PaymentPortal/ContactUs?id=AFCURGENT149','open-window');}} }, {xtype: 'button', text: 'English', align: 'right',menu:[{xtype: 'menuitem', text: 'English', handler: function(cmp) { PerformAction({Language:'en'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'en', cls: 'hiddenxs hiddensm', id: 'menuitem_en'},{xtype: 'menuitem', text: 'Español', handler: function(cmp) { PerformAction({Language:'es'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'es', cls: 'hiddenxs hiddensm', id: 'menuitem_es'},{xtype: 'menuitem', text: 'Français', handler: function(cmp) { PerformAction({Language:'fr'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'fr', cls: 'hiddenxs hiddensm', id: 'menuitem_fr'},], name: 'ForeignLanguages', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavFindAndSearch_button_ForeignLanguages' }] }, {xtype: 'container', cls: 'hiddenmd hiddenlg', scrollable: null, id: 'NavFindAndSearch_container_11', items: [ {xtype: 'container', layout: {type: 'hbox', pack: 'center'}, cls: 'x-center-helper', scrollable: null, id: 'NavFindAndSearch_container_12', items: [ {xtype: 'spacer', id: 'NavFindAndSearch_spacer_7' }, {xtype: 'container', name: 'poweredbylogo', cls: 'hidden', scrollable: null, id: 'NavFindAndSearch_poweredbylogo_1' }, {xtype: 'spacer', id: 'NavFindAndSearch_spacer_8' }] }, {xtype: 'container', layout: {type: 'hbox', pack: 'center'}, cls: 'x-center-helper', scrollable: null, id: 'NavFindAndSearch_container_13', items: [ {xtype: 'spacer', id: 'NavFindAndSearch_spacer_9' }, {xtype: 'container', cls: 'copyrightContainer', scrollable: null, id: 'NavFindAndSearch_container_14', items: [ {xtype: 'spacer', cls: 'hiddenmd hiddenlg', id: 'NavFindAndSearch_spacer_10' }, {xtype: 'label', html: '© 2024 InstaMed. All Rights Reserved.', name: 'copyrightFooter', ui: 'body1-primary', cls: 'margin-bottom-10 body1-primary', id: 'NavFindAndSearch_copyrightFooter_1' }, {xtype: 'spacer', cls: 'hiddenmd hiddenlg', id: 'NavFindAndSearch_spacer_11' }] }, {xtype: 'spacer', id: 'NavFindAndSearch_spacer_12' }] }, {xtype: 'container', layout: {type: 'hbox', pack: 'center'}, cls: 'x-center-helper', scrollable: null, id: 'NavFindAndSearch_container_15', items: [ {xtype: 'spacer', id: 'NavFindAndSearch_spacer_13' }, {xtype: 'container', cls: 'linkButtonContainer ', scrollable: null, id: 'NavFindAndSearch_container_16', items: [ {xtype: 'button', text: 'Security', iconCls: 'x-ma ma-lock-outline', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavFindAndSearch_button_Security_1', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/security/','open-window');}} }, {xtype: 'button', text: 'Privacy', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavFindAndSearch_button_Privacy_1', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/privacy-statement/','open-window');}} }, {xtype: 'button', text: 'Terms', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavFindAndSearch_button_Terms_1', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/terms-of-use/','open-window');}} }, {xtype: 'button', text: 'Help', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavFindAndSearch_button_Help_1', listeners: {tap: function() { InstaMed.popupNewWindow('../../Form/PaymentPortal/ContactUs?id=AFCURGENT149','open-window');}} }] }, {xtype: 'spacer', id: 'NavFindAndSearch_spacer_14' }] }, {xtype: 'container', layout: {type: 'hbox', pack: 'center'}, cls: 'x-center-helper', scrollable: null, id: 'NavFindAndSearch_container_17', items: [ {xtype: 'spacer', id: 'NavFindAndSearch_spacer_15' }, {xtype: 'container', scrollable: null, id: 'NavFindAndSearch_container_18', items: [ {xtype: 'button', text: 'English', align: 'right',menu:[{xtype: 'menuitem', text: 'English', handler: function(cmp) { PerformAction({Language:'en'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'en', cls: 'hiddenmd hiddenlg', id: 'menuitem_en_1'},{xtype: 'menuitem', text: 'Español', handler: function(cmp) { PerformAction({Language:'es'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'es', cls: 'hiddenmd hiddenlg', id: 'menuitem_es_1'},{xtype: 'menuitem', text: 'Français', handler: function(cmp) { PerformAction({Language:'fr'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'fr', cls: 'hiddenmd hiddenlg', id: 'menuitem_fr_1'},], name: 'ForeignLanguages', ui: 'grey', margin: '', hidden: false, ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavFindAndSearch_button_ForeignLanguages_1' }] }, {xtype: 'spacer', id: 'NavFindAndSearch_spacer_16' }] }] }] }, {xtype: 'spacer', id: 'spacer_2' }] }] }, {xtype: 'container', name: 'NavQuickPayPatientEntry', layout: {type: 'vbox', pack: 'start'}, showBackButton: true, showMenuButton: false, scrollable: 'true', id: 'NavQuickPayPatientEntry', items: [ {xtype: 'container', docked: 'top', scrollable: null, id: 'NavQuickPayPatientEntry_container', items: [ {xtype: 'instamedNavigationBar', name: 'headerBar', layout: {type: 'hbox'}, hidden: false, cls: 'im-ignore-custom-colors im-ignore-background', scrollable: null, id: 'NavQuickPayPatientEntry_headerBar', items: [ {xtype: 'spacer', id: 'NavQuickPayPatientEntry_spacer', plugins: 'responsive', responsiveConfig: {'width > 1272':{flex : 1,},'width <= 1272':{flex :0,},} }, {xtype: 'titlebar', title: '<a href=\\"../../Form/PaymentPortal/Start\\"> <img src=\\"https://cdn.instamed.com/V_2024_March/Content/Images/General/instamed-tagged-white.png?id=AFCURGENT149\\" alt=\\"InstaMed a J.P. Morgan company logo\\" style=\\"height: 40px\\">', maxWidth: 1272, cls: 'largeTwelveColumn mediumTwelveColumn smallTwelveColumn xsmallTwelveColumn im-ignore-custom-colors im-ignore-background', scrollable: null, id: 'NavQuickPayPatientEntry_titlebar', plugins: 'responsive', responsiveConfig: {'width >= 1272':{title :'',},'width < 1272':{title : ' ',},}, items: [ {xtype: 'button', accessibleText: 'Back', iconCls: 'x-ma ma-arrow-back', align: 'left', name: 'TitleBarNavigationViewBack', margin: '', hidden: false, ariaRole: 'button', cls: 'x-button-icon-link-style white hiddenlg noprint', id: 'NavQuickPayPatientEntry_TitleBarNavigationViewBack', plugins: 'responsive', responsiveConfig: {'width > 1272':{iconCls :'',},'width <= 1272':{iconCls : 'x-ma ma-arrow-back',},}, listeners: {tap: function(){ headerPatientPortalBack(); }} }, {xtype: 'container', html: ' ', align: 'left', scrollable: null, id: 'NavQuickPayPatientEntry_container_1', plugins: 'responsive', responsiveConfig: {'width >= 1272':{hidden : false,},'width < 1272':{hidden :true,},} }, {xtype: 'button', name: 'HeaderTitlebarButton', ui: 'white', margin: '', hidden: true, ariaRole: 'button', cls: 'x-button-link-style im-center-header-button white noprint', id: 'NavQuickPayPatientEntry_HeaderTitlebarButton' }, {xtype: 'button', text: 'Pay Any Healthcare Bill', align: 'right', name: 'PayAnyHealthcareBillButton', ui: 'white', margin: '', ariaRole: 'button', cls: 'x-button-link-style x-border hiddenxs hiddensm white noprint', id: 'NavQuickPayPatientEntry_button_PayAnyHealthcareBill', listeners: {tap: function() { if(InstaMed.isLoggedIn) { window.location.href ='../../Form/PaymentPortal/Dashboard?id=AFCURGENT149&pageStep=NavFindProvider'; } else { window.location.href ='../../Form/PaymentPortal/Start?pageStep=NavFindProvider'; }}} }, {xtype: 'button', text: 'Pay Bills', iconCls: 'x-ma ma-search', iconAlign: 'top', align: 'right', name: 'PayAnyHealthcareBillIcon', margin: '', ariaRole: 'button', cls: 'x-button-icon-ontop-link-style white hiddenmd hiddenlg noprint', id: 'NavQuickPayPatientEntry_button_PayBills', listeners: {tap: function() { if(InstaMed.isLoggedIn) { window.location.href ='../../Form/PaymentPortal/Dashboard?pageStep=NavFindProvider'; } else { window.location.href ='../../Form/PaymentPortal/Start?pageStep=NavFindProvider'; }}} }, {xtype: 'button', accessibleText: 'Log In or Sign Up', iconCls: 'x-ma ma-account-circle', align: 'right',menu:[{xtype: 'menuitem', text: 'Log In', handler: function() { PerformAction({}, PatientPortalLoginController.redirectToLogin,null); }, id: 'menuitem_LogIn_1'},{xtype: 'menuitem', text: 'Sign Up', handler: function() { PerformAction({}, SignUpController.redirectToSignUp,null); }, id: 'menuitem_SignUp_1'},], name: 'LoginOrSignUpProfileIcon', margin: '', ariaRole: 'button', cls: 'x-button-icon-link-style white noprint', id: 'NavQuickPayPatientEntry_button_LoginOrSignUpProfileIcon', plugins: 'responsive', responsiveConfig: {'!InstaMed.isLoggedIn & width > 960':{hidden: true,},'!InstaMed.isLoggedIn && width <= 960':{hidden: false,},}, listeners: {hiddenchange: function() { Ext.ComponentQuery.query('[name=LoginOrSignUpProfileIcon]')[0].getMenu().hide(); }} }, {xtype: 'button', text: '', align: 'right',menu:[{xtype: 'menuitem', text: 'Dashboard', handler: function(){ window.location.href='../../Form/PaymentPortal/Dashboard'; }, id: 'menuitem_Dashboard_2'},{xtype: 'menuitem', text: 'Help', handler: function() { window.open('https://help.instamed.com/patients/s/?dc_label=Patients')}, id: 'menuitem_Help_2'},{xtype: 'menuitem', text: 'Log Out', handler: function(){ window.location.href='../../Form/PaymentPortal/Logout?id=AFCURGENT149'; }, id: 'menuitem_LogOut_2'},], name: 'Profile', ui: 'white', margin: '', hidden: true, ariaRole: 'button', cls: 'x-button-link-style white noprint', id: 'NavQuickPayPatientEntry_button_Profile', plugins: 'responsive', responsiveConfig: {'InstaMed.isLoggedIn & width > 960':{hidden: false,},'InstaMed.isLoggedIn && width <= 960':{hidden: true,},}, listeners: {hiddenchange: function() { Ext.ComponentQuery.query('[name=Profile]')[0].getMenu().hide(); }} }, {xtype: 'container', align: 'right', name: 'LoginOrSignUpContainer', layout: {type: 'hbox'}, scrollable: null, id: 'NavQuickPayPatientEntry_LoginOrSignUpContainer', plugins: 'responsive', responsiveConfig: {'!InstaMed.isLoggedIn & width > 960':{hidden: false,},'!InstaMed.isLoggedIn && width <= 960':{hidden: true,},}, items: [ {xtype: 'button', text: 'Log In', align: 'right', name: 'LoginForDualLogin', ui: 'white', margin: '', hidden: false, ariaRole: 'button', cls: 'x-button-link-style hiddenxs hiddensm white noprint', id: 'NavQuickPayPatientEntry_button_LoginForDualLogin', listeners: {tap: function() { PerformAction({}, PatientPortalLoginController.redirectToLogin,null); }} }, {xtype: 'label', html: 'or', align: 'right', name: 'Or', ui: 'body1-white', cls: 'hiddenxs hiddensm body1-white', id: 'NavQuickPayPatientEntry_Or' }, {xtype: 'button', text: 'Sign Up', align: 'right', name: 'SignUpForDualLogin', ui: 'white', margin: '', ariaRole: 'button', cls: 'x-button-link-style hiddenxs hiddensm white noprint', id: 'NavQuickPayPatientEntry_button_SignUpForDualLogin', listeners: {tap: function() { PerformAction({}, SignUpController.redirectToSignUp,null); }} }] }, {xtype: 'button', accessibleText: 'Profile', iconCls: 'x-ma ma-account-circle', align: 'right',menu:[{xtype: 'menuitem', text: 'Dashboard', handler: function(){ window.location.href='../../Form/PaymentPortal/Dashboard'; }, id: 'menuitem_Dashboard_3'},{xtype: 'menuitem', text: 'Help', handler: function() { window.open('https://help.instamed.com/patients/s/?dc_label=Patients')}, id: 'menuitem_Help_3'},{xtype: 'menuitem', text: 'Log Out', handler: function(){ window.location.href='../../Form/PaymentPortal/Logout?id=AFCURGENT149'; }, id: 'menuitem_LogOut_3'},], name: 'ProfileIcon', margin: '', hidden: true, ariaRole: 'button', cls: 'x-button-icon-link-style white noprint', id: 'NavQuickPayPatientEntry_button_ProfileIcon', plugins: 'responsive', responsiveConfig: {'InstaMed.isLoggedIn & width > 960':{hidden: true,},'InstaMed.isLoggedIn && width <= 960':{hidden: false,},}, listeners: {hiddenchange: function() { Ext.ComponentQuery.query('[name=ProfileIcon]')[0].getMenu().hide(); }} }] }, {xtype: 'spacer', id: 'NavQuickPayPatientEntry_spacer_1', plugins: 'responsive', responsiveConfig: {'width > 1272':{flex : 1,},'width <= 1272':{flex :0,},} }] }] }, {xtype: 'container', layout: {type: 'hbox'}, cls: 'x-subheader-container', scrollable: null, id: 'NavQuickPayPatientEntry_container_2', items: [ {xtype: 'spacer', id: 'NavQuickPayPatientEntry_spacer_2', plugins: 'responsive', responsiveConfig: {'width > 1272':{flex : 1,},'width <= 1272':{flex :0,},} }, {xtype: 'container', maxWidth: 1272, layout: {type: 'hbox'}, cls: 'largeTwelveColumn mediumTwelveColumn smallTwelveColumn xsmallTwelveColumn x-subheader-panel ', scrollable: null, id: 'NavQuickPayPatientEntry_container_3', items: [ {xtype: 'image', src: '../../ContentHandler.aspx?URL=/Images/Database/326332D5-86DA-4881-BE6F-8DE62B1DD7E0&id=AFCURGENT149&crop=true&maxWidth=150&maxHeight=64', hidden: false, cls: 'x-clickable x-button-provider-img', id: 'NavQuickPayPatientEntry_image', listeners: {painted: function() { var cmp = this; cmp.el.dom.setAttribute('aria-label', 'AFC URGENT CARE - 149th Street logo'); cmp.el.dom.setAttribute('role', 'img'); cmp.el.dom.setAttribute('title', ''); },tap: function(){ window.location.href='../../Form/PaymentPortal/Default?id=AFCURGENT149'; }} }, {xtype: 'container', layout: {type: 'vbox', pack: 'center', align: 'left'}, cls: 'im-provider-header-buttons', scrollable: null, id: 'NavQuickPayPatientEntry_container_4', items: [ {xtype: 'label', html: 'AFC URGENT CARE - 149th Street', name: 'SubheaderProviderName', ui: 'subheading-primary', cls: 'initial-caps font-400 im-bold-button subheading-primary', id: 'NavQuickPayPatientEntry_SubheaderProviderName' }, {xtype: 'container', layout: {type: 'hbox'}, scrollable: null, id: 'NavQuickPayPatientEntry_container_5', items: [ {xtype: 'container', html: '', hidden: true, cls: 'im-address-verification-icon', scrollable: null, id: 'NavQuickPayPatientEntry_container_6' }, {xtype: 'label', html: '332 East 149th Street, Bronx, NY 10451', ui: 'body1-secondary', cls: 'line-height-20 body1-secondary', id: 'NavQuickPayPatientEntry_label' }] }, {xtype: 'container', layout: {type: 'hbox'}, hidden: false, scrollable: null, id: 'NavQuickPayPatientEntry_container_7', items: [ {xtype: 'label', html: '(347) 329-4010', ui: 'body1-primary', cls: 'body1-primary', id: 'NavQuickPayPatientEntry_label_1' }] }] }] }, {xtype: 'spacer', id: 'NavQuickPayPatientEntry_spacer_3', plugins: 'responsive', responsiveConfig: {'width > 1272':{flex : 1,},'width <= 1272':{flex :0,},} }] }, { xtype: 'panel', dock: 'top', frame: false, scrollable: 'true', id: 'panel_1', items: [ {xtype: 'container', maxWidth: 1272, layout: {type: 'hbox'}, cls: 'mainContent MainContentWithHeaerAndSubheader ', scrollable: null, id: 'container_3', items: [ {xtype: 'container', flex: 1, scrollable: null, id: 'container_4', items: [ { xtype: 'form', preventHeader: true, bodyCls: 'mypanel', api: { }, name: 'FormPatientPayment', itemId: 'FormPatientPayment', cls: 'col-large-offSet-3 col-medium-offSet-3 col-small-offSet-1 smallTenColumn xsmallTwelveColumn mediumSixColumn largeSixColumn ', scrollable: null, id: 'FormPatientPayment', items: [ {xtype: 'errorbox', name: 'ValidationSummary', ui: 'ErrorBox', hidden: true, cls: 'ErrorBox', id: 'ValidationSummary_1' }, {xtype: 'instamedHeading1', text: 'Patient Information', id: 'FormPatientPayment_instamedHeading1' }, {xtype: 'dataviewlite', tpl: ['

{PatientFirstName:htmlEncode} {PatientLastName:htmlEncode} ({PatientID:htmlEncode})

{PatientFirstName:htmlEncode} {PatientLastName:htmlEncode}

${Amount:htmlEncode}

Edit Remove

'], itemSelector: '.patientItem', emptyText: '', deferInitialRefresh: false,store: Ext.data.StoreManager.lookup('PatientPaymentPatientInfoMultiARDataViewstore'), name: 'PatientPaymentPatientInfoMultiARDataView', id: 'FormPatientPayment_PatientPaymentPatientInfoMultiARDataView' }, {xtype: 'instameddisplayfield', fieldLabel: 'Payment Amount', label: 'Payment Amount', readOnly: true, hidden: true, labelSeparator: ' ', required: false, labelWrap: true, labelAlign: 'top', errorTarget: 'under', clearable: false, requiredMessage: 'Payment Amount is required', autoComplete: 'on', name: 'PaymentAmount', ui: 'payment-flow', margin: '', ariaRole: '', cls: 'im-display-field payment-flow', id: 'FormPatientPayment_PaymentAmount', listeners: {blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'container', name: 'QuickPayAmountContainer', hidden: true, cls: 'im-amount-field-container', scrollable: null, id: 'FormPatientPayment_QuickPayAmountContainer', items: [ {xtype: 'container', layout: {type: 'hbox', pack: 'center'}, cls: 'x-center-helper', scrollable: null, id: 'FormPatientPayment_container', items: [ {xtype: 'spacer', id: 'FormPatientPayment_spacer' }, {xtype: 'container', scrollable: null, id: 'FormPatientPayment_container_1', listeners: {painted: function(){ if(InstaMed.get('QuickPayAmountContainer') && InstaMed.get('QuickPayAmountContainer').isVisible()){ if(InstaMed.get('Amount') && InstaMed.isFalse(InstaMed.get('Amount').isVisible())){ InstaMed.get('Amount').show(); window.stackCustomAmount97736513ad2c1a4f4aa8021a88f1aaacd389 = [] InstaMed.get('Amount') && InstaMed.get('Amount').setValue('0.00'); InstaMed.get('Amount') && InstaMed.get('Amount').setInputValue('$0.00'); InstaMed.get('Amount') && InstaMed.get('Amount').setReadOnly(false); InstaMed.get('DidSelectCustomAmount') && InstaMed.get('DidSelectCustomAmount').setValue(true); } } if(InstaMed.get('Amount') && InstaMed.get('Amount')._label == 'Total Amount'){ InstaMed.get('Amount') && InstaMed.get('Amount').setDisabled(true); } }}, items: [ {xtype: 'container', layout: {type: 'hbox', pack: 'center'}, cls: 'x-center-helper', scrollable: null, id: 'FormPatientPayment_container_2', items: [ {xtype: 'spacer', id: 'FormPatientPayment_spacer_1' }, {xtype: 'amountfield', regexText: 'Please enter a valid dollar amount.', allowBlank: false, allowOnlyWhitespace: false, maxLength: 12, maxLength: 12, enforceMaxLength: true, minLength: 0, selectOnFocus: true, autoCorrect: false, maskRe: /[\$\d\.\,]/i, fieldLabel: 'Amount', label: 'Amount', readOnly: false, disabled: false, hidden: true, labelSeparator: ' ', value: '$0.00', required: true, labelWrap: true, labelAlign: 'placeholder', errorTarget: 'under', clearable: false, requiredMessage: 'Amount is required', autoComplete: 'off', name: 'Amount', ui: 'NotOutlined', margin: '', cls: 'im-large-amount-text-field NotOutlined', id: 'FormPatientPayment_Amount', tooltip: {html:"", trackMouse:"True"}, listeners: {focus: function(){ if(InstaMed.isTrue(window.OutOfFocusCustomAmount)){ window.resetCustomAmountField = true; var btn = InstaMed.get('AmountOptions'); btn && btn.setText( 'Custom'); window.stackCustomAmount97736513ad2c1a4f4aa8021a88f1aaacd389 = [] InstaMed.get('Amount') && InstaMed.get('Amount').setValue('0.00'); InstaMed.get('Amount') && InstaMed.get('Amount').setInputValue('$0.00'); InstaMed.get('Amount') && InstaMed.get('Amount').setReadOnly(false); InstaMed.get('DidSelectCustomAmount') && InstaMed.get('DidSelectCustomAmount').setValue(true); }else{ window.resetCustomAmountField = false; }; window.OutOfFocusCustomAmount = false; },focusleave: function(cmp, e){ window.OutOfFocusCustomAmount = true; if(InstaMed.get('Amount')){ var amt = InstaMed.get('Amount').getValue(); if(amt == ''){ InstaMed.get('Amount') && InstaMed.get('Amount').setValue('$0.00'); } } },paste: function(cmp, e){ window.stackCustomAmount97736513ad2c1a4f4aa8021a88f1aaacd389 = []; var pasteVal = e.getClipboardData().replace(/,/g, '') var dollarIndex = pasteVal.indexOf('$'); if(dollarIndex >= 0){ pasteValArr = pasteVal.split(''); pasteValArr.splice(dollarIndex, 1); pasteVal = pasteValArr.join(''); } var amountVal = Ext.util.Format.usMoney(pasteVal); for(var i=0;i 10){ window.stackCustomAmount97736513ad2c1a4f4aa8021a88f1aaacd389.splice(10, window.stackCustomAmount97736513ad2c1a4f4aa8021a88f1aaacd389.length); } const iterator = window.stackCustomAmount97736513ad2c1a4f4aa8021a88f1aaacd389.values(); var i = window.stackCustomAmount97736513ad2c1a4f4aa8021a88f1aaacd389.length-1; for (const value of iterator) { amnt += (Math.pow(10,i) * value); i--; } InstaMed.get('Amount') && InstaMed.get('Amount').setValue(Ext.util.Format.usMoney(amnt*0.01)); setOtherAmounts(InstaMed.get('Amount')); },painted: function(e){ if(InstaMed.get('Amount') && InstaMed.get('Amount').getValue() == 0){ InstaMed.get('Amount') && InstaMed.get('Amount').setValue('0.00'); InstaMed.get('Amount') && InstaMed.get('Amount').setInputValue('$0.00'); window.stackCustomAmount97736513ad2c1a4f4aa8021a88f1aaacd389 = []; } //MultiAR if(InstaMed.get('IsMultiAR') && InstaMed.isTrue(InstaMed.get('IsMultiAR').getValue())){ if(InstaMed.get('IsMultiARTotalAmount') && InstaMed.isTrue(InstaMed.get('IsMultiARTotalAmount').getValue())){ InstaMed.get('Amount') && InstaMed.get('Amount').setDisabled(true); }else{ InstaMed.get('Amount') && InstaMed.get('Amount').setDisabled(false); } } if(InstaMed.get('Amount') && InstaMed.isTrue(InstaMed.get('Amount').isDisabled())){ InstaMed.get('Amount') && InstaMed.get('Amount').removeCls('x-pointer-cursor'); }else{ window.OutOfFocusCustomAmount = true; window.resetCustomAmountField = true; InstaMed.get('Amount') && InstaMed.get('Amount').addCls('x-pointer-cursor'); } InstaMed.get('Amount') && InstaMed.get('Amount').inputElement.dom.addEventListener('mouseup', function(e){ setTimeout(function(){ e.srcElement.selectionStart = e.srcElement.selectionEnd = 10000; }, 0); }); if(InstaMed.isTrue('True') && InstaMed.isTrue('False')){ InstaMed.get('Amount') && InstaMed.get('Amount').setDisabled(true); } InstaMed.get('Amount') && InstaMed.isTrue('False') && InstaMed.get('Amount').inputElement.dom.addEventListener('input', function(cmp){ var androidData = cmp.data; var androidKey = ''; if(cmp.data || cmp.inputType == 'deleteContentBackward'){ if(cmp.inputType == 'deleteContentBackward'){ androidKey = 'deleteContentBackward'; }else{ androidKey = androidData.slice(-1); } if(androidKey){ if (androidKey =='1'){ window.stackCustomAmount97736513ad2c1a4f4aa8021a88f1aaacd389.push(1); window.setAmountValues = true; window.resetCustomAmountField=false; } else if(androidKey =='2'){ window.stackCustomAmount97736513ad2c1a4f4aa8021a88f1aaacd389.push(2); window.setAmountValues = true; window.resetCustomAmountField=false; } else if(androidKey =='3'){ window.stackCustomAmount97736513ad2c1a4f4aa8021a88f1aaacd389.push(3); window.setAmountValues = true; window.resetCustomAmountField=false; } else if(androidKey =='4'){ window.stackCustomAmount97736513ad2c1a4f4aa8021a88f1aaacd389.push(4); window.setAmountValues = true; window.resetCustomAmountField=false; } else if(androidKey =='5'){ window.stackCustomAmount97736513ad2c1a4f4aa8021a88f1aaacd389.push(5); window.setAmountValues = true; window.resetCustomAmountField=false; } else if(androidKey =='6'){ window.stackCustomAmount97736513ad2c1a4f4aa8021a88f1aaacd389.push(6); window.setAmountValues = true; window.resetCustomAmountField=false; } else if(androidKey =='7'){ window.stackCustomAmount97736513ad2c1a4f4aa8021a88f1aaacd389.push(7); window.setAmountValues = true; window.resetCustomAmountField=false; } else if(androidKey =='8'){ window.stackCustomAmount97736513ad2c1a4f4aa8021a88f1aaacd389.push(8); window.setAmountValues = true; window.resetCustomAmountField=false; } else if(androidKey =='9'){ window.stackCustomAmount97736513ad2c1a4f4aa8021a88f1aaacd389.push(9); window.setAmountValues = true; window.resetCustomAmountField=false; } else if(androidKey =='0'){ window.stackCustomAmount97736513ad2c1a4f4aa8021a88f1aaacd389.push(0); window.setAmountValues = true; window.resetCustomAmountField=false; }else if(androidKey == 'deleteContentBackward'){ window.setAmountValues = true; if (InstaMed.get('Amount').getValue() != '') { window.stackCustomAmount97736513ad2c1a4f4aa8021a88f1aaacd389.pop(); } if(InstaMed.isTrue(window.resetCustomAmountField)){ InstaMed.get('Amount') && InstaMed.get('Amount').setValue(null); InstaMed.get('Amount') && InstaMed.get('Amount').setInputValue('$0.00'); window.stackCustomAmount97736513ad2c1a4f4aa8021a88f1aaacd389 = []; window.resetCustomAmountField = false; } } InstaMed.get('DidSelectCustomAmount') && InstaMed.get('DidSelectCustomAmount').setValue(true); window.stackCustomAmount97736513ad2c1a4f4aa8021a88f1aaacd389 = window.stackCustomAmount97736513ad2c1a4f4aa8021a88f1aaacd389|| []; if(window.setAmountValues){ var amnt=0; if(window.stackCustomAmount97736513ad2c1a4f4aa8021a88f1aaacd389.length > 10){ window.stackCustomAmount97736513ad2c1a4f4aa8021a88f1aaacd389.splice(10, window.stackCustomAmount97736513ad2c1a4f4aa8021a88f1aaacd389.length); } const iterator = window.stackCustomAmount97736513ad2c1a4f4aa8021a88f1aaacd389.values(); var i = window.stackCustomAmount97736513ad2c1a4f4aa8021a88f1aaacd389.length-1; for (const value of iterator) { amnt += (Math.pow(10,i) * value); i--; } if(Ext.util.Format.usMoney(amnt*0.01) == '$0.00'){ InstaMed.get('Amount') && InstaMed.get('Amount').setValue(null); InstaMed.get('Amount') && InstaMed.get('Amount').setInputValue('$0.00'); }else{ InstaMed.get('Amount') && InstaMed.get('Amount').setValue(Ext.util.Format.usMoney(amnt*0.01)); } setOtherAmounts(InstaMed.get('Amount')); cmp && cmp.stopImmediatePropagation(); } } } }); InstaMed.get('Amount') && InstaMed.isFalse('False') && InstaMed.get('Amount').inputElement.dom.addEventListener('keydown', function(cmp){ var btn = InstaMed.get('AmountOptions'); if(InstaMed.get('Amount').getValue() == null){ InstaMed.get('Amount') && InstaMed.get('Amount').setInputValue('$0.00'); } if(cmp.key != 'Tab'){ if(btn){ if(btn._text != 'Custom'){ btn.setText('Custom'); InstaMed.get('Amount') && InstaMed.get('Amount').setValue('$0.00'); InstaMed.get('Amount') && InstaMed.get('Amount').setReadOnly(false); window.stackCustomAmount97736513ad2c1a4f4aa8021a88f1aaacd389 = []; } } InstaMed.get('DidSelectCustomAmount') && InstaMed.get('DidSelectCustomAmount').setValue(true); window.stackCustomAmount97736513ad2c1a4f4aa8021a88f1aaacd389 = window.stackCustomAmount97736513ad2c1a4f4aa8021a88f1aaacd389|| []; if (cmp.key =='1'){ window.stackCustomAmount97736513ad2c1a4f4aa8021a88f1aaacd389.push(1); window.setAmountValues = true; window.resetCustomAmountField=false; } else if(cmp.key=='2'){ window.stackCustomAmount97736513ad2c1a4f4aa8021a88f1aaacd389.push(2); window.setAmountValues = true; window.resetCustomAmountField=false; } else if(cmp.key =='3'){ window.stackCustomAmount97736513ad2c1a4f4aa8021a88f1aaacd389.push(3); window.setAmountValues = true; window.resetCustomAmountField=false; } else if(cmp.key =='4'){ window.stackCustomAmount97736513ad2c1a4f4aa8021a88f1aaacd389.push(4); window.setAmountValues = true; window.resetCustomAmountField=false; } else if(cmp.key =='5'){ window.stackCustomAmount97736513ad2c1a4f4aa8021a88f1aaacd389.push(5); window.setAmountValues = true; window.resetCustomAmountField=false; } else if(cmp.key =='6'){ window.stackCustomAmount97736513ad2c1a4f4aa8021a88f1aaacd389.push(6); window.setAmountValues = true; window.resetCustomAmountField=false; } else if(cmp.key =='7'){ window.stackCustomAmount97736513ad2c1a4f4aa8021a88f1aaacd389.push(7); window.setAmountValues = true; window.resetCustomAmountField=false; } else if(cmp.key =='8'){ window.stackCustomAmount97736513ad2c1a4f4aa8021a88f1aaacd389.push(8); window.setAmountValues = true; window.resetCustomAmountField=false; } else if(cmp.key =='9'){ window.stackCustomAmount97736513ad2c1a4f4aa8021a88f1aaacd389.push(9); window.setAmountValues = true; window.resetCustomAmountField=false;} else if(cmp.key =='0'){ window.stackCustomAmount97736513ad2c1a4f4aa8021a88f1aaacd389.push(0); window.setAmountValues = true; window.resetCustomAmountField=false; } else if(cmp.key =='Backspace'){ window.setAmountValues = true; if (InstaMed.get('Amount').getValue() != '') { window.stackCustomAmount97736513ad2c1a4f4aa8021a88f1aaacd389.pop(); } if(InstaMed.isTrue(window.resetCustomAmountField)){ InstaMed.get('Amount') && InstaMed.get('Amount').setValue(null); InstaMed.get('Amount') && InstaMed.get('Amount').setInputValue('$0.00'); window.stackCustomAmount97736513ad2c1a4f4aa8021a88f1aaacd389 = []; window.resetCustomAmountField = false; } }else if(cmp.key =='ArrowLeft') { cmp.preventDefault(); window.setAmountValues = false; }else if(cmp.key =='ArrowRight'){ cmp.preventDefault(); window.setAmountValues = false; }else if(cmp.key =='ArrowDown'){ cmp.preventDefault(); window.setAmountValues = false; }else if(cmp.key =='ArrowUp'){ cmp.preventDefault(); window.setAmountValues = false; } if(window.setAmountValues){ var amnt=0; if(window.stackCustomAmount97736513ad2c1a4f4aa8021a88f1aaacd389.length > 10){ window.stackCustomAmount97736513ad2c1a4f4aa8021a88f1aaacd389.splice(10, window.stackCustomAmount97736513ad2c1a4f4aa8021a88f1aaacd389.length); } const iterator = window.stackCustomAmount97736513ad2c1a4f4aa8021a88f1aaacd389.values(); var i = window.stackCustomAmount97736513ad2c1a4f4aa8021a88f1aaacd389.length-1; for (const value of iterator) { amnt += (Math.pow(10,i) * value); i--; } if(Ext.util.Format.usMoney(amnt*0.01) == '$0.00'){ InstaMed.get('Amount') && InstaMed.get('Amount').setValue(null); InstaMed.get('Amount') && InstaMed.get('Amount').setInputValue('$0.00'); }else{ InstaMed.get('Amount') && InstaMed.get('Amount').setValue(Ext.util.Format.usMoney(amnt*0.01)); } setOtherAmounts(InstaMed.get('Amount')); cmp && cmp.stopImmediatePropagation(); cmp && cmp.stopPropagation(); cmp && cmp.preventDefault(); } } }) } ,action: submitOnEnter,blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'spacer', id: 'FormPatientPayment_spacer_2' }] }, {xtype: 'container', layout: {type: 'hbox', pack: 'center'}, hidden: true, cls: 'x-center-helper', scrollable: null, id: 'FormPatientPayment_container_3', items: [ {xtype: 'spacer', id: 'FormPatientPayment_spacer_3' }, {xtype: 'button', text: 'Balance', menuAlign: 't-t',menu:[{xtype: 'menuitem', text: 'Balance', value: '', handler: function(cmp) { var btn = InstaMed.get('AmountOptions'); if(cmp){ if(cmp._text == 'Custom'){ btn && btn.setText(window.CustomAmountMenuOptLabel); window.stackCustomAmount97736513ad2c1a4f4aa8021a88f1aaacd389 = [] InstaMed.get('Amount') && InstaMed.get('Amount').setValue('0.00'); InstaMed.get('Amount') && InstaMed.get('Amount').setInputValue('$0.00'); InstaMed.get('Amount') && InstaMed.get('Amount').setReadOnly(false); InstaMed.get('DidSelectCustomAmount') && InstaMed.get('DidSelectCustomAmount').setValue(true); } else { if(window.BalancemountMenuOptLabel){ btn && btn.setText(window.BalancemountMenuOptLabel); }else{ btn && btn.setText(cmp._text); } var originalAmount = InstaMed.get('OriginalAmount') && InstaMed.get('OriginalAmount').getValue(); InstaMed.get('DidSelectCustomAmount') && InstaMed.get('DidSelectCustomAmount').setValue(false); InstaMed.get('Amount') && InstaMed.get('Amount').setValue(originalAmount); var hasDollarSign = originalAmount.includes('$'); if(hasDollarSign){ var amountVal = cmp.getInputValue().replace('$', ''); } } } }, hidden: true, cls: 'im-menu-item-balance-button', id: 'menuitem_Balance', listeners: {initialize: function(cmp){ if(InstaMed.get('RemainingAmountDue')){ if(InstaMed.get('RemainingAmountDue').getValue() != ''){ window.remainingAmt = Ext.util.Format.usMoney(InstaMed.get('RemainingAmountDue').getValue()); }else{ window.remainingAmt = ''; } if(InstaMed.isFalse(InstaMed.get('IsPayAgain').getValue())){ if(InstaMed.get('RemainingAmountDue')){ cmp.setText( cmp._text + ' - ' + window.remainingAmt ); } }else { window.BalancemountMenuOptLabel = cmp._text; cmp.setText( cmp._text + ' - ' + window.remainingAmt); } }else{ window.remainingAmt = ''; cmp.setText( cmp._text + ' - ' + window.remainingAmt ); } }}},{xtype: 'menuitem', text: 'Custom', handler: function(cmp) { var btn = InstaMed.get('AmountOptions'); if(cmp){ if(cmp._text == 'Custom'){ btn && btn.setText(window.CustomAmountMenuOptLabel); window.stackCustomAmount97736513ad2c1a4f4aa8021a88f1aaacd389 = [] InstaMed.get('Amount') && InstaMed.get('Amount').setValue('0.00'); InstaMed.get('Amount') && InstaMed.get('Amount').setInputValue('$0.00'); InstaMed.get('Amount') && InstaMed.get('Amount').setReadOnly(false); InstaMed.get('DidSelectCustomAmount') && InstaMed.get('DidSelectCustomAmount').setValue(true); } else { if(window.BalancemountMenuOptLabel){ btn && btn.setText(window.BalancemountMenuOptLabel); }else{ btn && btn.setText(cmp._text); } var originalAmount = InstaMed.get('OriginalAmount') && InstaMed.get('OriginalAmount').getValue(); InstaMed.get('DidSelectCustomAmount') && InstaMed.get('DidSelectCustomAmount').setValue(false); InstaMed.get('Amount') && InstaMed.get('Amount').setValue(originalAmount); var hasDollarSign = originalAmount.includes('$'); if(hasDollarSign){ var amountVal = cmp.getInputValue().replace('$', ''); } } } }, hidden: false, cls: 'im-menu-item-balance-button', id: 'menuitem_Custom', listeners: {initialize: function(cmp){ window.CustomAmountMenuOptLabel = cmp._text; }}},], name: 'AmountOptions', margin: '', ariaRole: 'button', cls: 'im-balance-menu-btn noprint', id: 'FormPatientPayment_button_Balance', listeners: {painted: function(cmp){ if(InstaMed.get('IsPayAgain').getValue()){ window.BalancemountMenuOptLabel = 'Balance'; var btn = InstaMed.get('AmountOptions'); btn && btn.setText(window.BalancemountMenuOptLabel); InstaMed.get('IsPayAgain').setValue(false) } }} }, {xtype: 'spacer', id: 'FormPatientPayment_spacer_4' }] }, {xtype: 'hiddenfield', fieldLabel: 'IgnoreCustomAmountZero', label: 'IgnoreCustomAmountZero', labelSeparator: ' ', value: false, required: false, labelWrap: true, errorTarget: 'under', clearable: false, requiredMessage: 'IgnoreCustomAmountZero is required', autoComplete: 'on', name: 'IgnoreCustomAmountZero', margin: '', id: 'FormPatientPayment_IgnoreCustomAmountZero', listeners: {blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'hiddenfield', fieldLabel: 'DidSelectCustomAmount', label: 'DidSelectCustomAmount', labelSeparator: ' ', required: false, labelWrap: true, errorTarget: 'under', clearable: false, requiredMessage: 'DidSelectCustomAmount is required', autoComplete: 'on', name: 'DidSelectCustomAmount', margin: '', id: 'FormPatientPayment_DidSelectCustomAmount', listeners: {blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'hiddenfield', fieldLabel: 'Original Amount', label: 'Original Amount', labelSeparator: ' ', value: '', required: false, labelWrap: true, errorTarget: 'under', clearable: false, requiredMessage: 'Original Amount is required', autoComplete: 'on', name: 'OriginalAmount', margin: '', id: 'FormPatientPayment_OriginalAmount', listeners: {blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'hiddenfield', fieldLabel: 'TotalAmount', label: 'TotalAmount', labelSeparator: ' ', value: '', required: false, labelWrap: true, errorTarget: 'under', clearable: false, requiredMessage: 'TotalAmount is required', autoComplete: 'on', name: 'TotalAmount', margin: '', id: 'FormPatientPayment_TotalAmount', listeners: {blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'hiddenfield', fieldLabel: 'IsMultiARTotalAmount', label: 'IsMultiARTotalAmount', labelSeparator: ' ', value: false, required: false, labelWrap: true, errorTarget: 'under', clearable: false, requiredMessage: 'IsMultiARTotalAmount is required', autoComplete: 'on', name: 'IsMultiARTotalAmount', margin: '', id: 'FormPatientPayment_IsMultiARTotalAmount', listeners: {blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'hiddenfield', fieldLabel: 'IsMultiARAddAccount', label: 'IsMultiARAddAccount', labelSeparator: ' ', value: false, required: false, labelWrap: true, errorTarget: 'under', clearable: false, requiredMessage: 'IsMultiARAddAccount is required', autoComplete: 'on', name: 'IsMultiARAddAccount', margin: '', id: 'FormPatientPayment_IsMultiARAddAccount', listeners: {change: function(cmp){ if(cmp.getValue()){ window.stackCustomAmount97736513ad2c1a4f4aa8021a88f1aaacd389 = []; InstaMed.get('Amount') && InstaMed.get('Amount').setValue('0.00'); InstaMed.get('Amount') && InstaMed.get('Amount').setInputValue('$0.00'); } },blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'hiddenfield', fieldLabel: 'IsMultiAR', label: 'IsMultiAR', labelSeparator: ' ', value: false, required: false, labelWrap: true, errorTarget: 'under', clearable: false, requiredMessage: 'IsMultiAR is required', autoComplete: 'on', name: 'IsMultiAR', margin: '', id: 'FormPatientPayment_IsMultiAR', listeners: {blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'hiddenfield', fieldLabel: 'IsPayAgain', label: 'IsPayAgain', labelSeparator: ' ', value: false, required: false, labelWrap: true, errorTarget: 'under', clearable: false, requiredMessage: 'IsPayAgain is required', autoComplete: 'on', name: 'IsPayAgain', margin: '', id: 'FormPatientPayment_IsPayAgain', listeners: {blur: function(cmp){if(cmp.validate){cmp.validate();}}} }] }, {xtype: 'spacer', id: 'FormPatientPayment_spacer_5' }] }] }, {xtype: 'hiddenfield', fieldLabel: 'Payment Account', label: 'Payment Account', readOnly: false, labelSeparator: ' ', required: false, labelWrap: true, errorTarget: 'under', clearable: false, requiredMessage: 'Payment Account is required', autoComplete: 'on', name: 'PaymentPlanEntityID', margin: '', id: 'FormPatientPayment_PaymentPlanEntityID', listeners: {blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'textfield', allowBlank: false, allowOnlyWhitespace: false, maxLength: 50, maxLength: 50, enforceMaxLength: true, minLength: 1, selectOnFocus: true, autoCorrect: false, fieldLabel: 'Patient ID', label: 'Patient ID', readOnly: false, hidden: false, labelSeparator: ' ', resetValue: '', required: true, labelWrap: true, labelAlign: 'placeholder', errorTarget: 'under', clearable: false, requiredMessage: 'Patient ID is required', autoComplete: 'on', name: 'PatientID', margin: '', id: 'FormPatientPayment_PatientID', listeners: {action: submitOnEnter,blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'container', layout: {type: 'hbox'}, cls: 'MultipleFieldsContainer', scrollable: null, id: 'FormPatientPayment_container_4', plugins: 'responsive', responsiveConfig: {'width > 600':{layout : { type : 'hbox'},},'width <= 600':{layout : { type : 'vbox'},},}, items: [ {xtype: 'textfield', allowBlank: false, allowOnlyWhitespace: false, maxLength: 35, maxLength: 35, enforceMaxLength: true, minLength: 1, selectOnFocus: true, autoCorrect: false, fieldLabel: 'First Name', label: 'First Name', readOnly: false, disabled: false, hidden: false, labelSeparator: ' ', resetValue: '', required: true, labelWrap: true, labelAlign: 'placeholder', errorTarget: 'under', clearable: false, requiredMessage: 'First Name is required', autoComplete: 'on', name: 'PatientFirstName', flex: 1, margin: '', id: 'FormPatientPayment_PatientFirstName', listeners: {action: submitOnEnter,blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'container', width: 24, name: 'PatientFirstNamePatientLastNameSpacer', hidden: false, cls: 'x-spacer', id: 'FormPatientPayment_PatientFirstNamePatientLastNameSpacer' }, {xtype: 'textfield', allowBlank: false, allowOnlyWhitespace: false, maxLength: 60, maxLength: 60, enforceMaxLength: true, minLength: 1, selectOnFocus: true, autoCorrect: false, fieldLabel: 'Last Name', label: 'Last Name', readOnly: false, disabled: false, hidden: false, labelSeparator: ' ', resetValue: '', required: true, labelWrap: true, labelAlign: 'placeholder', errorTarget: 'under', clearable: false, requiredMessage: 'Last Name is required', autoComplete: 'on', name: 'PatientLastName', flex: 1, margin: '', id: 'FormPatientPayment_PatientLastName', listeners: {action: submitOnEnter,blur: function(cmp){if(cmp.validate){cmp.validate();}}} }] }, {xtype: 'textfield', allowBlank: false, allowOnlyWhitespace: false, maxLength: 200, maxLength: 200, enforceMaxLength: true, minLength: 1, selectOnFocus: true, autoCorrect: false, fieldLabel: 'Email Address', label: 'Email Address', component: {"type":"email","pattern":null}, inputType: 'email', readOnly: false, hidden: false, labelSeparator: ' ', resetValue: '', required: true, labelWrap: true, labelAlign: 'placeholder', errorTarget: 'under', clearable: false, requiredMessage: 'Email Address is required', autoComplete: 'on', name: 'EmailAddress', margin: '', id: 'FormPatientPayment_EmailAddress', listeners: {action: submitOnEnter,blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'hiddenfield', fieldLabel: 'WalletPatientEntityID', label: 'WalletPatientEntityID', readOnly: false, labelSeparator: ' ', resetValue: '', required: false, labelWrap: true, errorTarget: 'under', clearable: false, requiredMessage: 'WalletPatientEntityID is required', autoComplete: 'on', name: 'WalletPatientEntityID', margin: '', id: 'FormPatientPayment_WalletPatientEntityID', listeners: {blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'hiddenfield', fieldLabel: 'PatientEntityID', label: 'PatientEntityID', readOnly: false, labelSeparator: ' ', resetValue: '', required: false, labelWrap: true, errorTarget: 'under', clearable: false, requiredMessage: 'PatientEntityID is required', autoComplete: 'on', name: 'PatientEntityID', margin: '', id: 'FormPatientPayment_PatientEntityID', listeners: {blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'container', layout: {type: 'hbox'}, cls: 'MultipleFieldsContainer', scrollable: null, id: 'FormPatientPayment_container_5', plugins: 'responsive', responsiveConfig: {'width > 600':{layout : { type : 'hbox'},},'width <= 600':{layout : { type : 'vbox'},},}, items: [ {xtype: 'container', width: 24, name: 'PatientServiceBeginDatePatientServiceEndDateSpacer', cls: 'x-spacer', id: 'FormPatientPayment_PatientServiceBeginDatePatientServiceEndDat' }] }, {xtype: 'container', layout: {type: 'hbox'}, cls: 'MultipleFieldsContainer', scrollable: null, id: 'FormPatientPayment_container_6', plugins: 'responsive', responsiveConfig: {'width > 600':{layout : { type : 'hbox'},},'width <= 600':{layout : { type : 'vbox'},},}, items: [] }, {xtype: 'hiddenfield', fieldLabel: 'EditPaymentPlanEntityId', label: 'EditPaymentPlanEntityId', labelSeparator: ' ', required: false, labelWrap: true, errorTarget: 'under', clearable: false, requiredMessage: 'EditPaymentPlanEntityId is required', autoComplete: 'on', name: 'EditPaymentPlanEntityId', margin: '', id: 'FormPatientPayment_EditPaymentPlanEntityId', listeners: {blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'hiddenfield', fieldLabel: 'IsNewPaymentPlanFlow', label: 'IsNewPaymentPlanFlow', labelSeparator: ' ', value: false, required: false, labelWrap: true, errorTarget: 'under', clearable: false, requiredMessage: 'IsNewPaymentPlanFlow is required', autoComplete: 'on', name: 'IsNewPaymentPlanFlow', margin: '', id: 'FormPatientPayment_IsNewPaymentPlanFlow', listeners: {blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'hiddenfield', fieldLabel: 'IsEditPaymentPlanFlow', label: 'IsEditPaymentPlanFlow', labelSeparator: ' ', value: false, required: false, labelWrap: true, errorTarget: 'under', clearable: false, requiredMessage: 'IsEditPaymentPlanFlow is required', autoComplete: 'on', name: 'IsEditPaymentPlanFlow', margin: '', id: 'FormPatientPayment_IsEditPaymentPlanFlow', listeners: {blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'hiddenfield', fieldLabel: 'LineItemKey', label: 'LineItemKey', labelSeparator: ' ', required: false, labelWrap: true, errorTarget: 'under', clearable: false, requiredMessage: 'LineItemKey is required', autoComplete: 'on', name: 'LineItemKey', margin: '', id: 'FormPatientPayment_LineItemKey', listeners: {blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'hiddenfield', fieldLabel: 'Guarantor Name', label: 'Guarantor Name', labelSeparator: ' ', required: false, labelWrap: true, errorTarget: 'under', clearable: false, requiredMessage: 'Guarantor Name is required', autoComplete: 'on', name: 'GuarantorName', margin: '', id: 'FormPatientPayment_GuarantorName', listeners: {blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'container', layout: {type: 'hbox', pack: 'start', align: 'bottom'}, cls: 'buttonContainer', scrollable: null, id: 'FormPatientPayment_container_7', items: [ {xtype: 'button', text: 'Cancel Edit', name: 'btnCancelEditPatient', margin: '', hidden: true, ariaRole: 'button', cls: 'noprint', id: 'FormPatientPayment_button_CancelEdit', listeners: {tap: cancelEditLineItem} }, {xtype: 'spacer', id: 'FormPatientPayment_spacer_6' }, {xtype: 'button', text: 'Next', name: 'btnNext', ui: 'action', margin: '', ariaRole: 'button', cls: 'action noprint', id: 'FormPatientPayment_button_Next', listeners: {tap: function(cmp, e, options) { InstaMed.get('IsMultiAR') && InstaMed.get('IsMultiAR').setValue(true); var cmpForm = InstaMed.findParentForm(cmp); var myForm = cmpForm.getForm(); var data = myForm.getValues(); var records = InstaMed.get('PatientPaymentPatientInfoMultiARDataView').getStore().getRange(); data = myForm.getValues(); data['LineItems'] = []; data['UIAction'] = 'Default'; Ext.each(records, function(rec) { var lineItem = rec.data; lineItem.requestKey = Ext.app.REMOTING_API.requestKey; lineItem.singleSignOnToken = Ext.app.REMOTING_API.token; data['LineItems'].push(lineItem); }); var blockAction = !false; if(blockAction){PerformAction(data, QuickPayPatientEntryController.submitPatient);} }} }, {xtype: 'button', text: 'Update Patient', name: 'btnUpdatePatient', ui: 'action', margin: '', hidden: true, ariaRole: 'button', cls: 'action noprint', id: 'FormPatientPayment_button_UpdatePatient', listeners: {tap: function(cmp, e, options) { InstaMed.get('IsMultiAR') && InstaMed.get('IsMultiAR').setValue(true); var cmpForm = InstaMed.findParentForm(cmp); var myForm = cmpForm.getForm(); var data = myForm.getValues(); var records = InstaMed.get('PatientPaymentPatientInfoMultiARDataView').getStore().getRange(); data = myForm.getValues(); data['LineItems'] = []; data['UIAction'] = 'Default'; Ext.each(records, function(rec) { var lineItem = rec.data; lineItem.requestKey = Ext.app.REMOTING_API.requestKey; lineItem.singleSignOnToken = Ext.app.REMOTING_API.token; data['LineItems'].push(lineItem); }); var blockAction = !false; if(blockAction){PerformAction(data, QuickPayPatientEntryController.updatePatient, null, cancelEditLineItem);} }} }] }] }] }] }] }, {xtype: 'spacer', flex: 1, id: 'spacer_3' }, {xtype: 'container', layout: {type: 'hbox'}, hidden: false, cls: 'x-panel-footer im-powered-by', scrollable: null, id: 'container_5', items: [ {xtype: 'spacer', id: 'spacer_4' }, {xtype: 'container', maxWidth: 1272, layout: {type: 'hbox'}, cls: 'largeTwelveColumn mediumTwelveColumn ', scrollable: null, id: 'NavQuickPayPatientEntry_container_8', items: [ {xtype: 'container', name: 'poweredbylogo', cls: 'hidden hiddenxs hiddensm', scrollable: null, id: 'NavQuickPayPatientEntry_poweredbylogo' }, {xtype: 'container', cls: 'copyrightContainer hiddenxs hiddensm', scrollable: null, id: 'NavQuickPayPatientEntry_container_9', items: [ {xtype: 'spacer', cls: 'hiddenmd hiddenlg', id: 'NavQuickPayPatientEntry_spacer_4' }, {xtype: 'label', html: '© 2024 InstaMed. All Rights Reserved.', name: 'copyrightFooter', ui: 'body1-primary', cls: 'margin-bottom-10 body1-primary', id: 'NavQuickPayPatientEntry_copyrightFooter' }, {xtype: 'spacer', cls: 'hiddenmd hiddenlg', id: 'NavQuickPayPatientEntry_spacer_5' }] }, {xtype: 'spacer', cls: 'hiddenxs hiddensm', id: 'NavQuickPayPatientEntry_spacer_6' }, {xtype: 'container', cls: 'linkButtonContainer hiddenxs hiddensm', scrollable: null, id: 'NavQuickPayPatientEntry_container_10', items: [ {xtype: 'button', text: 'Security', iconCls: 'x-ma ma-lock-outline', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavQuickPayPatientEntry_button_Security', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/security/','open-window');}} }, {xtype: 'button', text: 'Privacy', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavQuickPayPatientEntry_button_Privacy', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/privacy-statement/','open-window');}} }, {xtype: 'button', text: 'Terms', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavQuickPayPatientEntry_button_Terms', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/terms-of-use/','open-window');}} }, {xtype: 'button', text: 'Help', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavQuickPayPatientEntry_button_Help', listeners: {tap: function() { InstaMed.popupNewWindow('../../Form/PaymentPortal/ContactUs?id=AFCURGENT149','open-window');}} }, {xtype: 'button', text: 'English', align: 'right',menu:[{xtype: 'menuitem', text: 'English', handler: function(cmp) { PerformAction({Language:'en'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'en', cls: 'hiddenxs hiddensm', id: 'menuitem_en_2'},{xtype: 'menuitem', text: 'Español', handler: function(cmp) { PerformAction({Language:'es'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'es', cls: 'hiddenxs hiddensm', id: 'menuitem_es_2'},{xtype: 'menuitem', text: 'Français', handler: function(cmp) { PerformAction({Language:'fr'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'fr', cls: 'hiddenxs hiddensm', id: 'menuitem_fr_2'},], name: 'ForeignLanguages', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavQuickPayPatientEntry_button_ForeignLanguages' }] }, {xtype: 'container', cls: 'hiddenmd hiddenlg', scrollable: null, id: 'NavQuickPayPatientEntry_container_11', items: [ {xtype: 'container', layout: {type: 'hbox', pack: 'center'}, cls: 'x-center-helper', scrollable: null, id: 'NavQuickPayPatientEntry_container_12', items: [ {xtype: 'spacer', id: 'NavQuickPayPatientEntry_spacer_7' }, {xtype: 'container', name: 'poweredbylogo', cls: 'hidden', scrollable: null, id: 'NavQuickPayPatientEntry_poweredbylogo_1' }, {xtype: 'spacer', id: 'NavQuickPayPatientEntry_spacer_8' }] }, {xtype: 'container', layout: {type: 'hbox', pack: 'center'}, cls: 'x-center-helper', scrollable: null, id: 'NavQuickPayPatientEntry_container_13', items: [ {xtype: 'spacer', id: 'NavQuickPayPatientEntry_spacer_9' }, {xtype: 'container', cls: 'copyrightContainer', scrollable: null, id: 'NavQuickPayPatientEntry_container_14', items: [ {xtype: 'spacer', cls: 'hiddenmd hiddenlg', id: 'NavQuickPayPatientEntry_spacer_10' }, {xtype: 'label', html: '© 2024 InstaMed. All Rights Reserved.', name: 'copyrightFooter', ui: 'body1-primary', cls: 'margin-bottom-10 body1-primary', id: 'NavQuickPayPatientEntry_copyrightFooter_1' }, {xtype: 'spacer', cls: 'hiddenmd hiddenlg', id: 'NavQuickPayPatientEntry_spacer_11' }] }, {xtype: 'spacer', id: 'NavQuickPayPatientEntry_spacer_12' }] }, {xtype: 'container', layout: {type: 'hbox', pack: 'center'}, cls: 'x-center-helper', scrollable: null, id: 'NavQuickPayPatientEntry_container_15', items: [ {xtype: 'spacer', id: 'NavQuickPayPatientEntry_spacer_13' }, {xtype: 'container', cls: 'linkButtonContainer ', scrollable: null, id: 'NavQuickPayPatientEntry_container_16', items: [ {xtype: 'button', text: 'Security', iconCls: 'x-ma ma-lock-outline', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavQuickPayPatientEntry_button_Security_1', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/security/','open-window');}} }, {xtype: 'button', text: 'Privacy', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavQuickPayPatientEntry_button_Privacy_1', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/privacy-statement/','open-window');}} }, {xtype: 'button', text: 'Terms', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavQuickPayPatientEntry_button_Terms_1', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/terms-of-use/','open-window');}} }, {xtype: 'button', text: 'Help', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavQuickPayPatientEntry_button_Help_1', listeners: {tap: function() { InstaMed.popupNewWindow('../../Form/PaymentPortal/ContactUs?id=AFCURGENT149','open-window');}} }] }, {xtype: 'spacer', id: 'NavQuickPayPatientEntry_spacer_14' }] }, {xtype: 'container', layout: {type: 'hbox', pack: 'center'}, cls: 'x-center-helper', scrollable: null, id: 'NavQuickPayPatientEntry_container_17', items: [ {xtype: 'spacer', id: 'NavQuickPayPatientEntry_spacer_15' }, {xtype: 'container', scrollable: null, id: 'NavQuickPayPatientEntry_container_18', items: [ {xtype: 'button', text: 'English', align: 'right',menu:[{xtype: 'menuitem', text: 'English', handler: function(cmp) { PerformAction({Language:'en'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'en', cls: 'hiddenmd hiddenlg', id: 'menuitem_en_3'},{xtype: 'menuitem', text: 'Español', handler: function(cmp) { PerformAction({Language:'es'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'es', cls: 'hiddenmd hiddenlg', id: 'menuitem_es_3'},{xtype: 'menuitem', text: 'Français', handler: function(cmp) { PerformAction({Language:'fr'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'fr', cls: 'hiddenmd hiddenlg', id: 'menuitem_fr_3'},], name: 'ForeignLanguages', ui: 'grey', margin: '', hidden: false, ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavQuickPayPatientEntry_button_ForeignLanguages_1' }] }, {xtype: 'spacer', id: 'NavQuickPayPatientEntry_spacer_16' }] }] }] }, {xtype: 'spacer', id: 'spacer_5' }] }] }, {xtype: 'container', name: 'NavQuickPayAccountSummary', layout: {type: 'vbox', pack: 'start'}, showBackButton: true, showMenuButton: false, scrollable: 'true', id: 'NavQuickPayAccountSummary', items: [ {xtype: 'container', docked: 'top', scrollable: null, id: 'NavQuickPayAccountSummary_container', items: [ {xtype: 'instamedNavigationBar', name: 'headerBar', layout: {type: 'hbox'}, hidden: false, cls: 'im-ignore-custom-colors im-ignore-background', scrollable: null, id: 'NavQuickPayAccountSummary_headerBar', items: [ {xtype: 'spacer', id: 'NavQuickPayAccountSummary_spacer', plugins: 'responsive', responsiveConfig: {'width > 1272':{flex : 1,},'width <= 1272':{flex :0,},} }, {xtype: 'titlebar', title: '<a href=\\"../../Form/PaymentPortal/Start\\"> <img src=\\"https://cdn.instamed.com/V_2024_March/Content/Images/General/instamed-tagged-white.png?id=AFCURGENT149\\" alt=\\"InstaMed a J.P. Morgan company logo\\" style=\\"height: 40px\\">', maxWidth: 1272, cls: 'largeTwelveColumn mediumTwelveColumn smallTwelveColumn xsmallTwelveColumn im-ignore-custom-colors im-ignore-background', scrollable: null, id: 'NavQuickPayAccountSummary_titlebar', plugins: 'responsive', responsiveConfig: {'width >= 1272':{title :'',},'width < 1272':{title : ' ',},}, items: [ {xtype: 'button', accessibleText: 'Back', iconCls: 'x-ma ma-arrow-back', align: 'left', name: 'TitleBarNavigationViewBack', margin: '', hidden: false, ariaRole: 'button', cls: 'x-button-icon-link-style white hiddenlg noprint', id: 'NavQuickPayAccountSummary_TitleBarNavigationViewBack', plugins: 'responsive', responsiveConfig: {'width > 1272':{iconCls :'',},'width <= 1272':{iconCls : 'x-ma ma-arrow-back',},}, listeners: {tap: function() { PerformAction({}, QuickPayPatientEntryController.navigateBack,null); }} }, {xtype: 'container', html: ' ', align: 'left', scrollable: null, id: 'NavQuickPayAccountSummary_container_1', plugins: 'responsive', responsiveConfig: {'width >= 1272':{hidden : false,},'width < 1272':{hidden :true,},} }, {xtype: 'button', name: 'HeaderTitlebarButton', ui: 'white', margin: '', hidden: true, ariaRole: 'button', cls: 'x-button-link-style im-center-header-button white noprint', id: 'NavQuickPayAccountSummary_HeaderTitlebarButton' }, {xtype: 'button', text: 'Pay Any Healthcare Bill', align: 'right', name: 'PayAnyHealthcareBillButton', ui: 'white', margin: '', ariaRole: 'button', cls: 'x-button-link-style x-border hiddenxs hiddensm white noprint', id: 'NavQuickPayAccountSummary_button_PayAnyHealthcareBill', listeners: {tap: function() { if(InstaMed.isLoggedIn) { window.location.href ='../../Form/PaymentPortal/Dashboard?id=AFCURGENT149&pageStep=NavFindProvider'; } else { window.location.href ='../../Form/PaymentPortal/Start?pageStep=NavFindProvider'; }}} }, {xtype: 'button', text: 'Pay Bills', iconCls: 'x-ma ma-search', iconAlign: 'top', align: 'right', name: 'PayAnyHealthcareBillIcon', margin: '', ariaRole: 'button', cls: 'x-button-icon-ontop-link-style white hiddenmd hiddenlg noprint', id: 'NavQuickPayAccountSummary_button_PayBills', listeners: {tap: function() { if(InstaMed.isLoggedIn) { window.location.href ='../../Form/PaymentPortal/Dashboard?pageStep=NavFindProvider'; } else { window.location.href ='../../Form/PaymentPortal/Start?pageStep=NavFindProvider'; }}} }, {xtype: 'button', accessibleText: 'Log In or Sign Up', iconCls: 'x-ma ma-account-circle', align: 'right',menu:[{xtype: 'menuitem', text: 'Log In', handler: function() { PerformAction({}, PatientPortalLoginController.redirectToLogin,null); }, id: 'menuitem_LogIn_2'},{xtype: 'menuitem', text: 'Sign Up', handler: function() { PerformAction({}, SignUpController.redirectToSignUp,null); }, id: 'menuitem_SignUp_2'},], name: 'LoginOrSignUpProfileIcon', margin: '', ariaRole: 'button', cls: 'x-button-icon-link-style white noprint', id: 'NavQuickPayAccountSummary_button_LoginOrSignUpProfileIcon', plugins: 'responsive', responsiveConfig: {'!InstaMed.isLoggedIn & width > 960':{hidden: true,},'!InstaMed.isLoggedIn && width <= 960':{hidden: false,},}, listeners: {hiddenchange: function() { Ext.ComponentQuery.query('[name=LoginOrSignUpProfileIcon]')[0].getMenu().hide(); }} }, {xtype: 'button', text: '', align: 'right',menu:[{xtype: 'menuitem', text: 'Dashboard', handler: function(){ window.location.href='../../Form/PaymentPortal/Dashboard'; }, id: 'menuitem_Dashboard_4'},{xtype: 'menuitem', text: 'Help', handler: function() { window.open('https://help.instamed.com/patients/s/?dc_label=Patients')}, id: 'menuitem_Help_4'},{xtype: 'menuitem', text: 'Log Out', handler: function(){ window.location.href='../../Form/PaymentPortal/Logout?id=AFCURGENT149'; }, id: 'menuitem_LogOut_4'},], name: 'Profile', ui: 'white', margin: '', hidden: true, ariaRole: 'button', cls: 'x-button-link-style white noprint', id: 'NavQuickPayAccountSummary_button_Profile', plugins: 'responsive', responsiveConfig: {'InstaMed.isLoggedIn & width > 960':{hidden: false,},'InstaMed.isLoggedIn && width <= 960':{hidden: true,},}, listeners: {hiddenchange: function() { Ext.ComponentQuery.query('[name=Profile]')[0].getMenu().hide(); }} }, {xtype: 'container', align: 'right', name: 'LoginOrSignUpContainer', layout: {type: 'hbox'}, scrollable: null, id: 'NavQuickPayAccountSummary_LoginOrSignUpContainer', plugins: 'responsive', responsiveConfig: {'!InstaMed.isLoggedIn & width > 960':{hidden: false,},'!InstaMed.isLoggedIn && width <= 960':{hidden: true,},}, items: [ {xtype: 'button', text: 'Log In', align: 'right', name: 'LoginForDualLogin', ui: 'white', margin: '', hidden: false, ariaRole: 'button', cls: 'x-button-link-style hiddenxs hiddensm white noprint', id: 'NavQuickPayAccountSummary_button_LoginForDualLogin', listeners: {tap: function() { PerformAction({}, PatientPortalLoginController.redirectToLogin,null); }} }, {xtype: 'label', html: 'or', align: 'right', name: 'Or', ui: 'body1-white', cls: 'hiddenxs hiddensm body1-white', id: 'NavQuickPayAccountSummary_Or' }, {xtype: 'button', text: 'Sign Up', align: 'right', name: 'SignUpForDualLogin', ui: 'white', margin: '', ariaRole: 'button', cls: 'x-button-link-style hiddenxs hiddensm white noprint', id: 'NavQuickPayAccountSummary_button_SignUpForDualLogin', listeners: {tap: function() { PerformAction({}, SignUpController.redirectToSignUp,null); }} }] }, {xtype: 'button', accessibleText: 'Profile', iconCls: 'x-ma ma-account-circle', align: 'right',menu:[{xtype: 'menuitem', text: 'Dashboard', handler: function(){ window.location.href='../../Form/PaymentPortal/Dashboard'; }, id: 'menuitem_Dashboard_5'},{xtype: 'menuitem', text: 'Help', handler: function() { window.open('https://help.instamed.com/patients/s/?dc_label=Patients')}, id: 'menuitem_Help_5'},{xtype: 'menuitem', text: 'Log Out', handler: function(){ window.location.href='../../Form/PaymentPortal/Logout?id=AFCURGENT149'; }, id: 'menuitem_LogOut_5'},], name: 'ProfileIcon', margin: '', hidden: true, ariaRole: 'button', cls: 'x-button-icon-link-style white noprint', id: 'NavQuickPayAccountSummary_button_ProfileIcon', plugins: 'responsive', responsiveConfig: {'InstaMed.isLoggedIn & width > 960':{hidden: true,},'InstaMed.isLoggedIn && width <= 960':{hidden: false,},}, listeners: {hiddenchange: function() { Ext.ComponentQuery.query('[name=ProfileIcon]')[0].getMenu().hide(); }} }] }, {xtype: 'spacer', id: 'NavQuickPayAccountSummary_spacer_1', plugins: 'responsive', responsiveConfig: {'width > 1272':{flex : 1,},'width <= 1272':{flex :0,},} }] }] }, {xtype: 'container', layout: {type: 'hbox'}, cls: 'x-subheader-container', scrollable: null, id: 'NavQuickPayAccountSummary_container_2', items: [ {xtype: 'spacer', id: 'NavQuickPayAccountSummary_spacer_2', plugins: 'responsive', responsiveConfig: {'width > 1272':{flex : 1,},'width <= 1272':{flex :0,},} }, {xtype: 'container', maxWidth: 1272, layout: {type: 'hbox'}, cls: 'largeTwelveColumn mediumTwelveColumn smallTwelveColumn xsmallTwelveColumn x-subheader-panel ', scrollable: null, id: 'NavQuickPayAccountSummary_container_3', items: [ {xtype: 'image', src: '../../ContentHandler.aspx?URL=/Images/Database/326332D5-86DA-4881-BE6F-8DE62B1DD7E0&id=AFCURGENT149&crop=true&maxWidth=150&maxHeight=64', hidden: false, cls: 'x-clickable x-button-provider-img', id: 'NavQuickPayAccountSummary_image', listeners: {painted: function() { var cmp = this; cmp.el.dom.setAttribute('aria-label', 'AFC URGENT CARE - 149th Street logo'); cmp.el.dom.setAttribute('role', 'img'); cmp.el.dom.setAttribute('title', ''); },tap: function(){ window.location.href='../../Form/PaymentPortal/Default?id=AFCURGENT149'; }} }, {xtype: 'container', layout: {type: 'vbox', pack: 'center', align: 'left'}, cls: 'im-provider-header-buttons', scrollable: null, id: 'NavQuickPayAccountSummary_container_4', items: [ {xtype: 'label', html: 'AFC URGENT CARE - 149th Street', name: 'SubheaderProviderName', ui: 'subheading-primary', cls: 'initial-caps font-400 im-bold-button subheading-primary', id: 'NavQuickPayAccountSummary_SubheaderProviderName' }, {xtype: 'container', layout: {type: 'hbox'}, scrollable: null, id: 'NavQuickPayAccountSummary_container_5', items: [ {xtype: 'container', html: '', hidden: true, cls: 'im-address-verification-icon', scrollable: null, id: 'NavQuickPayAccountSummary_container_6' }, {xtype: 'label', html: '332 East 149th Street, Bronx, NY 10451', ui: 'body1-secondary', cls: 'line-height-20 body1-secondary', id: 'NavQuickPayAccountSummary_label' }] }, {xtype: 'container', layout: {type: 'hbox'}, hidden: false, scrollable: null, id: 'NavQuickPayAccountSummary_container_7', items: [ {xtype: 'label', html: '(347) 329-4010', ui: 'body1-primary', cls: 'body1-primary', id: 'NavQuickPayAccountSummary_label_1' }] }] }] }, {xtype: 'spacer', id: 'NavQuickPayAccountSummary_spacer_3', plugins: 'responsive', responsiveConfig: {'width > 1272':{flex : 1,},'width <= 1272':{flex :0,},} }] }, { xtype: 'panel', dock: 'top', frame: false, scrollable: 'true', id: 'panel_2', items: [ {xtype: 'container', maxWidth: 1272, layout: {type: 'hbox'}, cls: 'mainContent MainContentWithHeaerAndSubheader ', scrollable: null, id: 'container_6', items: [ {xtype: 'container', flex: 1, scrollable: null, id: 'container_7', items: [ { xtype: 'form', preventHeader: true, bodyCls: 'mypanel', api: { }, name: 'FormAccountSummary', itemId: 'FormAccountSummary', cls: 'col-large-offSet-3 col-medium-offSet-3 col-small-offSet-1 smallTenColumn xsmallTwelveColumn mediumSixColumn largeSixColumn ', scrollable: null, id: 'FormAccountSummary', items: [ {xtype: 'errorbox', name: 'ValidationSummary', ui: 'ErrorBox', hidden: true, cls: 'ErrorBox', id: 'ValidationSummary_2' }, {xtype: 'instamedHeading1', text: 'Account Summary', id: 'FormAccountSummary_instamedHeading1' }, {xtype: 'container', margin: '24 0 0 0', scrollable: null, id: 'FormAccountSummary_container', items: [ {xtype: 'container', layout: {type: 'hbox'}, cls: 'MultipleFieldsContainer im-account-summary-form-section-information', scrollable: null, id: 'FormAccountSummary_container_1', plugins: 'responsive', responsiveConfig: {'width > 600':{layout : { type : 'hbox'},},'width <= 600':{layout : { type : 'vbox'},},}, items: [ {xtype: 'container', flex: 1, scrollable: null, id: 'FormAccountSummary_container_2', items: [ {xtype: 'label', html: '', name: 'PatientInformation', ui: 'light-subheading-primary', cls: 'light-subheading-primary', id: 'FormAccountSummary_PatientInformation' }, {xtype: 'label', html: 'AFC URGENT CARE - 149th Street', name: 'ProviderName', ui: 'body1-secondary', cls: 'im-account-summary-form-patientname body1-secondary', id: 'FormAccountSummary_ProviderName' }] }, {xtype: 'container', width: 24, name: 'ViewStatementAsOfContainerSpacer', cls: 'x-spacer', id: 'FormAccountSummary_ViewStatementAsOfContainerSpacer' }, {xtype: 'container', align: 'right', name: 'ViewStatementAsOfContainer', flex: 1, hidden: true, cls: 'im-view-statement-asof-component', scrollable: null, id: 'FormAccountSummary_ViewStatementAsOfContainer', items: [ {xtype: 'container', html: '', name: 'ViewStatementLinkContainer', cls: 'im-view-statement-link im-view-statement-asof-component-link', scrollable: null, id: 'FormAccountSummary_ViewStatementLinkContainer' }, {xtype: 'label', html: '', name: 'AsOfDate', ui: 'body1-secondary', hidden: true, cls: 'im-view-statement-asof-component-asof body1-secondary', id: 'FormAccountSummary_AsOfDate' }] }] }] }, {xtype: 'container', margin: '24 0 0 0', cls: 'im-account-summary-form-section-graph', scrollable: null, id: 'FormAccountSummary_container_3', items: [ {xtype: 'container', layout: {type: 'hbox'}, scrollable: null, id: 'FormAccountSummary_container_4', plugins: 'responsive', responsiveConfig: {'width > 600':{layout : { type : 'hbox'},},'width <= 600':{layout : { type : 'vbox'},},}, items: [ {xtype: 'container', scrollable: null, id: 'FormAccountSummary_container_5', items: [ {xtype: 'container', width: 180, height: 180, cls: 'im-centered-content-donut-chart', scrollable: null, id: 'FormAccountSummary_container_6', items: [ {xtype: 'container', centered: true, cls: 'im-center-text-wrapper', scrollable: null, id: 'FormAccountSummary_container_7', items: [ {xtype: 'container', html: '

Total Balance

', name: 'AccountSummaryChartCenterText', scrollable: null, id: 'FormAccountSummary_AccountSummaryChartCenterText' }] }, {xtype: 'polar', reference: 'chart', flipXY: false, theme: 'instamed', store: Ext.data.StoreManager.lookup('AccountSummaryPaymentInformationStore'),axes:[],series:[{type: 'pie', angleField: 'Angle', donut: 90,label:{display: 'none',field: 'Label'},subStyle:{lineWidth: 0,strokeStyle: 'none'}, renderer: function (sprite, config, rendererData, index) { var colorsObject = {}, rendererObject = {}, output = {};colorsObject.fillStyle = this.getTheme().getColors()[index];;var renderer = function (sprite, config, renderedData, index) { return { fill: renderedData.store.getData().items[index].data.Color }; };rendererObject = renderer.apply(this, arguments);;return Ext.merge({}, colorsObject, rendererObject); },yField:[],tooltip:{renderer: function (tooltip, record, item) { if(record){ var label = record.get('Label'); var isMaxAngle = record.get('IsMaxAngle'); var angle = record.get('Angle'); if(label && angle && isMaxAngle) { tooltip.setHtml(label + ' : ' + Ext.util.Format.currency(isMaxAngle.toLowerCase() === 'true' ? 0 : angle)); } } },trackMouse: true}}], width: 180, height: 180, cls: 'im-chart im-chart-polar', id: 'FormAccountSummary_polar' }] }] }, {xtype: 'container', flex: 2, cls: 'im-account-summary-legend', scrollable: null, id: 'FormAccountSummary_container_8', items: [ {xtype: 'container', cls: 'im-account-summary-legend-centered', scrollable: null, id: 'FormAccountSummary_container_9', items: [ {xtype: 'instameddisplayfield', fieldLabel: 'Total Charges', label: 'Total Charges', readOnly: true, hidden: true, labelSeparator: ' ', value: '-', required: false, labelWrap: true, labelWidth: 'auto', labelAlign: 'left', errorTarget: 'under', clearable: false, requiredMessage: 'Total Charges is required', autoComplete: 'on', name: 'TotalCharges', margin: '', ariaRole: '', cls: 'im-display-field im-legend-label im-legend-label-disable-custom-color im-legend-label-empty mod-rounded', id: 'FormAccountSummary_TotalCharges', plugins: 'responsive', responsiveConfig: {'width < 600':{labelAlign : 'top',},'width >= 600':{labelAlign : 'left',},}, listeners: {blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'instameddisplayfield', fieldLabel: 'Insurance & Adjustments', label: 'Insurance & Adjustments', readOnly: true, hidden: true, labelSeparator: ' ', value: '-', required: false, labelWrap: true, labelWidth: 'auto', labelAlign: 'left', errorTarget: 'under', clearable: false, requiredMessage: 'Insurance & Adjustments is required', autoComplete: 'on', name: 'InsuranceAdjustments', margin: '', ariaRole: '', cls: 'im-display-field im-legend-label im-legend-label-disable-custom-color im-legend-label-grey-400 mod-rounded', id: 'FormAccountSummary_InsuranceAdjustments', plugins: 'responsive', responsiveConfig: {'width < 600':{labelAlign : 'top',},'width >= 600':{labelAlign : 'left',},}, listeners: {blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'instameddisplayfield', fieldLabel: 'Previously Paid', label: 'Previously Paid', readOnly: true, hidden: true, labelSeparator: ' ', value: '-', required: false, labelWrap: true, labelWidth: 'auto', labelAlign: 'left', errorTarget: 'under', clearable: false, requiredMessage: 'Previously Paid is required', autoComplete: 'on', name: 'PreviouslyPaid', margin: '', ariaRole: '', cls: 'im-display-field im-legend-label im-legend-label-disable-custom-color im-legend-label-primary-green mod-rounded', id: 'FormAccountSummary_PreviouslyPaid', plugins: 'responsive', responsiveConfig: {'width < 600':{labelAlign : 'top',},'width >= 600':{labelAlign : 'left',},}, listeners: {blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'container', name: 'AccountSummaryLegendTotalBalanceDivider', hidden: true, cls: 'im-account-summary-legend-total-balance-divider', scrollable: null, id: 'FormAccountSummary_AccountSummaryLegendTotalBalanceDivider' }, {xtype: 'instameddisplayfield', fieldLabel: 'Balance', label: 'Balance', readOnly: true, hidden: false, labelSeparator: ' ', value: '', required: false, labelWrap: true, labelWidth: 'auto', labelAlign: 'left', errorTarget: 'under', clearable: false, requiredMessage: 'Balance is required', autoComplete: 'on', name: 'PatientBalance', margin: '', ariaRole: '', cls: 'im-display-field im-legend-label im-legend-label-disable-custom-color im-legend-label-primary-blue-500 mod-title-blue-500-value mod-rounded', id: 'FormAccountSummary_PatientBalance', plugins: 'responsive', responsiveConfig: {'width < 600':{labelAlign : 'top',},'width >= 600':{labelAlign : 'left',},}, listeners: {blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'instameddisplayfield', fieldLabel: 'Pending Payments', label: 'Pending Payments', readOnly: true, hidden: true, labelSeparator: ' ', value: '(- $0.00)', required: false, labelWrap: true, labelWidth: 'auto', labelAlign: 'left', errorTarget: 'under', clearable: false, requiredMessage: 'Pending Payments is required', autoComplete: 'on', name: 'GeneralPendingPaymentsLabel', margin: '', ariaRole: '', cls: 'im-display-field im-legend-label im-legend-label-disable-custom-color im-legend-label-value-stroked mod-rounded', id: 'FormAccountSummary_GeneralPendingPaymentsLabel', plugins: 'responsive', responsiveConfig: {'width < 600':{labelAlign : 'top',},'width >= 600':{labelAlign : 'left',},}, listeners: {blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'instameddisplayfield', fieldLabel: 'Payment Amount', label: 'Payment Amount', readOnly: true, hidden: true, labelSeparator: ' ', value: '', required: false, labelWrap: true, labelWidth: 'auto', labelAlign: 'left', errorTarget: 'under', clearable: false, requiredMessage: 'Payment Amount is required', autoComplete: 'on', name: 'PaymentAmount', margin: '', ariaRole: '', cls: 'im-display-field im-legend-label im-legend-label-disable-custom-color im-legend-label-value-blue mod-rounded', id: 'FormAccountSummary_PaymentAmount', plugins: 'responsive', responsiveConfig: {'width < 600':{labelAlign : 'top',},'width >= 600':{labelAlign : 'left',},}, listeners: {blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'container', cls: 'im-account-summary-form-section-detailslink', scrollable: null, id: 'FormAccountSummary_container_10', items: [ {xtype: 'button', text: 'View Details', name: 'AccountSummaryShow', ui: 'inline-hyperlink', margin: '', ariaRole: 'button', cls: 'x-button-link-style inline-hyperlink noprint', id: 'FormAccountSummary_button_ViewDetails', listeners: {tap: function(cmp, event) { event.preventDefault();InstaMed.get('MoreDetailsContainer').show(); InstaMed.get('AccountSummaryHide').show(); InstaMed.get('AccountSummaryShow').hide(); }} }, {xtype: 'button', text: 'Hide Details', name: 'AccountSummaryHide', ui: 'inline-hyperlink', margin: '', hidden: true, ariaRole: 'button', cls: 'x-button-link-style inline-hyperlink noprint', id: 'FormAccountSummary_button_HideDetails', listeners: {tap: function(cmp, event) { event.preventDefault();InstaMed.get('AccountSummaryShow').show(); InstaMed.get('AccountSummaryHide').hide(); InstaMed.get('MoreDetailsContainer').hide(); }} }] }] }] }] }] }, {xtype: 'container', name: 'MoreDetailsContainer', margin: '16 0 16 0', hidden: true, cls: 'im-account-summary-form-section-details', scrollable: null, id: 'FormAccountSummary_MoreDetailsContainer', items: [ {xtype: 'container', layout: {type: 'float'}, cls: 'floatedContainer', scrollable: null, id: 'FormAccountSummary_container_11', items: [ {xtype: 'instameddisplayfield', fieldLabel: 'Patient Name', label: 'Patient Name', readOnly: true, labelSeparator: ' ', value: '', required: false, labelWrap: true, labelAlign: 'top', errorTarget: 'under', clearable: false, requiredMessage: 'Patient Name is required', autoComplete: 'on', name: 'PatientName', ui: 'payment-flow', margin: '', ariaRole: '', cls: 'im-display-field payment-flow', id: 'FormAccountSummary_PatientName', listeners: {blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'instameddisplayfield', fieldLabel: 'Guarantor Name', label: 'Guarantor Name', readOnly: true, hidden: true, labelSeparator: ' ', required: false, labelWrap: true, labelAlign: 'top', errorTarget: 'under', clearable: false, requiredMessage: 'Guarantor Name is required', autoComplete: 'on', name: 'GuarantorName', ui: 'payment-flow', margin: '', ariaRole: '', cls: 'im-display-field payment-flow', id: 'FormAccountSummary_GuarantorName', listeners: {blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'instameddisplayfield', fieldLabel: 'Patient ID', label: 'Patient ID', readOnly: true, labelSeparator: ' ', required: false, labelWrap: true, labelAlign: 'top', errorTarget: 'under', clearable: false, requiredMessage: 'Patient ID is required', autoComplete: 'on', name: 'PatientID', ui: 'payment-flow', margin: '', ariaRole: '', cls: 'im-display-field payment-flow', id: 'FormAccountSummary_PatientID', listeners: {blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'instameddisplayfield', fieldLabel: 'Date of Birth', label: 'Date of Birth', readOnly: true, hidden: true, labelSeparator: ' ', required: false, labelWrap: true, labelAlign: 'top', errorTarget: 'under', clearable: false, requiredMessage: 'Date of Birth is required', autoComplete: 'on', name: 'PatientBirthDate', ui: 'payment-flow', margin: '', ariaRole: '', cls: 'im-display-field payment-flow', id: 'FormAccountSummary_PatientBirthDate', listeners: {blur: function(cmp){if(cmp.validate){cmp.validate();}}} }] }] }, {xtype: 'hiddenfield', fieldLabel: 'StatementID', label: 'StatementID', labelSeparator: ' ', required: false, labelWrap: true, errorTarget: 'under', clearable: false, requiredMessage: 'StatementID is required', autoComplete: 'on', name: 'StatementID', margin: '', id: 'FormAccountSummary_StatementID', listeners: {blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'container', layout: {type: 'hbox', pack: 'start', align: 'bottom'}, cls: 'buttonContainer', scrollable: null, id: 'FormAccountSummary_container_12', items: [ {xtype: 'spacer', id: 'FormAccountSummary_spacer' }, {xtype: 'button', text: 'Back', name: 'btnBack', ui: 'secondary', margin: '', ariaRole: 'button', cls: 'secondary noprint', id: 'FormAccountSummary_button_Back', listeners: {tap: function() { PerformAction({}, QuickPayPatientEntryController.navigateBack,null); }} }, {xtype: 'button', text: 'Pay Over Time', name: 'PayOverTime', ui: 'secondary', margin: '', hidden: true, ariaRole: 'button', cls: 'secondary noprint', id: 'FormAccountSummary_button_PayOverTime', listeners: {tap: function(cmp, newValue, oldValue, eOpts) { myForm = InstaMed.findParentForm(cmp); PerformAction(myForm.getValues(),QuickPayAccountSummaryController.payOverTime,cmp,undefined,undefined,undefined,undefined,undefined); }} }, {xtype: 'button', text: 'Pay Now', name: 'PayNow', ui: 'action', margin: '', ariaRole: 'button', cls: 'action noprint', id: 'FormAccountSummary_button_PayNow', listeners: {tap: function(cmp, newValue, oldValue, eOpts) { myForm = InstaMed.findParentForm(cmp); PerformAction(myForm.getValues(),QuickPayAccountSummaryController.payNow,cmp,undefined,undefined,undefined,undefined,undefined); }} }] }] }] }] }] }, {xtype: 'spacer', flex: 1, id: 'spacer_6' }, {xtype: 'container', layout: {type: 'hbox'}, hidden: false, cls: 'x-panel-footer im-powered-by', scrollable: null, id: 'container_8', items: [ {xtype: 'spacer', id: 'spacer_7' }, {xtype: 'container', maxWidth: 1272, layout: {type: 'hbox'}, cls: 'largeTwelveColumn mediumTwelveColumn ', scrollable: null, id: 'NavQuickPayAccountSummary_container_8', items: [ {xtype: 'container', name: 'poweredbylogo', cls: 'hidden hiddenxs hiddensm', scrollable: null, id: 'NavQuickPayAccountSummary_poweredbylogo' }, {xtype: 'container', cls: 'copyrightContainer hiddenxs hiddensm', scrollable: null, id: 'NavQuickPayAccountSummary_container_9', items: [ {xtype: 'spacer', cls: 'hiddenmd hiddenlg', id: 'NavQuickPayAccountSummary_spacer_4' }, {xtype: 'label', html: '© 2024 InstaMed. All Rights Reserved.', name: 'copyrightFooter', ui: 'body1-primary', cls: 'margin-bottom-10 body1-primary', id: 'NavQuickPayAccountSummary_copyrightFooter' }, {xtype: 'spacer', cls: 'hiddenmd hiddenlg', id: 'NavQuickPayAccountSummary_spacer_5' }] }, {xtype: 'spacer', cls: 'hiddenxs hiddensm', id: 'NavQuickPayAccountSummary_spacer_6' }, {xtype: 'container', cls: 'linkButtonContainer hiddenxs hiddensm', scrollable: null, id: 'NavQuickPayAccountSummary_container_10', items: [ {xtype: 'button', text: 'Security', iconCls: 'x-ma ma-lock-outline', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavQuickPayAccountSummary_button_Security', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/security/','open-window');}} }, {xtype: 'button', text: 'Privacy', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavQuickPayAccountSummary_button_Privacy', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/privacy-statement/','open-window');}} }, {xtype: 'button', text: 'Terms', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavQuickPayAccountSummary_button_Terms', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/terms-of-use/','open-window');}} }, {xtype: 'button', text: 'Help', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavQuickPayAccountSummary_button_Help', listeners: {tap: function() { InstaMed.popupNewWindow('../../Form/PaymentPortal/ContactUs?id=AFCURGENT149','open-window');}} }, {xtype: 'button', text: 'English', align: 'right',menu:[{xtype: 'menuitem', text: 'English', handler: function(cmp) { PerformAction({Language:'en'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'en', cls: 'hiddenxs hiddensm', id: 'menuitem_en_4'},{xtype: 'menuitem', text: 'Español', handler: function(cmp) { PerformAction({Language:'es'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'es', cls: 'hiddenxs hiddensm', id: 'menuitem_es_4'},{xtype: 'menuitem', text: 'Français', handler: function(cmp) { PerformAction({Language:'fr'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'fr', cls: 'hiddenxs hiddensm', id: 'menuitem_fr_4'},], name: 'ForeignLanguages', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavQuickPayAccountSummary_button_ForeignLanguages' }] }, {xtype: 'container', cls: 'hiddenmd hiddenlg', scrollable: null, id: 'NavQuickPayAccountSummary_container_11', items: [ {xtype: 'container', layout: {type: 'hbox', pack: 'center'}, cls: 'x-center-helper', scrollable: null, id: 'NavQuickPayAccountSummary_container_12', items: [ {xtype: 'spacer', id: 'NavQuickPayAccountSummary_spacer_7' }, {xtype: 'container', name: 'poweredbylogo', cls: 'hidden', scrollable: null, id: 'NavQuickPayAccountSummary_poweredbylogo_1' }, {xtype: 'spacer', id: 'NavQuickPayAccountSummary_spacer_8' }] }, {xtype: 'container', layout: {type: 'hbox', pack: 'center'}, cls: 'x-center-helper', scrollable: null, id: 'NavQuickPayAccountSummary_container_13', items: [ {xtype: 'spacer', id: 'NavQuickPayAccountSummary_spacer_9' }, {xtype: 'container', cls: 'copyrightContainer', scrollable: null, id: 'NavQuickPayAccountSummary_container_14', items: [ {xtype: 'spacer', cls: 'hiddenmd hiddenlg', id: 'NavQuickPayAccountSummary_spacer_10' }, {xtype: 'label', html: '© 2024 InstaMed. All Rights Reserved.', name: 'copyrightFooter', ui: 'body1-primary', cls: 'margin-bottom-10 body1-primary', id: 'NavQuickPayAccountSummary_copyrightFooter_1' }, {xtype: 'spacer', cls: 'hiddenmd hiddenlg', id: 'NavQuickPayAccountSummary_spacer_11' }] }, {xtype: 'spacer', id: 'NavQuickPayAccountSummary_spacer_12' }] }, {xtype: 'container', layout: {type: 'hbox', pack: 'center'}, cls: 'x-center-helper', scrollable: null, id: 'NavQuickPayAccountSummary_container_15', items: [ {xtype: 'spacer', id: 'NavQuickPayAccountSummary_spacer_13' }, {xtype: 'container', cls: 'linkButtonContainer ', scrollable: null, id: 'NavQuickPayAccountSummary_container_16', items: [ {xtype: 'button', text: 'Security', iconCls: 'x-ma ma-lock-outline', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavQuickPayAccountSummary_button_Security_1', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/security/','open-window');}} }, {xtype: 'button', text: 'Privacy', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavQuickPayAccountSummary_button_Privacy_1', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/privacy-statement/','open-window');}} }, {xtype: 'button', text: 'Terms', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavQuickPayAccountSummary_button_Terms_1', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/terms-of-use/','open-window');}} }, {xtype: 'button', text: 'Help', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavQuickPayAccountSummary_button_Help_1', listeners: {tap: function() { InstaMed.popupNewWindow('../../Form/PaymentPortal/ContactUs?id=AFCURGENT149','open-window');}} }] }, {xtype: 'spacer', id: 'NavQuickPayAccountSummary_spacer_14' }] }, {xtype: 'container', layout: {type: 'hbox', pack: 'center'}, cls: 'x-center-helper', scrollable: null, id: 'NavQuickPayAccountSummary_container_17', items: [ {xtype: 'spacer', id: 'NavQuickPayAccountSummary_spacer_15' }, {xtype: 'container', scrollable: null, id: 'NavQuickPayAccountSummary_container_18', items: [ {xtype: 'button', text: 'English', align: 'right',menu:[{xtype: 'menuitem', text: 'English', handler: function(cmp) { PerformAction({Language:'en'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'en', cls: 'hiddenmd hiddenlg', id: 'menuitem_en_5'},{xtype: 'menuitem', text: 'Español', handler: function(cmp) { PerformAction({Language:'es'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'es', cls: 'hiddenmd hiddenlg', id: 'menuitem_es_5'},{xtype: 'menuitem', text: 'Français', handler: function(cmp) { PerformAction({Language:'fr'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'fr', cls: 'hiddenmd hiddenlg', id: 'menuitem_fr_5'},], name: 'ForeignLanguages', ui: 'grey', margin: '', hidden: false, ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavQuickPayAccountSummary_button_ForeignLanguages_1' }] }, {xtype: 'spacer', id: 'NavQuickPayAccountSummary_spacer_16' }] }] }] }, {xtype: 'spacer', id: 'spacer_8' }] }] }, {xtype: 'container', name: 'NavSelectProvider', layout: {type: 'vbox', pack: 'start'}, scrollable: 'true', id: 'NavSelectProvider', items: [ {xtype: 'container', docked: 'top', scrollable: null, id: 'NavSelectProvider_container', items: [ {xtype: 'instamedNavigationBar', name: 'headerBar', layout: {type: 'hbox'}, hidden: false, cls: 'im-ignore-custom-colors im-ignore-background', scrollable: null, id: 'NavSelectProvider_headerBar', items: [ {xtype: 'spacer', id: 'NavSelectProvider_spacer', plugins: 'responsive', responsiveConfig: {'width > 1272':{flex : 1,},'width <= 1272':{flex :0,},} }, {xtype: 'titlebar', title: '<a href=\\"../../Form/PaymentPortal/Start\\"> <img src=\\"https://cdn.instamed.com/V_2024_March/Content/Images/General/instamed-tagged-white.png?id=AFCURGENT149\\" alt=\\"InstaMed a J.P. Morgan company logo\\" style=\\"height: 40px\\">', maxWidth: 1272, cls: 'largeTwelveColumn mediumTwelveColumn smallTwelveColumn xsmallTwelveColumn im-ignore-custom-colors im-ignore-background', scrollable: null, id: 'NavSelectProvider_titlebar', plugins: 'responsive', responsiveConfig: {'width >= 1272':{title :'',},'width < 1272':{title : ' ',},}, items: [ {xtype: 'button', accessibleText: 'Back', iconCls: 'x-ma ma-arrow-back', align: 'left', name: 'TitleBarNavigationViewBack', margin: '', hidden: false, ariaRole: 'button', cls: 'x-button-icon-link-style white hiddenlg noprint', id: 'NavSelectProvider_TitleBarNavigationViewBack', plugins: 'responsive', responsiveConfig: {'width > 1272':{iconCls :'',},'width <= 1272':{iconCls : 'x-ma ma-arrow-back',},}, listeners: {tap: function() { PerformAction({}, QuickPayPatientEntryController.navigateBack,null); }} }, {xtype: 'container', html: ' ', align: 'left', scrollable: null, id: 'NavSelectProvider_container_1', plugins: 'responsive', responsiveConfig: {'width >= 1272':{hidden : false,},'width < 1272':{hidden :true,},} }, {xtype: 'button', name: 'HeaderTitlebarButton', ui: 'white', margin: '', hidden: true, ariaRole: 'button', cls: 'x-button-link-style im-center-header-button white noprint', id: 'NavSelectProvider_HeaderTitlebarButton' }, {xtype: 'button', text: 'Pay Any Healthcare Bill', align: 'right', name: 'PayAnyHealthcareBillButton', ui: 'white', margin: '', ariaRole: 'button', cls: 'x-button-link-style x-border hiddenxs hiddensm white noprint', id: 'NavSelectProvider_button_PayAnyHealthcareBill', listeners: {tap: function() { if(InstaMed.isLoggedIn) { window.location.href ='../../Form/PaymentPortal/Dashboard?id=AFCURGENT149&pageStep=NavFindProvider'; } else { window.location.href ='../../Form/PaymentPortal/Start?pageStep=NavFindProvider'; }}} }, {xtype: 'button', text: 'Pay Bills', iconCls: 'x-ma ma-search', iconAlign: 'top', align: 'right', name: 'PayAnyHealthcareBillIcon', margin: '', ariaRole: 'button', cls: 'x-button-icon-ontop-link-style white hiddenmd hiddenlg noprint', id: 'NavSelectProvider_button_PayBills', listeners: {tap: function() { if(InstaMed.isLoggedIn) { window.location.href ='../../Form/PaymentPortal/Dashboard?pageStep=NavFindProvider'; } else { window.location.href ='../../Form/PaymentPortal/Start?pageStep=NavFindProvider'; }}} }, {xtype: 'button', accessibleText: 'Log In or Sign Up', iconCls: 'x-ma ma-account-circle', align: 'right',menu:[{xtype: 'menuitem', text: 'Log In', handler: function() { PerformAction({}, PatientPortalLoginController.redirectToLogin,null); }, id: 'menuitem_LogIn_3'},{xtype: 'menuitem', text: 'Sign Up', handler: function() { PerformAction({}, SignUpController.redirectToSignUp,null); }, id: 'menuitem_SignUp_3'},], name: 'LoginOrSignUpProfileIcon', margin: '', ariaRole: 'button', cls: 'x-button-icon-link-style white noprint', id: 'NavSelectProvider_button_LoginOrSignUpProfileIcon', plugins: 'responsive', responsiveConfig: {'!InstaMed.isLoggedIn & width > 960':{hidden: true,},'!InstaMed.isLoggedIn && width <= 960':{hidden: false,},}, listeners: {hiddenchange: function() { Ext.ComponentQuery.query('[name=LoginOrSignUpProfileIcon]')[0].getMenu().hide(); }} }, {xtype: 'button', text: '', align: 'right',menu:[{xtype: 'menuitem', text: 'Dashboard', handler: function(){ window.location.href='../../Form/PaymentPortal/Dashboard'; }, id: 'menuitem_Dashboard_6'},{xtype: 'menuitem', text: 'Help', handler: function() { window.open('https://help.instamed.com/patients/s/?dc_label=Patients')}, id: 'menuitem_Help_6'},{xtype: 'menuitem', text: 'Log Out', handler: function(){ window.location.href='../../Form/PaymentPortal/Logout?id=AFCURGENT149'; }, id: 'menuitem_LogOut_6'},], name: 'Profile', ui: 'white', margin: '', hidden: true, ariaRole: 'button', cls: 'x-button-link-style white noprint', id: 'NavSelectProvider_button_Profile', plugins: 'responsive', responsiveConfig: {'InstaMed.isLoggedIn & width > 960':{hidden: false,},'InstaMed.isLoggedIn && width <= 960':{hidden: true,},}, listeners: {hiddenchange: function() { Ext.ComponentQuery.query('[name=Profile]')[0].getMenu().hide(); }} }, {xtype: 'container', align: 'right', name: 'LoginOrSignUpContainer', layout: {type: 'hbox'}, scrollable: null, id: 'NavSelectProvider_LoginOrSignUpContainer', plugins: 'responsive', responsiveConfig: {'!InstaMed.isLoggedIn & width > 960':{hidden: false,},'!InstaMed.isLoggedIn && width <= 960':{hidden: true,},}, items: [ {xtype: 'button', text: 'Log In', align: 'right', name: 'LoginForDualLogin', ui: 'white', margin: '', hidden: false, ariaRole: 'button', cls: 'x-button-link-style hiddenxs hiddensm white noprint', id: 'NavSelectProvider_button_LoginForDualLogin', listeners: {tap: function() { PerformAction({}, PatientPortalLoginController.redirectToLogin,null); }} }, {xtype: 'label', html: 'or', align: 'right', name: 'Or', ui: 'body1-white', cls: 'hiddenxs hiddensm body1-white', id: 'NavSelectProvider_Or' }, {xtype: 'button', text: 'Sign Up', align: 'right', name: 'SignUpForDualLogin', ui: 'white', margin: '', ariaRole: 'button', cls: 'x-button-link-style hiddenxs hiddensm white noprint', id: 'NavSelectProvider_button_SignUpForDualLogin', listeners: {tap: function() { PerformAction({}, SignUpController.redirectToSignUp,null); }} }] }, {xtype: 'button', accessibleText: 'Profile', iconCls: 'x-ma ma-account-circle', align: 'right',menu:[{xtype: 'menuitem', text: 'Dashboard', handler: function(){ window.location.href='../../Form/PaymentPortal/Dashboard'; }, id: 'menuitem_Dashboard_7'},{xtype: 'menuitem', text: 'Help', handler: function() { window.open('https://help.instamed.com/patients/s/?dc_label=Patients')}, id: 'menuitem_Help_7'},{xtype: 'menuitem', text: 'Log Out', handler: function(){ window.location.href='../../Form/PaymentPortal/Logout?id=AFCURGENT149'; }, id: 'menuitem_LogOut_7'},], name: 'ProfileIcon', margin: '', hidden: true, ariaRole: 'button', cls: 'x-button-icon-link-style white noprint', id: 'NavSelectProvider_button_ProfileIcon', plugins: 'responsive', responsiveConfig: {'InstaMed.isLoggedIn & width > 960':{hidden: true,},'InstaMed.isLoggedIn && width <= 960':{hidden: false,},}, listeners: {hiddenchange: function() { Ext.ComponentQuery.query('[name=ProfileIcon]')[0].getMenu().hide(); }} }] }, {xtype: 'spacer', id: 'NavSelectProvider_spacer_1', plugins: 'responsive', responsiveConfig: {'width > 1272':{flex : 1,},'width <= 1272':{flex :0,},} }] }] }, {xtype: 'container', layout: {type: 'hbox'}, cls: 'x-subheader-container', scrollable: null, id: 'NavSelectProvider_container_2', items: [ {xtype: 'spacer', id: 'NavSelectProvider_spacer_2', plugins: 'responsive', responsiveConfig: {'width > 1272':{flex : 1,},'width <= 1272':{flex :0,},} }, {xtype: 'container', maxWidth: 1272, layout: {type: 'hbox'}, cls: 'largeTwelveColumn mediumTwelveColumn smallTwelveColumn xsmallTwelveColumn x-subheader-panel ', scrollable: null, id: 'NavSelectProvider_container_3', items: [ {xtype: 'image', src: '../../ContentHandler.aspx?URL=/Images/Database/326332D5-86DA-4881-BE6F-8DE62B1DD7E0&id=AFCURGENT149&crop=true&maxWidth=150&maxHeight=64', hidden: false, cls: 'x-clickable x-button-provider-img', id: 'NavSelectProvider_image', listeners: {painted: function() { var cmp = this; cmp.el.dom.setAttribute('aria-label', 'AFC URGENT CARE - 149th Street logo'); cmp.el.dom.setAttribute('role', 'img'); cmp.el.dom.setAttribute('title', ''); },tap: function(){ window.location.href='../../Form/PaymentPortal/Default?id=AFCURGENT149'; }} }, {xtype: 'container', layout: {type: 'vbox', pack: 'center', align: 'left'}, cls: 'im-provider-header-buttons', scrollable: null, id: 'NavSelectProvider_container_4', items: [ {xtype: 'label', html: 'AFC URGENT CARE - 149th Street', name: 'SubheaderProviderName', ui: 'subheading-primary', cls: 'initial-caps font-400 im-bold-button subheading-primary', id: 'NavSelectProvider_SubheaderProviderName' }, {xtype: 'container', layout: {type: 'hbox'}, scrollable: null, id: 'NavSelectProvider_container_5', items: [ {xtype: 'container', html: '', hidden: true, cls: 'im-address-verification-icon', scrollable: null, id: 'NavSelectProvider_container_6' }, {xtype: 'label', html: '332 East 149th Street, Bronx, NY 10451', ui: 'body1-secondary', cls: 'line-height-20 body1-secondary', id: 'NavSelectProvider_label' }] }, {xtype: 'container', layout: {type: 'hbox'}, hidden: false, scrollable: null, id: 'NavSelectProvider_container_7', items: [ {xtype: 'label', html: '(347) 329-4010', ui: 'body1-primary', cls: 'body1-primary', id: 'NavSelectProvider_label_1' }] }] }] }, {xtype: 'spacer', id: 'NavSelectProvider_spacer_3', plugins: 'responsive', responsiveConfig: {'width > 1272':{flex : 1,},'width <= 1272':{flex :0,},} }] }, { xtype: 'panel', dock: 'top', frame: false, scrollable: 'true', id: 'panel_3', items: [ {xtype: 'container', maxWidth: 1272, layout: {type: 'hbox'}, cls: 'mainContent MainContentWithHeaerAndSubheader ', scrollable: null, id: 'container_9', items: [ {xtype: 'container', flex: 1, scrollable: null, id: 'container_10', items: [ { xtype: 'form', preventHeader: true, bodyCls: 'mypanel', api: { }, name: 'MyFormPanel', itemId: 'MyFormPanel', cls: 'col-large-offSet-3 col-medium-offSet-3 col-small-offSet-1 smallTenColumn xsmallTwelveColumn mediumSixColumn largeSixColumn ', scrollable: null, id: 'MyFormPanel', items: [ {xtype: 'errorbox', name: 'ValidationSummary', ui: 'ErrorBox', hidden: true, cls: 'ErrorBox', id: 'ValidationSummary_3' }, {xtype: 'instamedHeading1', text: 'Select Healthcare Provider', id: 'MyFormPanel_instamedHeading1' }, {xtype: 'dataviewliteproviders', tpl: ['

{AutoLogo:htmlEncode}{ProviderName:htmlEncode}

{ProviderName:htmlEncode}

{ProviderFormatedAddress:htmlEncode}

{ProviderName:htmlEncode}

{ProviderAddress1:htmlEncode}

Features

This provider offers automatic payments, paperless billing, and payment plans.

{GroupName:htmlEncode}

{ProviderInitials:htmlEncode}{OffNetworkProviderName:htmlEncode}

{OffNetworkProviderName:htmlEncode}

{OffNetworkProviderAddress1:htmlEncode} {OffNetworkProviderAddress2:htmlEncode}, {OffNetworkProviderCity:htmlEncode} {OffNetworkProviderState:htmlEncode} {OffNetworkProviderZip:htmlEncode}

Features

This provider offers automatic payments, paperless billing, and payment plans.

',{isShow: function(group){return !(group == null || group == "")},isTrue: function(value){return (value == "True")},isInternal: function(isInternal){ return !(isInternal == null || isInternal == "True")} }], itemSelector: '.ma-more-vert', customClickEvent: function(element,event){ if(element.classList.contains('x-listpaging')){ Ext.fly(element).fireEvent('tap'); }else{ element && element.firstElementChild && element.firstElementChild.onkeydown && element.firstElementChild.onkeydown(event); } }, emptyText: '', deferEmptyText: false, deferInitialRefresh: false,store: Ext.data.StoreManager.lookup('MyAccountProvidersList-init'), name: 'ProviderBadgesProviderList', margin: '', cls: 'im-providers-dataview-search', inContextWidth: 800, id: 'MyFormPanel_ProviderBadgesProviderList' }, {xtype: 'container', layout: {type: 'hbox', pack: 'start', align: 'bottom'}, cls: 'buttonContainer', scrollable: null, id: 'MyFormPanel_container', items: [ {xtype: 'spacer', id: 'MyFormPanel_spacer' }, {xtype: 'button', text: 'Back', name: 'btnBack', ui: 'secondary', margin: '', ariaRole: 'button', cls: 'secondary noprint', id: 'MyFormPanel_button_Back', listeners: {tap: function() { PerformAction({}, QuickPayPatientEntryController.navigateBack,null); }} }] }] }] }] }] }, {xtype: 'spacer', flex: 1, id: 'spacer_9' }, {xtype: 'container', layout: {type: 'hbox'}, hidden: false, cls: 'x-panel-footer im-powered-by', scrollable: null, id: 'container_11', items: [ {xtype: 'spacer', id: 'spacer_10' }, {xtype: 'container', maxWidth: 1272, layout: {type: 'hbox'}, cls: 'largeTwelveColumn mediumTwelveColumn ', scrollable: null, id: 'NavSelectProvider_container_8', items: [ {xtype: 'container', name: 'poweredbylogo', cls: 'hidden hiddenxs hiddensm', scrollable: null, id: 'NavSelectProvider_poweredbylogo' }, {xtype: 'container', cls: 'copyrightContainer hiddenxs hiddensm', scrollable: null, id: 'NavSelectProvider_container_9', items: [ {xtype: 'spacer', cls: 'hiddenmd hiddenlg', id: 'NavSelectProvider_spacer_4' }, {xtype: 'label', html: '© 2024 InstaMed. All Rights Reserved.', name: 'copyrightFooter', ui: 'body1-primary', cls: 'margin-bottom-10 body1-primary', id: 'NavSelectProvider_copyrightFooter' }, {xtype: 'spacer', cls: 'hiddenmd hiddenlg', id: 'NavSelectProvider_spacer_5' }] }, {xtype: 'spacer', cls: 'hiddenxs hiddensm', id: 'NavSelectProvider_spacer_6' }, {xtype: 'container', cls: 'linkButtonContainer hiddenxs hiddensm', scrollable: null, id: 'NavSelectProvider_container_10', items: [ {xtype: 'button', text: 'Security', iconCls: 'x-ma ma-lock-outline', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavSelectProvider_button_Security', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/security/','open-window');}} }, {xtype: 'button', text: 'Privacy', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavSelectProvider_button_Privacy', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/privacy-statement/','open-window');}} }, {xtype: 'button', text: 'Terms', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavSelectProvider_button_Terms', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/terms-of-use/','open-window');}} }, {xtype: 'button', text: 'Help', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavSelectProvider_button_Help', listeners: {tap: function() { InstaMed.popupNewWindow('../../Form/PaymentPortal/ContactUs?id=AFCURGENT149','open-window');}} }, {xtype: 'button', text: 'English', align: 'right',menu:[{xtype: 'menuitem', text: 'English', handler: function(cmp) { PerformAction({Language:'en'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'en', cls: 'hiddenxs hiddensm', id: 'menuitem_en_6'},{xtype: 'menuitem', text: 'Español', handler: function(cmp) { PerformAction({Language:'es'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'es', cls: 'hiddenxs hiddensm', id: 'menuitem_es_6'},{xtype: 'menuitem', text: 'Français', handler: function(cmp) { PerformAction({Language:'fr'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'fr', cls: 'hiddenxs hiddensm', id: 'menuitem_fr_6'},], name: 'ForeignLanguages', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavSelectProvider_button_ForeignLanguages' }] }, {xtype: 'container', cls: 'hiddenmd hiddenlg', scrollable: null, id: 'NavSelectProvider_container_11', items: [ {xtype: 'container', layout: {type: 'hbox', pack: 'center'}, cls: 'x-center-helper', scrollable: null, id: 'NavSelectProvider_container_12', items: [ {xtype: 'spacer', id: 'NavSelectProvider_spacer_7' }, {xtype: 'container', name: 'poweredbylogo', cls: 'hidden', scrollable: null, id: 'NavSelectProvider_poweredbylogo_1' }, {xtype: 'spacer', id: 'NavSelectProvider_spacer_8' }] }, {xtype: 'container', layout: {type: 'hbox', pack: 'center'}, cls: 'x-center-helper', scrollable: null, id: 'NavSelectProvider_container_13', items: [ {xtype: 'spacer', id: 'NavSelectProvider_spacer_9' }, {xtype: 'container', cls: 'copyrightContainer', scrollable: null, id: 'NavSelectProvider_container_14', items: [ {xtype: 'spacer', cls: 'hiddenmd hiddenlg', id: 'NavSelectProvider_spacer_10' }, {xtype: 'label', html: '© 2024 InstaMed. All Rights Reserved.', name: 'copyrightFooter', ui: 'body1-primary', cls: 'margin-bottom-10 body1-primary', id: 'NavSelectProvider_copyrightFooter_1' }, {xtype: 'spacer', cls: 'hiddenmd hiddenlg', id: 'NavSelectProvider_spacer_11' }] }, {xtype: 'spacer', id: 'NavSelectProvider_spacer_12' }] }, {xtype: 'container', layout: {type: 'hbox', pack: 'center'}, cls: 'x-center-helper', scrollable: null, id: 'NavSelectProvider_container_15', items: [ {xtype: 'spacer', id: 'NavSelectProvider_spacer_13' }, {xtype: 'container', cls: 'linkButtonContainer ', scrollable: null, id: 'NavSelectProvider_container_16', items: [ {xtype: 'button', text: 'Security', iconCls: 'x-ma ma-lock-outline', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavSelectProvider_button_Security_1', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/security/','open-window');}} }, {xtype: 'button', text: 'Privacy', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavSelectProvider_button_Privacy_1', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/privacy-statement/','open-window');}} }, {xtype: 'button', text: 'Terms', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavSelectProvider_button_Terms_1', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/terms-of-use/','open-window');}} }, {xtype: 'button', text: 'Help', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavSelectProvider_button_Help_1', listeners: {tap: function() { InstaMed.popupNewWindow('../../Form/PaymentPortal/ContactUs?id=AFCURGENT149','open-window');}} }] }, {xtype: 'spacer', id: 'NavSelectProvider_spacer_14' }] }, {xtype: 'container', layout: {type: 'hbox', pack: 'center'}, cls: 'x-center-helper', scrollable: null, id: 'NavSelectProvider_container_17', items: [ {xtype: 'spacer', id: 'NavSelectProvider_spacer_15' }, {xtype: 'container', scrollable: null, id: 'NavSelectProvider_container_18', items: [ {xtype: 'button', text: 'English', align: 'right',menu:[{xtype: 'menuitem', text: 'English', handler: function(cmp) { PerformAction({Language:'en'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'en', cls: 'hiddenmd hiddenlg', id: 'menuitem_en_7'},{xtype: 'menuitem', text: 'Español', handler: function(cmp) { PerformAction({Language:'es'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'es', cls: 'hiddenmd hiddenlg', id: 'menuitem_es_7'},{xtype: 'menuitem', text: 'Français', handler: function(cmp) { PerformAction({Language:'fr'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'fr', cls: 'hiddenmd hiddenlg', id: 'menuitem_fr_7'},], name: 'ForeignLanguages', ui: 'grey', margin: '', hidden: false, ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavSelectProvider_button_ForeignLanguages_1' }] }, {xtype: 'spacer', id: 'NavSelectProvider_spacer_16' }] }] }] }, {xtype: 'spacer', id: 'spacer_11' }] }] }, {xtype: 'container', name: 'NavQuickPayGoGreen', layout: {type: 'vbox', pack: 'start'}, showBackButton: true, showMenuButton: false, scrollable: 'true', id: 'NavQuickPayGoGreen', items: [ {xtype: 'container', docked: 'top', scrollable: null, id: 'NavQuickPayGoGreen_container', items: [ {xtype: 'instamedNavigationBar', name: 'headerBar', layout: {type: 'hbox'}, hidden: false, cls: 'im-ignore-custom-colors im-ignore-background', scrollable: null, id: 'NavQuickPayGoGreen_headerBar', items: [ {xtype: 'spacer', id: 'NavQuickPayGoGreen_spacer', plugins: 'responsive', responsiveConfig: {'width > 1272':{flex : 1,},'width <= 1272':{flex :0,},} }, {xtype: 'titlebar', title: '<a href=\\"../../Form/PaymentPortal/Start\\"> <img src=\\"https://cdn.instamed.com/V_2024_March/Content/Images/General/instamed-tagged-white.png?id=AFCURGENT149\\" alt=\\"InstaMed a J.P. Morgan company logo\\" style=\\"height: 40px\\">', maxWidth: 1272, cls: 'largeTwelveColumn mediumTwelveColumn smallTwelveColumn xsmallTwelveColumn im-ignore-custom-colors im-ignore-background', scrollable: null, id: 'NavQuickPayGoGreen_titlebar', plugins: 'responsive', responsiveConfig: {'width >= 1272':{title :'',},'width < 1272':{title : ' ',},}, items: [ {xtype: 'button', accessibleText: 'Back', iconCls: 'x-ma ma-arrow-back', align: 'left', name: 'TitleBarNavigationViewBack', margin: '', hidden: false, ariaRole: 'button', cls: 'x-button-icon-link-style white hiddenlg noprint', id: 'NavQuickPayGoGreen_TitleBarNavigationViewBack', plugins: 'responsive', responsiveConfig: {'width > 1272':{iconCls :'',},'width <= 1272':{iconCls : 'x-ma ma-arrow-back',},}, listeners: {tap: function(){ headerPatientPortalBack(); }} }, {xtype: 'container', html: ' ', align: 'left', scrollable: null, id: 'NavQuickPayGoGreen_container_1', plugins: 'responsive', responsiveConfig: {'width >= 1272':{hidden : false,},'width < 1272':{hidden :true,},} }, {xtype: 'button', name: 'HeaderTitlebarButton', ui: 'white', margin: '', hidden: true, ariaRole: 'button', cls: 'x-button-link-style im-center-header-button white noprint', id: 'NavQuickPayGoGreen_HeaderTitlebarButton' }, {xtype: 'button', text: 'Pay Any Healthcare Bill', align: 'right', name: 'PayAnyHealthcareBillButton', ui: 'white', margin: '', ariaRole: 'button', cls: 'x-button-link-style x-border hiddenxs hiddensm white noprint', id: 'NavQuickPayGoGreen_button_PayAnyHealthcareBill', listeners: {tap: function() { if(InstaMed.isLoggedIn) { window.location.href ='../../Form/PaymentPortal/Dashboard?id=AFCURGENT149&pageStep=NavFindProvider'; } else { window.location.href ='../../Form/PaymentPortal/Start?pageStep=NavFindProvider'; }}} }, {xtype: 'button', text: 'Pay Bills', iconCls: 'x-ma ma-search', iconAlign: 'top', align: 'right', name: 'PayAnyHealthcareBillIcon', margin: '', ariaRole: 'button', cls: 'x-button-icon-ontop-link-style white hiddenmd hiddenlg noprint', id: 'NavQuickPayGoGreen_button_PayBills', listeners: {tap: function() { if(InstaMed.isLoggedIn) { window.location.href ='../../Form/PaymentPortal/Dashboard?pageStep=NavFindProvider'; } else { window.location.href ='../../Form/PaymentPortal/Start?pageStep=NavFindProvider'; }}} }, {xtype: 'button', accessibleText: 'Log In or Sign Up', iconCls: 'x-ma ma-account-circle', align: 'right',menu:[{xtype: 'menuitem', text: 'Log In', handler: function() { PerformAction({}, PatientPortalLoginController.redirectToLogin,null); }, id: 'menuitem_LogIn_8'},{xtype: 'menuitem', text: 'Sign Up', handler: function() { PerformAction({}, SignUpController.redirectToSignUp,null); }, id: 'menuitem_SignUp_8'},], name: 'LoginOrSignUpProfileIcon', margin: '', ariaRole: 'button', cls: 'x-button-icon-link-style white noprint', id: 'NavQuickPayGoGreen_button_LoginOrSignUpProfileIcon', plugins: 'responsive', responsiveConfig: {'!InstaMed.isLoggedIn & width > 960':{hidden: true,},'!InstaMed.isLoggedIn && width <= 960':{hidden: false,},}, listeners: {hiddenchange: function() { Ext.ComponentQuery.query('[name=LoginOrSignUpProfileIcon]')[0].getMenu().hide(); }} }, {xtype: 'button', text: '', align: 'right',menu:[{xtype: 'menuitem', text: 'Dashboard', handler: function(){ window.location.href='../../Form/PaymentPortal/Dashboard'; }, id: 'menuitem_Dashboard_16'},{xtype: 'menuitem', text: 'Help', handler: function() { window.open('https://help.instamed.com/patients/s/?dc_label=Patients')}, id: 'menuitem_Help_16'},{xtype: 'menuitem', text: 'Log Out', handler: function(){ window.location.href='../../Form/PaymentPortal/Logout?id=AFCURGENT149'; }, id: 'menuitem_LogOut_16'},], name: 'Profile', ui: 'white', margin: '', hidden: true, ariaRole: 'button', cls: 'x-button-link-style white noprint', id: 'NavQuickPayGoGreen_button_Profile', plugins: 'responsive', responsiveConfig: {'InstaMed.isLoggedIn & width > 960':{hidden: false,},'InstaMed.isLoggedIn && width <= 960':{hidden: true,},}, listeners: {hiddenchange: function() { Ext.ComponentQuery.query('[name=Profile]')[0].getMenu().hide(); }} }, {xtype: 'container', align: 'right', name: 'LoginOrSignUpContainer', layout: {type: 'hbox'}, scrollable: null, id: 'NavQuickPayGoGreen_LoginOrSignUpContainer', plugins: 'responsive', responsiveConfig: {'!InstaMed.isLoggedIn & width > 960':{hidden: false,},'!InstaMed.isLoggedIn && width <= 960':{hidden: true,},}, items: [ {xtype: 'button', text: 'Log In', align: 'right', name: 'LoginForDualLogin', ui: 'white', margin: '', hidden: false, ariaRole: 'button', cls: 'x-button-link-style hiddenxs hiddensm white noprint', id: 'NavQuickPayGoGreen_button_LoginForDualLogin', listeners: {tap: function() { PerformAction({}, PatientPortalLoginController.redirectToLogin,null); }} }, {xtype: 'label', html: 'or', align: 'right', name: 'Or', ui: 'body1-white', cls: 'hiddenxs hiddensm body1-white', id: 'NavQuickPayGoGreen_Or' }, {xtype: 'button', text: 'Sign Up', align: 'right', name: 'SignUpForDualLogin', ui: 'white', margin: '', ariaRole: 'button', cls: 'x-button-link-style hiddenxs hiddensm white noprint', id: 'NavQuickPayGoGreen_button_SignUpForDualLogin', listeners: {tap: function() { PerformAction({}, SignUpController.redirectToSignUp,null); }} }] }, {xtype: 'button', accessibleText: 'Profile', iconCls: 'x-ma ma-account-circle', align: 'right',menu:[{xtype: 'menuitem', text: 'Dashboard', handler: function(){ window.location.href='../../Form/PaymentPortal/Dashboard'; }, id: 'menuitem_Dashboard_17'},{xtype: 'menuitem', text: 'Help', handler: function() { window.open('https://help.instamed.com/patients/s/?dc_label=Patients')}, id: 'menuitem_Help_17'},{xtype: 'menuitem', text: 'Log Out', handler: function(){ window.location.href='../../Form/PaymentPortal/Logout?id=AFCURGENT149'; }, id: 'menuitem_LogOut_17'},], name: 'ProfileIcon', margin: '', hidden: true, ariaRole: 'button', cls: 'x-button-icon-link-style white noprint', id: 'NavQuickPayGoGreen_button_ProfileIcon', plugins: 'responsive', responsiveConfig: {'InstaMed.isLoggedIn & width > 960':{hidden: true,},'InstaMed.isLoggedIn && width <= 960':{hidden: false,},}, listeners: {hiddenchange: function() { Ext.ComponentQuery.query('[name=ProfileIcon]')[0].getMenu().hide(); }} }] }, {xtype: 'spacer', id: 'NavQuickPayGoGreen_spacer_1', plugins: 'responsive', responsiveConfig: {'width > 1272':{flex : 1,},'width <= 1272':{flex :0,},} }] }] }, {xtype: 'container', layout: {type: 'hbox'}, cls: 'x-subheader-container', scrollable: null, id: 'NavQuickPayGoGreen_container_2', items: [ {xtype: 'spacer', id: 'NavQuickPayGoGreen_spacer_2', plugins: 'responsive', responsiveConfig: {'width > 1272':{flex : 1,},'width <= 1272':{flex :0,},} }, {xtype: 'container', maxWidth: 1272, layout: {type: 'hbox'}, cls: 'largeTwelveColumn mediumTwelveColumn smallTwelveColumn xsmallTwelveColumn x-subheader-panel ', scrollable: null, id: 'NavQuickPayGoGreen_container_3', items: [ {xtype: 'image', src: '../../ContentHandler.aspx?URL=/Images/Database/326332D5-86DA-4881-BE6F-8DE62B1DD7E0&id=AFCURGENT149&crop=true&maxWidth=150&maxHeight=64', hidden: false, cls: 'x-clickable x-button-provider-img', id: 'NavQuickPayGoGreen_image', listeners: {painted: function() { var cmp = this; cmp.el.dom.setAttribute('aria-label', 'AFC URGENT CARE - 149th Street logo'); cmp.el.dom.setAttribute('role', 'img'); cmp.el.dom.setAttribute('title', ''); },tap: function(){ window.location.href='../../Form/PaymentPortal/Default?id=AFCURGENT149'; }} }, {xtype: 'container', layout: {type: 'vbox', pack: 'center', align: 'left'}, cls: 'im-provider-header-buttons', scrollable: null, id: 'NavQuickPayGoGreen_container_4', items: [ {xtype: 'label', html: 'AFC URGENT CARE - 149th Street', name: 'SubheaderProviderName', ui: 'subheading-primary', cls: 'initial-caps font-400 im-bold-button subheading-primary', id: 'NavQuickPayGoGreen_SubheaderProviderName' }, {xtype: 'container', layout: {type: 'hbox'}, scrollable: null, id: 'NavQuickPayGoGreen_container_5', items: [ {xtype: 'container', html: '', hidden: true, cls: 'im-address-verification-icon', scrollable: null, id: 'NavQuickPayGoGreen_container_6' }, {xtype: 'label', html: '332 East 149th Street, Bronx, NY 10451', ui: 'body1-secondary', cls: 'line-height-20 body1-secondary', id: 'NavQuickPayGoGreen_label' }] }, {xtype: 'container', layout: {type: 'hbox'}, hidden: false, scrollable: null, id: 'NavQuickPayGoGreen_container_7', items: [ {xtype: 'label', html: '(347) 329-4010', ui: 'body1-primary', cls: 'body1-primary', id: 'NavQuickPayGoGreen_label_1' }] }] }] }, {xtype: 'spacer', id: 'NavQuickPayGoGreen_spacer_3', plugins: 'responsive', responsiveConfig: {'width > 1272':{flex : 1,},'width <= 1272':{flex :0,},} }] }, { xtype: 'panel', dock: 'top', frame: false, scrollable: 'true', id: 'panel_8', items: [ {xtype: 'container', maxWidth: 1272, layout: {type: 'hbox'}, cls: 'mainContent MainContentWithHeaerAndSubheader ', scrollable: null, id: 'container_27', items: [ {xtype: 'container', flex: 1, scrollable: null, id: 'container_28', items: [ { xtype: 'form', preventHeader: true, bodyCls: 'mypanel', api: { }, name: 'FormQuickPayGoGreen', itemId: 'FormQuickPayGoGreen', cls: 'col-large-offSet-3 col-medium-offSet-3 col-small-offSet-1 smallTenColumn xsmallTwelveColumn mediumSixColumn largeSixColumn ', scrollable: null, id: 'FormQuickPayGoGreen', items: [ {xtype: 'errorbox', name: 'ValidationSummary', ui: 'ErrorBox', hidden: true, cls: 'ErrorBox', id: 'ValidationSummary_8' }, {xtype: 'instamedHeading1', text: 'Paperless Statements', id: 'FormQuickPayGoGreen_instamedHeading1' }, {xtype: 'label', html: 'Enroll today and start receiving your statements online.', name: 'ReceiveEmailStatements', ui: 'body1-primary', hidden: false, cls: 'im-top-label im-bottom-label body1-primary', id: 'FormQuickPayGoGreen_ReceiveEmailStatements' }, {xtype: 'container', name: 'EStatementEnrollmentContainer', hidden: false, cls: 'im-estatement-enrollment-container', scrollable: null, id: 'FormQuickPayGoGreen_EStatementEnrollmentContainer', items: [ {xtype: 'container', layout: {type: 'hbox'}, scrollable: null, id: 'FormQuickPayGoGreen_container', items: [ {xtype: 'checkboxfield', value: 'true', uncheckedValue: 'false', checked: true, labelFieldComponentName: 'CheckboxScreenReadableLabel', fieldLabel: '', label: '', labelSeparator: ' ', required: false, labelWrap: true, labelAlign: 'right', errorTarget: 'under', clearable: false, requiredMessage: ' is required', autoComplete: 'on', name: 'EnrollInEstatement', ui: 'subheading-primary', hideLabel: true, margin: '', cls: 'im-estatement-enrollment-checkbox x-circle-checkboxfield subheading-primary', id: 'FormQuickPayGoGreen_EnrollInEstatement', listeners: {blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'container', html: '

Go Green! Enroll in Paperless Statements
Learn More

', cls: 'im-estatement-enrollment-checkbox im-checkbox-label', scrollable: null, id: 'FormQuickPayGoGreen_container_1' }] }] }, {xtype: 'hiddenfield', fieldLabel: 'EnrollInEStatementHidden', label: 'EnrollInEStatementHidden', labelSeparator: ' ', value: false, required: false, labelWrap: true, errorTarget: 'under', clearable: false, requiredMessage: 'EnrollInEStatementHidden is required', autoComplete: 'on', name: 'EnrollInEStatementHidden', margin: '', id: 'FormQuickPayGoGreen_EnrollInEStatementHidden', listeners: {blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'container', layout: {type: 'hbox', pack: 'start', align: 'bottom'}, cls: 'buttonContainer', scrollable: null, id: 'FormQuickPayGoGreen_container_2', items: [ {xtype: 'spacer', id: 'FormQuickPayGoGreen_spacer' }, {xtype: 'button', text: 'Back', name: 'btnBack', ui: 'secondary', margin: '', ariaRole: 'button', cls: 'secondary noprint', id: 'FormQuickPayGoGreen_button_Back', listeners: {tap: function(){ var form = InstaMed.getNavigationView(); form.back(); }} }, {xtype: 'button', text: 'Next', name: 'btnNext', ui: 'action', margin: '', ariaRole: 'button', cls: 'action noprint', id: 'FormQuickPayGoGreen_button_Next', listeners: {tap: function(cmp, newValue, oldValue, eOpts) { myForm = InstaMed.findParentForm(cmp); PerformAction(myForm.getValues(),QuickPayGoGreenController.storeEStatementPreference,cmp,undefined,undefined,undefined,undefined,undefined); }} }] }] }] }] }] }, {xtype: 'spacer', flex: 1, id: 'spacer_24' }, {xtype: 'container', layout: {type: 'hbox'}, hidden: false, cls: 'x-panel-footer im-powered-by', scrollable: null, id: 'container_29', items: [ {xtype: 'spacer', id: 'spacer_25' }, {xtype: 'container', maxWidth: 1272, layout: {type: 'hbox'}, cls: 'largeTwelveColumn mediumTwelveColumn ', scrollable: null, id: 'NavQuickPayGoGreen_container_8', items: [ {xtype: 'container', name: 'poweredbylogo', cls: 'hidden hiddenxs hiddensm', scrollable: null, id: 'NavQuickPayGoGreen_poweredbylogo' }, {xtype: 'container', cls: 'copyrightContainer hiddenxs hiddensm', scrollable: null, id: 'NavQuickPayGoGreen_container_9', items: [ {xtype: 'spacer', cls: 'hiddenmd hiddenlg', id: 'NavQuickPayGoGreen_spacer_4' }, {xtype: 'label', html: '© 2024 InstaMed. All Rights Reserved.', name: 'copyrightFooter', ui: 'body1-primary', cls: 'margin-bottom-10 body1-primary', id: 'NavQuickPayGoGreen_copyrightFooter' }, {xtype: 'spacer', cls: 'hiddenmd hiddenlg', id: 'NavQuickPayGoGreen_spacer_5' }] }, {xtype: 'spacer', cls: 'hiddenxs hiddensm', id: 'NavQuickPayGoGreen_spacer_6' }, {xtype: 'container', cls: 'linkButtonContainer hiddenxs hiddensm', scrollable: null, id: 'NavQuickPayGoGreen_container_10', items: [ {xtype: 'button', text: 'Security', iconCls: 'x-ma ma-lock-outline', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavQuickPayGoGreen_button_Security', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/security/','open-window');}} }, {xtype: 'button', text: 'Privacy', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavQuickPayGoGreen_button_Privacy', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/privacy-statement/','open-window');}} }, {xtype: 'button', text: 'Terms', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavQuickPayGoGreen_button_Terms', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/terms-of-use/','open-window');}} }, {xtype: 'button', text: 'Help', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavQuickPayGoGreen_button_Help', listeners: {tap: function() { InstaMed.popupNewWindow('../../Form/PaymentPortal/ContactUs?id=AFCURGENT149','open-window');}} }, {xtype: 'button', text: 'English', align: 'right',menu:[{xtype: 'menuitem', text: 'English', handler: function(cmp) { PerformAction({Language:'en'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'en', cls: 'hiddenxs hiddensm', id: 'menuitem_en_16'},{xtype: 'menuitem', text: 'Español', handler: function(cmp) { PerformAction({Language:'es'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'es', cls: 'hiddenxs hiddensm', id: 'menuitem_es_16'},{xtype: 'menuitem', text: 'Français', handler: function(cmp) { PerformAction({Language:'fr'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'fr', cls: 'hiddenxs hiddensm', id: 'menuitem_fr_16'},], name: 'ForeignLanguages', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavQuickPayGoGreen_button_ForeignLanguages' }] }, {xtype: 'container', cls: 'hiddenmd hiddenlg', scrollable: null, id: 'NavQuickPayGoGreen_container_11', items: [ {xtype: 'container', layout: {type: 'hbox', pack: 'center'}, cls: 'x-center-helper', scrollable: null, id: 'NavQuickPayGoGreen_container_12', items: [ {xtype: 'spacer', id: 'NavQuickPayGoGreen_spacer_7' }, {xtype: 'container', name: 'poweredbylogo', cls: 'hidden', scrollable: null, id: 'NavQuickPayGoGreen_poweredbylogo_1' }, {xtype: 'spacer', id: 'NavQuickPayGoGreen_spacer_8' }] }, {xtype: 'container', layout: {type: 'hbox', pack: 'center'}, cls: 'x-center-helper', scrollable: null, id: 'NavQuickPayGoGreen_container_13', items: [ {xtype: 'spacer', id: 'NavQuickPayGoGreen_spacer_9' }, {xtype: 'container', cls: 'copyrightContainer', scrollable: null, id: 'NavQuickPayGoGreen_container_14', items: [ {xtype: 'spacer', cls: 'hiddenmd hiddenlg', id: 'NavQuickPayGoGreen_spacer_10' }, {xtype: 'label', html: '© 2024 InstaMed. All Rights Reserved.', name: 'copyrightFooter', ui: 'body1-primary', cls: 'margin-bottom-10 body1-primary', id: 'NavQuickPayGoGreen_copyrightFooter_1' }, {xtype: 'spacer', cls: 'hiddenmd hiddenlg', id: 'NavQuickPayGoGreen_spacer_11' }] }, {xtype: 'spacer', id: 'NavQuickPayGoGreen_spacer_12' }] }, {xtype: 'container', layout: {type: 'hbox', pack: 'center'}, cls: 'x-center-helper', scrollable: null, id: 'NavQuickPayGoGreen_container_15', items: [ {xtype: 'spacer', id: 'NavQuickPayGoGreen_spacer_13' }, {xtype: 'container', cls: 'linkButtonContainer ', scrollable: null, id: 'NavQuickPayGoGreen_container_16', items: [ {xtype: 'button', text: 'Security', iconCls: 'x-ma ma-lock-outline', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavQuickPayGoGreen_button_Security_1', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/security/','open-window');}} }, {xtype: 'button', text: 'Privacy', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavQuickPayGoGreen_button_Privacy_1', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/privacy-statement/','open-window');}} }, {xtype: 'button', text: 'Terms', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavQuickPayGoGreen_button_Terms_1', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/terms-of-use/','open-window');}} }, {xtype: 'button', text: 'Help', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavQuickPayGoGreen_button_Help_1', listeners: {tap: function() { InstaMed.popupNewWindow('../../Form/PaymentPortal/ContactUs?id=AFCURGENT149','open-window');}} }] }, {xtype: 'spacer', id: 'NavQuickPayGoGreen_spacer_14' }] }, {xtype: 'container', layout: {type: 'hbox', pack: 'center'}, cls: 'x-center-helper', scrollable: null, id: 'NavQuickPayGoGreen_container_17', items: [ {xtype: 'spacer', id: 'NavQuickPayGoGreen_spacer_15' }, {xtype: 'container', scrollable: null, id: 'NavQuickPayGoGreen_container_18', items: [ {xtype: 'button', text: 'English', align: 'right',menu:[{xtype: 'menuitem', text: 'English', handler: function(cmp) { PerformAction({Language:'en'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'en', cls: 'hiddenmd hiddenlg', id: 'menuitem_en_17'},{xtype: 'menuitem', text: 'Español', handler: function(cmp) { PerformAction({Language:'es'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'es', cls: 'hiddenmd hiddenlg', id: 'menuitem_es_17'},{xtype: 'menuitem', text: 'Français', handler: function(cmp) { PerformAction({Language:'fr'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'fr', cls: 'hiddenmd hiddenlg', id: 'menuitem_fr_17'},], name: 'ForeignLanguages', ui: 'grey', margin: '', hidden: false, ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavQuickPayGoGreen_button_ForeignLanguages_1' }] }, {xtype: 'spacer', id: 'NavQuickPayGoGreen_spacer_16' }] }] }] }, {xtype: 'spacer', id: 'spacer_26' }] }] }, { xtype: 'window', title: 'What is Automatic Payment?', titleAlign: 'center', itemId: 'APCAboutWindow', flex: 1, defaultFocus: 'tool', closable: true, modal: true, draggable: false, constrainHeader: true, constrainTo: 'mainBorderPanel', closeAction: 'hide', name: 'APCAboutWindow', ui: 'large', maxWidth: 600, flex: 1, cls: 'large', id: 'APCAboutWindow', listeners: {show: function(cmp) { Ext.each(Ext.DomQuery.select('.x-panel-body', Ext.DomQuery.selectNode('.x-window[id=APCAboutWindow]')), function(p) { Ext.get(p.id).scrollTo('top', 0); }); }}, items: [ {xtype: 'label', html: '

Automatic Payments is a feature that notifies you of future balances and automatically schedules a payment for your balance up to your Automatic Payment Limit.

\r\n\r\n

Q: Which payment method will be used for the scheduled payment?
\r\n A: The automatically scheduled payment will be charged to the payment method you have on file.

\r\n

Q: What is an Automatic Payment Limit?
\r\n A: The Automatic Payment Limit is the maximum amount a single payment will be scheduled for. If your new balance exceeds this amount, a payment will be scheduled for the maximum amount. This limit applies to each new balance.

\r\n

Q: Can I edit my Automatic Payments enrollment after I sign up?
\r\n A: Yes, you can edit the maximum payment amount, payment method, or cancel your enrollment from this portal.

\r\n

Q: How will I be notified of future balances?
\r\n A: A notification will be sent with your balance, the scheduled payment amount, and the date the payment is scheduled for.

', flex: 1, id: 'label' }] }, {xtype: 'container', name: 'NavReceiptPreview', layout: {type: 'vbox', pack: 'start'}, showBackButton: false, showMenuButton: false, scrollable: 'true', id: 'NavReceiptPreview', items: [ {xtype: 'container', docked: 'top', scrollable: null, id: 'NavReceiptPreview_container', items: [ {xtype: 'instamedNavigationBar', name: 'headerBar', layout: {type: 'hbox'}, hidden: false, cls: 'im-ignore-custom-colors im-ignore-background', scrollable: null, id: 'NavReceiptPreview_headerBar', items: [ {xtype: 'spacer', id: 'NavReceiptPreview_spacer', plugins: 'responsive', responsiveConfig: {'width > 1272':{flex : 1,},'width <= 1272':{flex :0,},} }, {xtype: 'titlebar', title: '<a href=\\"../../Form/PaymentPortal/Start\\"> <img src=\\"https://cdn.instamed.com/V_2024_March/Content/Images/General/instamed-tagged-white.png?id=AFCURGENT149\\" alt=\\"InstaMed a J.P. Morgan company logo\\" style=\\"height: 40px\\">', maxWidth: 1272, cls: 'largeTwelveColumn mediumTwelveColumn smallTwelveColumn xsmallTwelveColumn im-ignore-custom-colors im-ignore-background', scrollable: null, id: 'NavReceiptPreview_titlebar', plugins: 'responsive', responsiveConfig: {'width >= 1272':{title :'',},'width < 1272':{title : ' ',},}, items: [ {xtype: 'button', accessibleText: 'Back', iconCls: 'x-ma ma-arrow-back', align: 'left', name: 'TitleBarNavigationViewBack', margin: '', hidden: false, ariaRole: 'button', cls: 'x-button-icon-link-style white hiddenlg noprint', id: 'NavReceiptPreview_TitleBarNavigationViewBack', plugins: 'responsive', responsiveConfig: {'width > 1272':{iconCls :'',},'width <= 1272':{iconCls : 'x-ma ma-arrow-back',},}, listeners: {tap: function(){ headerPatientPortalBack(); }} }, {xtype: 'container', html: ' ', align: 'left', scrollable: null, id: 'NavReceiptPreview_container_1', plugins: 'responsive', responsiveConfig: {'width >= 1272':{hidden : false,},'width < 1272':{hidden :true,},} }, {xtype: 'button', name: 'HeaderTitlebarButton', ui: 'white', margin: '', hidden: true, ariaRole: 'button', cls: 'x-button-link-style im-center-header-button white noprint', id: 'NavReceiptPreview_HeaderTitlebarButton' }, {xtype: 'button', text: 'Pay Any Healthcare Bill', align: 'right', name: 'PayAnyHealthcareBillButton', ui: 'white', margin: '', ariaRole: 'button', cls: 'x-button-link-style x-border hiddenxs hiddensm white noprint', id: 'NavReceiptPreview_button_PayAnyHealthcareBill', listeners: {tap: function() { if(InstaMed.isLoggedIn) { window.location.href ='../../Form/PaymentPortal/Dashboard?id=AFCURGENT149&pageStep=NavFindProvider'; } else { window.location.href ='../../Form/PaymentPortal/Start?pageStep=NavFindProvider'; }}} }, {xtype: 'button', text: 'Pay Bills', iconCls: 'x-ma ma-search', iconAlign: 'top', align: 'right', name: 'PayAnyHealthcareBillIcon', margin: '', ariaRole: 'button', cls: 'x-button-icon-ontop-link-style white hiddenmd hiddenlg noprint', id: 'NavReceiptPreview_button_PayBills', listeners: {tap: function() { if(InstaMed.isLoggedIn) { window.location.href ='../../Form/PaymentPortal/Dashboard?pageStep=NavFindProvider'; } else { window.location.href ='../../Form/PaymentPortal/Start?pageStep=NavFindProvider'; }}} }, {xtype: 'button', accessibleText: 'Log In or Sign Up', iconCls: 'x-ma ma-account-circle', align: 'right',menu:[{xtype: 'menuitem', text: 'Log In', handler: function() { PerformAction({}, PatientPortalLoginController.redirectToLogin,null); }, id: 'menuitem_LogIn_10'},{xtype: 'menuitem', text: 'Sign Up', handler: function() { PerformAction({}, SignUpController.redirectToSignUp,null); }, id: 'menuitem_SignUp_10'},], name: 'LoginOrSignUpProfileIcon', margin: '', ariaRole: 'button', cls: 'x-button-icon-link-style white noprint', id: 'NavReceiptPreview_button_LoginOrSignUpProfileIcon', plugins: 'responsive', responsiveConfig: {'!InstaMed.isLoggedIn & width > 960':{hidden: true,},'!InstaMed.isLoggedIn && width <= 960':{hidden: false,},}, listeners: {hiddenchange: function() { Ext.ComponentQuery.query('[name=LoginOrSignUpProfileIcon]')[0].getMenu().hide(); }} }, {xtype: 'button', text: '', align: 'right',menu:[{xtype: 'menuitem', text: 'Dashboard', handler: function(){ window.location.href='../../Form/PaymentPortal/Dashboard'; }, id: 'menuitem_Dashboard_20'},{xtype: 'menuitem', text: 'Help', handler: function() { window.open('https://help.instamed.com/patients/s/?dc_label=Patients')}, id: 'menuitem_Help_20'},{xtype: 'menuitem', text: 'Log Out', handler: function(){ window.location.href='../../Form/PaymentPortal/Logout?id=AFCURGENT149'; }, id: 'menuitem_LogOut_20'},], name: 'Profile', ui: 'white', margin: '', hidden: true, ariaRole: 'button', cls: 'x-button-link-style white noprint', id: 'NavReceiptPreview_button_Profile', plugins: 'responsive', responsiveConfig: {'InstaMed.isLoggedIn & width > 960':{hidden: false,},'InstaMed.isLoggedIn && width <= 960':{hidden: true,},}, listeners: {hiddenchange: function() { Ext.ComponentQuery.query('[name=Profile]')[0].getMenu().hide(); }} }, {xtype: 'container', align: 'right', name: 'LoginOrSignUpContainer', layout: {type: 'hbox'}, scrollable: null, id: 'NavReceiptPreview_LoginOrSignUpContainer', plugins: 'responsive', responsiveConfig: {'!InstaMed.isLoggedIn & width > 960':{hidden: false,},'!InstaMed.isLoggedIn && width <= 960':{hidden: true,},}, items: [ {xtype: 'button', text: 'Log In', align: 'right', name: 'LoginForDualLogin', ui: 'white', margin: '', hidden: false, ariaRole: 'button', cls: 'x-button-link-style hiddenxs hiddensm white noprint', id: 'NavReceiptPreview_button_LoginForDualLogin', listeners: {tap: function() { PerformAction({}, PatientPortalLoginController.redirectToLogin,null); }} }, {xtype: 'label', html: 'or', align: 'right', name: 'Or', ui: 'body1-white', cls: 'hiddenxs hiddensm body1-white', id: 'NavReceiptPreview_Or' }, {xtype: 'button', text: 'Sign Up', align: 'right', name: 'SignUpForDualLogin', ui: 'white', margin: '', ariaRole: 'button', cls: 'x-button-link-style hiddenxs hiddensm white noprint', id: 'NavReceiptPreview_button_SignUpForDualLogin', listeners: {tap: function() { PerformAction({}, SignUpController.redirectToSignUp,null); }} }] }, {xtype: 'button', accessibleText: 'Profile', iconCls: 'x-ma ma-account-circle', align: 'right',menu:[{xtype: 'menuitem', text: 'Dashboard', handler: function(){ window.location.href='../../Form/PaymentPortal/Dashboard'; }, id: 'menuitem_Dashboard_21'},{xtype: 'menuitem', text: 'Help', handler: function() { window.open('https://help.instamed.com/patients/s/?dc_label=Patients')}, id: 'menuitem_Help_21'},{xtype: 'menuitem', text: 'Log Out', handler: function(){ window.location.href='../../Form/PaymentPortal/Logout?id=AFCURGENT149'; }, id: 'menuitem_LogOut_21'},], name: 'ProfileIcon', margin: '', hidden: true, ariaRole: 'button', cls: 'x-button-icon-link-style white noprint', id: 'NavReceiptPreview_button_ProfileIcon', plugins: 'responsive', responsiveConfig: {'InstaMed.isLoggedIn & width > 960':{hidden: true,},'InstaMed.isLoggedIn && width <= 960':{hidden: false,},}, listeners: {hiddenchange: function() { Ext.ComponentQuery.query('[name=ProfileIcon]')[0].getMenu().hide(); }} }] }, {xtype: 'spacer', id: 'NavReceiptPreview_spacer_1', plugins: 'responsive', responsiveConfig: {'width > 1272':{flex : 1,},'width <= 1272':{flex :0,},} }] }] }, {xtype: 'container', layout: {type: 'hbox'}, cls: 'x-subheader-container', scrollable: null, id: 'NavReceiptPreview_container_2', items: [ {xtype: 'spacer', id: 'NavReceiptPreview_spacer_2', plugins: 'responsive', responsiveConfig: {'width > 1272':{flex : 1,},'width <= 1272':{flex :0,},} }, {xtype: 'container', maxWidth: 1272, layout: {type: 'hbox'}, cls: 'largeTwelveColumn mediumTwelveColumn smallTwelveColumn xsmallTwelveColumn x-subheader-panel ', scrollable: null, id: 'NavReceiptPreview_container_3', items: [ {xtype: 'image', src: '../../ContentHandler.aspx?URL=/Images/Database/326332D5-86DA-4881-BE6F-8DE62B1DD7E0&id=AFCURGENT149&crop=true&maxWidth=150&maxHeight=64', hidden: false, cls: 'x-clickable x-button-provider-img', id: 'NavReceiptPreview_image', listeners: {painted: function() { var cmp = this; cmp.el.dom.setAttribute('aria-label', 'AFC URGENT CARE - 149th Street logo'); cmp.el.dom.setAttribute('role', 'img'); cmp.el.dom.setAttribute('title', ''); },tap: function(){ window.location.href='../../Form/PaymentPortal/Default?id=AFCURGENT149'; }} }, {xtype: 'container', layout: {type: 'vbox', pack: 'center', align: 'left'}, cls: 'im-provider-header-buttons', scrollable: null, id: 'NavReceiptPreview_container_4', items: [ {xtype: 'label', html: 'AFC URGENT CARE - 149th Street', name: 'SubheaderProviderName', ui: 'subheading-primary', cls: 'initial-caps font-400 im-bold-button subheading-primary', id: 'NavReceiptPreview_SubheaderProviderName' }, {xtype: 'container', layout: {type: 'hbox'}, scrollable: null, id: 'NavReceiptPreview_container_5', items: [ {xtype: 'container', html: '', hidden: true, cls: 'im-address-verification-icon', scrollable: null, id: 'NavReceiptPreview_container_6' }, {xtype: 'label', html: '332 East 149th Street, Bronx, NY 10451', ui: 'body1-secondary', cls: 'line-height-20 body1-secondary', id: 'NavReceiptPreview_label' }] }, {xtype: 'container', layout: {type: 'hbox'}, hidden: false, scrollable: null, id: 'NavReceiptPreview_container_7', items: [ {xtype: 'label', html: '(347) 329-4010', ui: 'body1-primary', cls: 'body1-primary', id: 'NavReceiptPreview_label_1' }] }] }] }, {xtype: 'spacer', id: 'NavReceiptPreview_spacer_3', plugins: 'responsive', responsiveConfig: {'width > 1272':{flex : 1,},'width <= 1272':{flex :0,},} }] }, { xtype: 'panel', dock: 'top', frame: false, scrollable: 'true', id: 'panel_10', items: [ {xtype: 'container', maxWidth: 1272, layout: {type: 'hbox'}, cls: 'mainContent MainContentWithHeaerAndSubheader ', scrollable: null, id: 'container_33', items: [ {xtype: 'container', flex: 1, scrollable: null, id: 'container_34', items: [ {xtype: 'container', cls: 'col-large-offSet-3 col-medium-offSet-3 col-small-offSet-1 smallTenColumn xsmallTwelveColumn mediumSixColumn largeSixColumn reverse im-form-wrapper', scrollable: null, id: 'container_35', items: [ { xtype: 'form', preventHeader: true, bodyCls: 'mypanel', api: { }, defaultSubmitButton: 'Verify', name: 'TextMsgEnrollTile', itemId: 'TextMsgEnrollTile', cls: 'bottom-pad-20', scrollable: null, id: 'TextMsgEnrollTile', items: [ {xtype: 'errorbox', name: 'ValidationSummary', ui: 'ErrorBox', hidden: true, cls: 'ErrorBox', id: 'ValidationSummary_11' }, {xtype: 'button', iconCls: 'md-icon-close', name: 'HideContainerX', ui: 'grey', margin: '', ariaRole: 'button', cls: 'container-x-closebutton grey noprint', id: 'TextMsgEnrollTile_HideContainerX', listeners: {tap: function(cmp) { var cmpForm = InstaMed.findParentForm(cmp); var containerToHide = Ext.getCmp('TextMsgEnrollTile'); if(containerToHide, cmpForm) { containerToHide.setVisible(false); }}} }, {xtype: 'container', name: 'TextMsgEnroll', flex: 2, scrollable: null, id: 'TextMsgEnrollTile_TextMsgEnroll', items: [ {xtype: 'instamedHeading1', text: 'Keep Your Account Safe and Updated', name: 'TextMessageEnrollTileTitle', id: 'TextMsgEnrollTile_TextMessageEnrollTileTitle' }, {xtype: 'container', html: 'To increase your security, please verify your mobile phone number. Add Number\r\n You can use this to reset passwords, enable two-step verification and \r\n enroll in payment alerts via text message.', name: 'TextMsgTwoStepFactorAndText', hidden: true, cls: 'im-form-bodytext', scrollable: null, id: 'TextMsgEnrollTile_TextMsgTwoStepFactorAndText' }, {xtype: 'container', html: 'To increase your security, please add and verify your mobile phone number. Add Number \r\n You can use this to reset passwords and enable two-step verification.', name: 'TextMsgTwoStepFactorOnly', hidden: false, cls: 'im-form-bodytext', scrollable: null, id: 'TextMsgEnrollTile_TextMsgTwoStepFactorOnly' }, {xtype: 'textfield', selectOnFocus: true, autoCorrect: false, fieldLabel: 'Mobile Phone Number', label: 'Mobile Phone Number', component: {"type":"tel","pattern":null}, inputType: 'tel', hidden: true, labelSeparator: ' ', required: false, labelWrap: true, labelAlign: 'placeholder', errorTarget: 'under', clearable: false, requiredMessage: 'Mobile Phone Number is required', autoComplete: 'on', name: 'MobilePhoneNumber2', margin: '', id: 'TextMsgEnrollTile_MobilePhoneNumber2', listeners: {action: submitOnEnter,blur: function(cmp){if(cmp.validate){cmp.validate();}},change: function(field, event, opts ){ var s = new String(field.getValue()); if(s != null && s != '') { s = s.replace(/[-,()\s]/g,'');var newValue='(';newValue+=s.substring(0,3);if(s.length>3){newValue+=') ';}newValue+=s.substring(3,6);if(s.length>6){newValue+='-';}newValue+=s.substring(6,10); if(isNaN(parseInt(newValue.substring(1,3)))){ newValue = ''; } field.setValue(newValue); if(InstaMed.isResponsive){ field.setInputValue(newValue); } } }} }, {xtype: 'container', layout: {type: 'hbox', pack: 'start', align: 'bottom'}, cls: 'ppp-button-group', scrollable: null, id: 'TextMsgEnrollTile_container', items: [ {xtype: 'button', text: 'Verify', name: 'Verify', ui: 'action', margin: '', ariaRole: 'button', cls: 'action noprint', id: 'TextMsgEnrollTile_button_Verify', listeners: {tap: function(cmp, newValue, oldValue, eOpts) { myForm = InstaMed.findParentForm(cmp); PerformAction(myForm.getValues(),TextMessageEnrollmentController.sendEnrollmentText,cmp,undefined,undefined,undefined,undefined,undefined); }} }, {xtype: 'button', text: 'Enroll', name: 'Enroll', ui: 'action', margin: '', hidden: true, ariaRole: 'button', cls: 'action noprint', id: 'TextMsgEnrollTile_button_Enroll', listeners: {tap: function(cmp, newValue, oldValue, eOpts) { myForm = InstaMed.findParentForm(cmp); PerformAction(myForm.getValues(),TextMessageEnrollmentController.enableTwoStepVerification,cmp,undefined,undefined,undefined,undefined,undefined); }} }, {xtype: 'button', text: 'No, Thanks', name: 'NoThanks', ui: 'secondary', margin: '', ariaRole: 'button', cls: 'secondary noprint', id: 'TextMsgEnrollTile_button_NoThanks', listeners: {tap: function(cmp) { if (cmp) { var containerToHide = Ext.getCmp('TextMsgEnrollTile'); containerToHide.setVisible(false); }}} }] }, {xtype: 'container', name: 'EnableTwoStepCheckbox', layout: {type: 'hbox'}, scrollable: null, id: 'TextMsgEnrollTile_EnableTwoStepCheckbox', items: [ {xtype: 'checkboxfield', value: 'true', uncheckedValue: 'false', checked: true, labelFieldComponentName: 'LabelEnableTwoStepVerification', fieldLabel: '', label: '', labelSeparator: ' ', required: false, labelWrap: true, labelAlign: 'right', errorTarget: 'under', clearable: false, requiredMessage: ' is required', autoComplete: 'on', name: 'EnableTwoStepVerification', hideLabel: true, margin: '', id: 'TextMsgEnrollTile_EnableTwoStepVerification', listeners: {render: function(cmp){ cmp.setChecked(true); cmp.setValue(true); },change: function(cmp){ if(InstaMed.isTrue(cmp.getChecked())){ cmp.setValue(true); }else{ cmp.setValue(false); } },blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'container', html: 'Enable Two-Step Verification', name: 'LabelEnableTwoStepVerification', cls: 'im-checkbox-label im-checkbox-label-single-field-form ', scrollable: null, id: 'TextMsgEnrollTile_LabelEnableTwoStepVerification' }] }, {xtype: 'container', html: 'By enrolling in two-step verification and/or text alerts, you agree to all InstaMed Communications\r\n Terms and Conditions. InstaMed will only use this number for account security and payment alerts. Message and data rates may apply.', name: 'TextMsgTwoStepTermsClause', cls: 'im-form-bodytext', scrollable: null, id: 'TextMsgEnrollTile_TextMsgTwoStepTermsClause' }] }, {xtype: 'container', name: 'TextMsgConfirmation', flex: 2, hidden: true, scrollable: null, id: 'TextMsgEnrollTile_TextMsgConfirmation', items: [ {xtype: 'instamedHeading1', text: 'Please Complete Verification', id: 'TextMsgEnrollTile_instamedHeading1' }, {xtype: 'container', html: 'Use the link in the text we just sent to complete verification. Once verified, you can go to preferences to manage your security and text message settings.', name: 'TextMsgEnrollVerifyDescription', cls: 'im-form-bodytext', scrollable: null, id: 'TextMsgEnrollTile_TextMsgEnrollVerifyDescription' }] }] }, { xtype: 'form', preventHeader: true, bodyCls: 'mypanel', api: { }, name: 'FormPaymentReceipt', itemId: 'FormPaymentReceipt', showBackButton: false, scrollable: null, id: 'FormPaymentReceipt', items: [ {xtype: 'errorbox', name: 'ValidationSummary', ui: 'ErrorBox', hidden: true, cls: 'ErrorBox', id: 'ValidationSummary_12' }, {xtype: 'instamedHeading1', text: 'Payment Summary', id: 'FormPaymentReceipt_instamedHeading1' }, {xtype: 'container', name: 'PaymentPlanContainer', hidden: true, cls: 'im-dataview-tile im-dataview-tile-relative im-dataview-tile-payment-plan mod-is-selectable mod-is-not-selectable', scrollable: null, id: 'FormPaymentReceipt_PaymentPlanContainer', items: [ {xtype: 'container', layout: {type: 'hbox'}, cls: 'im-dataview-tile-container', scrollable: null, id: 'FormPaymentReceipt_container', items: [ {xtype: 'container', name: 'PaymentPlanStatus', cls: 'im-dataview-tile-select-item', scrollable: null, id: 'FormPaymentReceipt_PaymentPlanStatus' }, {xtype: 'container', cls: 'im-dataview-tile-content', scrollable: null, id: 'FormPaymentReceipt_container_1', items: [ {xtype: 'label', name: 'PaymentPlanInstallment', cls: 'im-dataview-text-label', id: 'FormPaymentReceipt_PaymentPlanInstallment' }, {xtype: 'label', name: 'PaymentPlanDuration', ui: 'body1-secondary', cls: 'im-dataview-text-value x-show-block body1-secondary', id: 'FormPaymentReceipt_PaymentPlanDuration' }, {xtype: 'label', name: 'PaymentPlanStartDate', ui: 'body1-secondary', cls: 'im-dataview-text-value x-show-block body1-secondary', id: 'FormPaymentReceipt_PaymentPlanStartDate' }, {xtype: 'label', name: 'PaymentPlanInitialPaymentStatus', ui: 'body1-secondary', cls: 'im-dataview-text-value x-show-block body1-secondary', id: 'FormPaymentReceipt_PaymentPlanInitialPaymentStatus' }] }] }] }, {xtype: 'container', cls: 'im-transaction-status-wrapper', scrollable: null, id: 'FormPaymentReceipt_container_2', items: [ {xtype: 'container', name: 'TransactionStatusResponseMessage', layout: {type: 'hbox'}, hidden: false, cls: 'im-transaction-status-container', scrollable: null, id: 'FormPaymentReceipt_TransactionStatusResponseMessage', items: [ {xtype: 'container', name: 'htmlTransactionStatusResponseMessage', scrollable: null, id: 'FormPaymentReceipt_htmlTransactionStatusResponseMessage' }, {xtype: 'label', name: 'labelTransactionStatusResponseMessage', ui: 'light-subheading-primary', cls: 'light-subheading-primary', id: 'FormPaymentReceipt_labelTransactionStatusResponseMessage' }] }, {xtype: 'container', name: 'TransactionStatusAPC', layout: {type: 'hbox'}, hidden: true, cls: 'im-transaction-status-container', scrollable: null, id: 'FormPaymentReceipt_TransactionStatusAPC', items: [ {xtype: 'container', name: 'htmlTransactionStatusAPC', scrollable: null, id: 'FormPaymentReceipt_htmlTransactionStatusAPC' }, {xtype: 'label', name: 'labelTransactionStatusAPC', ui: 'light-subheading-primary', cls: 'light-subheading-primary', id: 'FormPaymentReceipt_labelTransactionStatusAPC' }] }, {xtype: 'container', name: 'TransactionEStatement', layout: {type: 'hbox'}, hidden: true, cls: 'im-transaction-status-container', scrollable: null, id: 'FormPaymentReceipt_TransactionEStatement', items: [ {xtype: 'container', name: 'htmlTransactionEStatement', scrollable: null, id: 'FormPaymentReceipt_htmlTransactionEStatement' }, {xtype: 'label', name: 'labelTransactionEStatement', ui: 'light-subheading-primary', cls: 'light-subheading-primary', id: 'FormPaymentReceipt_labelTransactionEStatement' }] }, {xtype: 'container', name: 'InitialPayment', layout: {type: 'hbox'}, hidden: true, cls: 'im-transaction-status-container', scrollable: null, id: 'FormPaymentReceipt_InitialPayment', items: [ {xtype: 'container', name: 'htmlInitialPayment', scrollable: null, id: 'FormPaymentReceipt_htmlInitialPayment' }, {xtype: 'label', name: 'labelInitialPayment', ui: 'light-subheading-primary', cls: 'light-subheading-primary', id: 'FormPaymentReceipt_labelInitialPayment' }] }, {xtype: 'container', name: 'PaymentPlanPrint', layout: {type: 'hbox'}, hidden: true, cls: 'im-transaction-status-container', scrollable: null, id: 'FormPaymentReceipt_PaymentPlanPrint', items: [ {xtype: 'container', name: 'htmlPaymentPlanPrint', scrollable: null, id: 'FormPaymentReceipt_htmlPaymentPlanPrint' }, {xtype: 'label', name: 'labelPaymentPlanPrint', ui: 'light-subheading-primary', cls: 'light-subheading-primary', id: 'FormPaymentReceipt_labelPaymentPlanPrint' }] }] }, {xtype: 'container', name: 'PatientPaymentConfirmHeaderContainer', cls: 'x-payment-header-container', scrollable: null, id: 'FormPaymentReceipt_PatientPaymentConfirmHeaderContainer', items: [ {xtype: 'instamedHeading1', name: '', hidden: true, id: 'FormPaymentReceipt_instamedHeading1_1' }, {xtype: 'container', layout: {type: 'hbox'}, scrollable: null, id: 'FormPaymentReceipt_container_3', items: [ {xtype: 'label', align: 'left', name: 'PatientPaymentConfirmHeaderMessage', ui: 'body1-primary', cls: 'body1-primary', id: 'FormPaymentReceipt_PatientPaymentConfirmHeaderMessage' }] }, {xtype: 'label', align: 'left', name: 'TransactionMessage', ui: 'body2-secondary', hidden: true, cls: 'x-label-payment-header body2-secondary', id: 'FormPaymentReceipt_TransactionMessage' }] }, {xtype: 'label', html: 'Your request for eStatement Enrollment has been sent. If you prefer to receive statements by mail, you can update your Statement Delivery Settings.', name: 'eStatementDelivery', ui: 'body1-primary', hidden: true, cls: 'im-bottom-label body1-primary', id: 'FormPaymentReceipt_eStatementDelivery' }, {xtype: 'container', hidden: true, cls: 'im-subtitle-container', scrollable: null, id: 'FormPaymentReceipt_container_4', items: [ {xtype: 'instamedLabelHeading2', html: 'Provider Information', ui: 'body2-secondary', cls: 'im-subtitle-header body2-secondary', id: 'FormPaymentReceipt_instamedLabelHeading2' }, {xtype: 'container', layout: {type: 'hbox'}, cls: 'im-editable-provider-info', scrollable: null, id: 'FormPaymentReceipt_container_5', items: [ {xtype: 'container', scrollable: null, id: 'FormPaymentReceipt_container_6', items: [ {xtype: 'label', name: 'ProviderName', ui: 'light-subheading-primary', cls: 'light-subheading-primary', id: 'FormPaymentReceipt_ProviderName' }, {xtype: 'label', name: 'ProviderAddress', ui: 'body1-secondary', cls: 'body1-secondary', id: 'FormPaymentReceipt_ProviderAddress' }, {xtype: 'label', name: 'PayeePhoneNumber', ui: 'body1-secondary', cls: 'body1-secondary', id: 'FormPaymentReceipt_PayeePhoneNumber' }] }] }] }, {xtype: 'container', name: 'PatientInformationContainer', cls: 'im-subtitle-container', scrollable: null, id: 'FormPaymentReceipt_PatientInformationContainer', items: [ {xtype: 'instamedLabelHeading2', html: 'Patient Information', ui: 'body2-secondary', cls: 'im-subtitle-header body2-secondary', id: 'FormPaymentReceipt_instamedLabelHeading2_1' }, {xtype: 'dataviewlite', tpl: ['', '', '

', '

', '{PatientFirstName:htmlEncode} ', '{PatientLastName:htmlEncode} ', '({PatientID:htmlEncode})', '

', '

', '${Amount:htmlEncode}', '

', '

','

', '', '

', '

', '{PatientFirstName:htmlEncode} ', '{PatientLastName:htmlEncode} ', '

', '

', '${Amount:htmlEncode}', '

', '

','

', '',, '' ], itemSelector: '.patientItem', emptyText: '', deferInitialRefresh: false,store: Ext.data.StoreManager.lookup('PatientPaymentConfirmMultiARDataViewstore'), name: 'PatientPaymentConfirmMultiARDataView', id: 'FormPaymentReceipt_PatientPaymentConfirmMultiARDataView' }] }, {xtype: 'container', cls: 'im-subtitle-container', scrollable: null, id: 'FormPaymentReceipt_container_7', items: [ {xtype: 'instamedLabelHeading2', html: 'Payment Method', ui: 'body2-secondary', cls: 'im-subtitle-header body2-secondary', id: 'FormPaymentReceipt_instamedLabelHeading2_2' }, {xtype: 'container', layout: {type: 'hbox'}, cls: 'im-editable-payment-info', scrollable: null, id: 'FormPaymentReceipt_container_8', items: [ {xtype: 'container', name: 'PaymentType', scrollable: null, id: 'FormPaymentReceipt_PaymentType' }, {xtype: 'container', scrollable: null, id: 'FormPaymentReceipt_container_9', items: [ {xtype: 'label', name: 'CardHolderName', ui: 'subheading-primary', hidden: true, cls: 'subheading-primary', id: 'FormPaymentReceipt_CardHolderName' }, {xtype: 'label', name: 'CheckingAccountHolderName', ui: 'subheading-primary', hidden: true, cls: 'subheading-primary', id: 'FormPaymentReceipt_CheckingAccountHolderName' }, {xtype: 'container', layout: {type: 'hbox'}, scrollable: null, id: 'FormPaymentReceipt_container_10', items: [ {xtype: 'label', html: 'Ending in ', name: 'CreditCardNumber', ui: 'body1-secondary', hidden: true, cls: 'body1-secondary', id: 'FormPaymentReceipt_CreditCardNumber' }, {xtype: 'label', html: 'Ending in ', name: 'AccountNumber', ui: 'body1-secondary', hidden: true, cls: 'body1-secondary', id: 'FormPaymentReceipt_AccountNumber' }, {xtype: 'label', html: '', ui: 'body1-primary', cls: 'body1-primary', id: 'FormPaymentReceipt_label' }, {xtype: 'label', html: '(Exp: )', name: 'ExpDate', ui: 'body1-secondary', hidden: true, cls: 'body1-secondary', id: 'FormPaymentReceipt_ExpDate' }, {xtype: 'label', html: '()', name: 'RoutingNumber', ui: 'body1-secondary', hidden: true, cls: 'body1-secondary', id: 'FormPaymentReceipt_RoutingNumber' }] }, {xtype: 'container', name: 'AdditionalPaymentReceiptContainer', hidden: true, scrollable: null, id: 'FormPaymentReceipt_AdditionalPaymentReceiptContainer', items: [ {xtype: 'container', layout: {type: 'hbox'}, scrollable: null, id: 'FormPaymentReceipt_container_11', items: [ {xtype: 'label', html: 'Date:', ui: 'body1-secondary', cls: 'body1-secondary', id: 'FormPaymentReceipt_label_1' }, {xtype: 'label', html: '', ui: 'body1-primary', cls: 'body1-primary', id: 'FormPaymentReceipt_label_2' }, {xtype: 'label', name: 'Date', ui: 'body1-primary', cls: 'body1-primary', id: 'FormPaymentReceipt_Date' }] }, {xtype: 'container', name: 'AuthCodeContainer', layout: {type: 'hbox'}, scrollable: null, id: 'FormPaymentReceipt_AuthCodeContainer', items: [ {xtype: 'label', html: 'Auth. Code:', ui: 'body1-secondary', cls: 'body1-secondary', id: 'FormPaymentReceipt_label_3' }, {xtype: 'label', html: '', ui: 'body1-primary', cls: 'body1-primary', id: 'FormPaymentReceipt_label_4' }, {xtype: 'label', name: 'AuthorizationCode', ui: 'body1-primary', cls: 'body1-primary', id: 'FormPaymentReceipt_AuthorizationCode' }] }, {xtype: 'container', layout: {type: 'hbox'}, scrollable: null, id: 'FormPaymentReceipt_container_12', items: [ {xtype: 'label', html: 'Response', ui: 'body1-secondary', cls: 'body1-secondary', id: 'FormPaymentReceipt_label_5' }, {xtype: 'label', html: ':', ui: 'body1-primary', cls: 'body1-primary', id: 'FormPaymentReceipt_label_6' }, {xtype: 'label', name: 'ResponseCode', ui: 'body1-primary', cls: 'body1-primary', id: 'FormPaymentReceipt_ResponseCode' }] }] }] }, {xtype: 'label', name: 'Amount', ui: 'subheading-primary', hidden: true, cls: 'subheading-primary', id: 'FormPaymentReceipt_Amount' }] }] }, {xtype: 'container', name: 'AutomaticPaymentInformationContainer', hidden: true, cls: 'im-subtitle-container', scrollable: null, id: 'FormPaymentReceipt_AutomaticPaymentInformationContainer', items: [ {xtype: 'instamedLabelHeading2', html: 'Automatic Payments Information', ui: 'body2-secondary', cls: 'im-subtitle-header body2-secondary', id: 'FormPaymentReceipt_instamedLabelHeading2_3' }, {xtype: 'container', name: 'AutomaticPaymentInformationContainer', cls: 'im-multiar-line-item', scrollable: null, id: 'FormPaymentReceipt_AutomaticPaymentInformationContainer_1', items: [ {xtype: 'container', scrollable: null, id: 'FormPaymentReceipt_container_13', items: [ {xtype: 'label', name: 'APCAmountText', ui: 'body1-primary', cls: 'im-multiar-patient body1-primary', id: 'FormPaymentReceipt_APCAmountText' }] }, {xtype: 'container', minHeight: 2, scrollable: null, id: 'FormPaymentReceipt_container_14' }, {xtype: 'container', scrollable: null, id: 'FormPaymentReceipt_container_15', items: [ {xtype: 'label', name: 'APCProcessDateText', ui: 'body1-primary', cls: 'body1-primary', id: 'FormPaymentReceipt_APCProcessDateText' }] }, {xtype: 'container', name: 'APCProcessDateShortMonthWarningTextContainer', scrollable: null, id: 'FormPaymentReceipt_APCProcessDateShortMonthWarningTextContainer', items: [ {xtype: 'container', minHeight: 24, scrollable: null, id: 'FormPaymentReceipt_container_16' }, {xtype: 'label', name: 'APCProcessDateShortMonthWarningText', ui: 'body1-primary', cls: 'body1-primary', id: 'FormPaymentReceipt_APCProcessDateShortMonthWarningText' }] }, {xtype: 'container', name: 'ScheduledPaymentsExplanationTextContainer', hidden: true, scrollable: null, id: 'FormPaymentReceipt_ScheduledPaymentsExplanationTextContainer', items: [ {xtype: 'container', minHeight: 24, scrollable: null, id: 'FormPaymentReceipt_container_17' }, {xtype: 'label', html: 'Note: The changes made to your automatic payment draft date will not apply to your currently scheduled payment but will take effect on any future scheduled payments.', ui: 'body1-primary', cls: 'body1-primary', id: 'FormPaymentReceipt_label_7' }] }] }] }, {xtype: 'label', name: 'EmailReceiptNotificationLabel', ui: 'body1-secondary', cls: 'body1-secondary', id: 'FormPaymentReceipt_EmailReceiptNotificationLabel' }, {xtype: 'label', name: 'EmailReceiptNotification', ui: 'body1-secondary', cls: 'body1-secondary', id: 'FormPaymentReceipt_EmailReceiptNotification' }, {xtype: 'label', name: 'ReceiptText', ui: 'body1-secondary', hidden: true, cls: 'body1-secondary', id: 'FormPaymentReceipt_ReceiptText' }, {xtype: 'hiddenfield', fieldLabel: 'ReceiptNavigation', label: 'ReceiptNavigation', labelSeparator: ' ', value: 'NavCreditCardReceipt', required: false, labelWrap: true, errorTarget: 'under', clearable: false, requiredMessage: 'ReceiptNavigation is required', autoComplete: 'on', name: 'ReceiptNavigation', margin: '', id: 'FormPaymentReceipt_ReceiptNavigation', listeners: {blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'hiddenfield', fieldLabel: 'EntityID', label: 'EntityID', labelSeparator: ' ', required: false, labelWrap: true, errorTarget: 'under', clearable: false, requiredMessage: 'EntityID is required', autoComplete: 'on', name: 'EntityID', margin: '', id: 'FormPaymentReceipt_EntityID', listeners: {blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'hiddenfield', fieldLabel: 'PkTransaction', label: 'PkTransaction', labelSeparator: ' ', required: false, labelWrap: true, errorTarget: 'under', clearable: false, requiredMessage: 'PkTransaction is required', autoComplete: 'on', name: 'PkTransaction', margin: '', id: 'FormPaymentReceipt_PkTransaction', listeners: {blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'hiddenfield', fieldLabel: 'Account ID', label: 'Account ID', labelSeparator: ' ', required: false, labelWrap: true, errorTarget: 'under', clearable: false, requiredMessage: 'Account ID is required', autoComplete: 'on', name: 'InstaMedAccountID', margin: '', id: 'FormPaymentReceipt_InstaMedAccountID', listeners: {blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'hiddenfield', fieldLabel: 'Merchant ID', label: 'Merchant ID', labelSeparator: ' ', required: false, labelWrap: true, errorTarget: 'under', clearable: false, requiredMessage: 'Merchant ID is required', autoComplete: 'on', name: 'MerchantID', margin: '', id: 'FormPaymentReceipt_MerchantID', listeners: {blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'hiddenfield', fieldLabel: 'Store ID', label: 'Store ID', labelSeparator: ' ', required: false, labelWrap: true, errorTarget: 'under', clearable: false, requiredMessage: 'Store ID is required', autoComplete: 'on', name: 'StoreID', margin: '', id: 'FormPaymentReceipt_StoreID', listeners: {blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'hiddenfield', fieldLabel: 'Terminal ID', label: 'Terminal ID', labelSeparator: ' ', required: false, labelWrap: true, errorTarget: 'under', clearable: false, requiredMessage: 'Terminal ID is required', autoComplete: 'on', name: 'TerminalID', margin: '', id: 'FormPaymentReceipt_TerminalID', listeners: {blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'hiddenfield', fieldLabel: 'Transaction Type', label: 'Transaction Type', labelSeparator: ' ', required: false, labelWrap: true, errorTarget: 'under', clearable: false, requiredMessage: 'Transaction Type is required', autoComplete: 'on', name: 'TransactionType', margin: '', id: 'FormPaymentReceipt_TransactionType', listeners: {blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'hiddenfield', fieldLabel: 'BusinessEntityType', label: 'BusinessEntityType', labelSeparator: ' ', required: false, labelWrap: true, errorTarget: 'under', clearable: false, requiredMessage: 'BusinessEntityType is required', autoComplete: 'on', name: 'BusinessEntityType', margin: '', id: 'FormPaymentReceipt_BusinessEntityType', listeners: {blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, { xtype: 'container', titleAlign: 'center', flex: 1, defaultFocus: 'tool', closable: true, modal: false, draggable: false, flex: 1, id: 'FormPaymentReceipt_window', listeners: {show: function(cmp) { Ext.each(Ext.DomQuery.select('.x-window .x-panel-body'), function(p) { Ext.get(p.id).scrollTo('top', 0); });var myHeight = cmp.getSize().height; var windowHeight = Ext.getBody().getViewSize().height; var yPos = Math.max((windowHeight-myHeight)/2, 0); cmp.setY(yPos); }} }, {xtype: 'container', layout: {type: 'hbox', pack: 'start', align: 'bottom'}, cls: 'buttonContainer', scrollable: null, id: 'FormPaymentReceipt_container_18', items: [ {xtype: 'button', text: 'View Receipt', name: 'ViewReceipt', margin: '', hidden: true, ariaRole: 'button', cls: 'noprint', id: 'FormPaymentReceipt_button_ViewReceipt', listeners: {tap: function(cmp, newValue, oldValue, eOpts) {myForm = InstaMed.findParentForm(cmp);PerformAction(myForm.getValues(),PaymentHistoryController.viewPaymentReceipt,cmp);}} }, {xtype: 'button', text: 'View Receipt', name: 'ViewPaymentPlanReceipt', margin: '', hidden: true, ariaRole: 'button', cls: 'noprint', id: 'FormPaymentReceipt_button_ViewReceipt_1', listeners: {tap: function(cmp, newValue, oldValue, eOpts) {myForm = InstaMed.findParentForm(cmp);PerformAction(myForm.getValues(),QuickPayReviewAndConfirmController.viewReceipt,cmp);}} }, {xtype: 'spacer', id: 'FormPaymentReceipt_spacer' }, {xtype: 'button', text: 'Share Receipt', name: 'ShareReceipt', ui: 'secondary', margin: '', ariaRole: 'button', cls: 'shareReceipt secondary noprint', id: 'FormPaymentReceipt_button_ShareReceipt', listeners: {tap: function() { var form = InstaMed.getNavigationView(); form.push('ShareReceiptWindow'); }} }, {xtype: 'button', text: 'Log In', name: 'Login', ui: 'action', margin: '', hidden: true, ariaRole: 'button', cls: 'action noprint', id: 'FormPaymentReceipt_button_LogIn', listeners: {tap: function(cmp, newValue, oldValue, eOpts) { myForm = InstaMed.findParentForm(cmp); PerformAction(myForm.getValues(),QuickPayPaymentSummaryController.redirectToLogin,cmp,undefined,undefined,undefined,undefined,undefined); }} }, {xtype: 'button', text: 'Sign Up for Account', name: 'btnSignUp', ui: 'action', margin: '', hidden: true, ariaRole: 'button', cls: 'action noprint', id: 'FormPaymentReceipt_button_SignUpforAccount', listeners: {tap: function(cmp, newValue, oldValue, eOpts) { myForm = InstaMed.findParentForm(cmp); PerformAction(myForm.getValues(),QuickPayPaymentSummaryController.redirectToSignUp,cmp,undefined,undefined,undefined,undefined,undefined); }} }, {xtype: 'button', text: 'Explore My Account', name: 'ExploreMyAccount', ui: 'action', margin: '', hidden: true, ariaRole: 'button', cls: 'action noprint', id: 'FormPaymentReceipt_button_ExploreMyAccount', listeners: {tap: function(cmp, newValue, oldValue, eOpts) { myForm = InstaMed.findParentForm(cmp); PerformAction(myForm.getValues(),QuickPayPaymentSummaryController.redirectToPatientProfile,cmp,undefined,undefined,undefined,undefined,undefined); }} }] }] }] }] }] }] }, {xtype: 'spacer', flex: 1, id: 'spacer_30' }, {xtype: 'container', layout: {type: 'hbox'}, hidden: false, cls: 'x-panel-footer im-powered-by', scrollable: null, id: 'container_36', items: [ {xtype: 'spacer', id: 'spacer_31' }, {xtype: 'container', maxWidth: 1272, layout: {type: 'hbox'}, cls: 'largeTwelveColumn mediumTwelveColumn ', scrollable: null, id: 'NavReceiptPreview_container_8', items: [ {xtype: 'container', name: 'poweredbylogo', cls: 'hidden hiddenxs hiddensm', scrollable: null, id: 'NavReceiptPreview_poweredbylogo' }, {xtype: 'container', cls: 'copyrightContainer hiddenxs hiddensm', scrollable: null, id: 'NavReceiptPreview_container_9', items: [ {xtype: 'spacer', cls: 'hiddenmd hiddenlg', id: 'NavReceiptPreview_spacer_4' }, {xtype: 'label', html: '© 2024 InstaMed. All Rights Reserved.', name: 'copyrightFooter', ui: 'body1-primary', cls: 'margin-bottom-10 body1-primary', id: 'NavReceiptPreview_copyrightFooter' }, {xtype: 'spacer', cls: 'hiddenmd hiddenlg', id: 'NavReceiptPreview_spacer_5' }] }, {xtype: 'spacer', cls: 'hiddenxs hiddensm', id: 'NavReceiptPreview_spacer_6' }, {xtype: 'container', cls: 'linkButtonContainer hiddenxs hiddensm', scrollable: null, id: 'NavReceiptPreview_container_10', items: [ {xtype: 'button', text: 'Security', iconCls: 'x-ma ma-lock-outline', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavReceiptPreview_button_Security', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/security/','open-window');}} }, {xtype: 'button', text: 'Privacy', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavReceiptPreview_button_Privacy', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/privacy-statement/','open-window');}} }, {xtype: 'button', text: 'Terms', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavReceiptPreview_button_Terms', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/terms-of-use/','open-window');}} }, {xtype: 'button', text: 'Help', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavReceiptPreview_button_Help', listeners: {tap: function() { InstaMed.popupNewWindow('../../Form/PaymentPortal/ContactUs?id=AFCURGENT149','open-window');}} }, {xtype: 'button', text: 'English', align: 'right',menu:[{xtype: 'menuitem', text: 'English', handler: function(cmp) { PerformAction({Language:'en'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'en', cls: 'hiddenxs hiddensm', id: 'menuitem_en_20'},{xtype: 'menuitem', text: 'Español', handler: function(cmp) { PerformAction({Language:'es'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'es', cls: 'hiddenxs hiddensm', id: 'menuitem_es_20'},{xtype: 'menuitem', text: 'Français', handler: function(cmp) { PerformAction({Language:'fr'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'fr', cls: 'hiddenxs hiddensm', id: 'menuitem_fr_20'},], name: 'ForeignLanguages', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavReceiptPreview_button_ForeignLanguages' }] }, {xtype: 'container', cls: 'hiddenmd hiddenlg', scrollable: null, id: 'NavReceiptPreview_container_11', items: [ {xtype: 'container', layout: {type: 'hbox', pack: 'center'}, cls: 'x-center-helper', scrollable: null, id: 'NavReceiptPreview_container_12', items: [ {xtype: 'spacer', id: 'NavReceiptPreview_spacer_7' }, {xtype: 'container', name: 'poweredbylogo', cls: 'hidden', scrollable: null, id: 'NavReceiptPreview_poweredbylogo_1' }, {xtype: 'spacer', id: 'NavReceiptPreview_spacer_8' }] }, {xtype: 'container', layout: {type: 'hbox', pack: 'center'}, cls: 'x-center-helper', scrollable: null, id: 'NavReceiptPreview_container_13', items: [ {xtype: 'spacer', id: 'NavReceiptPreview_spacer_9' }, {xtype: 'container', cls: 'copyrightContainer', scrollable: null, id: 'NavReceiptPreview_container_14', items: [ {xtype: 'spacer', cls: 'hiddenmd hiddenlg', id: 'NavReceiptPreview_spacer_10' }, {xtype: 'label', html: '© 2024 InstaMed. All Rights Reserved.', name: 'copyrightFooter', ui: 'body1-primary', cls: 'margin-bottom-10 body1-primary', id: 'NavReceiptPreview_copyrightFooter_1' }, {xtype: 'spacer', cls: 'hiddenmd hiddenlg', id: 'NavReceiptPreview_spacer_11' }] }, {xtype: 'spacer', id: 'NavReceiptPreview_spacer_12' }] }, {xtype: 'container', layout: {type: 'hbox', pack: 'center'}, cls: 'x-center-helper', scrollable: null, id: 'NavReceiptPreview_container_15', items: [ {xtype: 'spacer', id: 'NavReceiptPreview_spacer_13' }, {xtype: 'container', cls: 'linkButtonContainer ', scrollable: null, id: 'NavReceiptPreview_container_16', items: [ {xtype: 'button', text: 'Security', iconCls: 'x-ma ma-lock-outline', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavReceiptPreview_button_Security_1', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/security/','open-window');}} }, {xtype: 'button', text: 'Privacy', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavReceiptPreview_button_Privacy_1', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/privacy-statement/','open-window');}} }, {xtype: 'button', text: 'Terms', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavReceiptPreview_button_Terms_1', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/terms-of-use/','open-window');}} }, {xtype: 'button', text: 'Help', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavReceiptPreview_button_Help_1', listeners: {tap: function() { InstaMed.popupNewWindow('../../Form/PaymentPortal/ContactUs?id=AFCURGENT149','open-window');}} }] }, {xtype: 'spacer', id: 'NavReceiptPreview_spacer_14' }] }, {xtype: 'container', layout: {type: 'hbox', pack: 'center'}, cls: 'x-center-helper', scrollable: null, id: 'NavReceiptPreview_container_17', items: [ {xtype: 'spacer', id: 'NavReceiptPreview_spacer_15' }, {xtype: 'container', scrollable: null, id: 'NavReceiptPreview_container_18', items: [ {xtype: 'button', text: 'English', align: 'right',menu:[{xtype: 'menuitem', text: 'English', handler: function(cmp) { PerformAction({Language:'en'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'en', cls: 'hiddenmd hiddenlg', id: 'menuitem_en_21'},{xtype: 'menuitem', text: 'Español', handler: function(cmp) { PerformAction({Language:'es'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'es', cls: 'hiddenmd hiddenlg', id: 'menuitem_es_21'},{xtype: 'menuitem', text: 'Français', handler: function(cmp) { PerformAction({Language:'fr'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'fr', cls: 'hiddenmd hiddenlg', id: 'menuitem_fr_21'},], name: 'ForeignLanguages', ui: 'grey', margin: '', hidden: false, ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavReceiptPreview_button_ForeignLanguages_1' }] }, {xtype: 'spacer', id: 'NavReceiptPreview_spacer_16' }] }] }] }, {xtype: 'spacer', id: 'spacer_32' }] }] }, { xtype: 'window', title: 'Share Receipt', titleAlign: 'center', itemId: 'ShareReceiptWindow', flex: 1, defaultFocus: 'textfield', closable: true, modal: true, draggable: false, constrainHeader: true, constrainTo: 'mainBorderPanel', closeAction: 'hide', name: 'ShareReceiptWindow', ui: 'medium', flex: 1, cls: 'medium', id: 'ShareReceiptWindow', listeners: {show: function(cmp) { Ext.each(Ext.DomQuery.select('.x-panel-body', Ext.DomQuery.selectNode('.x-window[id=ShareReceiptWindow]')), function(p) { Ext.get(p.id).scrollTo('top', 0); }); }}, items: [ { xtype: 'form', preventHeader: true, bodyCls: 'mypanel', api: { submit: QuickPayReviewAndConfirmController.emailReceipt }, defaultSubmitButton: 'Submit', allowReset: false, name: 'MyFormPanel', ui: 'flat', itemId: 'MyFormPanel', flex: 1, cls: 'flat', scrollable: null, id: 'MyFormPanel_2', items: [ {xtype: 'errorbox', name: 'ValidationSummary', ui: 'ErrorBox', flex: 1, hidden: true, cls: 'ErrorBox', id: 'ValidationSummary_15' }, {xtype: 'container', flex: 1, scrollable: null, id: 'MyFormPanel_container_3', items: [ {xtype: 'textfield', allowBlank: false, allowOnlyWhitespace: false, maxLength: 200, maxLength: 200, enforceMaxLength: true, minLength: 0, selectOnFocus: true, autoCorrect: false, fieldLabel: 'Email Receipt To:', label: 'Email Receipt To:', component: {"type":"email","pattern":null}, inputType: 'email', labelSeparator: ' ', required: true, labelWrap: true, labelAlign: 'placeholder', errorTarget: 'under', clearable: false, requiredMessage: 'Email Receipt To: is required', autoComplete: 'on', name: 'Email', flex: 5, margin: '', id: 'MyFormPanel_Email', listeners: {action: submitOnEnter,blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'hiddenfield', fieldLabel: 'TransactionAccountID', label: 'TransactionAccountID', labelSeparator: ' ', required: false, labelWrap: true, errorTarget: 'under', clearable: false, requiredMessage: 'TransactionAccountID is required', autoComplete: 'on', name: 'TransactionAccountID', flex: 1, margin: '', id: 'MyFormPanel_TransactionAccountID', listeners: {blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'hiddenfield', fieldLabel: 'TransactionGroupID', label: 'TransactionGroupID', labelSeparator: ' ', required: false, labelWrap: true, errorTarget: 'under', clearable: false, requiredMessage: 'TransactionGroupID is required', autoComplete: 'on', name: 'TransactionGroupID', flex: 1, margin: '', id: 'MyFormPanel_TransactionGroupID', listeners: {blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'hiddenfield', fieldLabel: 'PkTransaction', label: 'PkTransaction', labelSeparator: ' ', required: false, labelWrap: true, errorTarget: 'under', clearable: false, requiredMessage: 'PkTransaction is required', autoComplete: 'on', name: 'PkTransaction', flex: 1, margin: '', id: 'MyFormPanel_PkTransaction', listeners: {blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'hiddenfield', fieldLabel: 'Transaction Type', label: 'Transaction Type', labelSeparator: ' ', required: false, labelWrap: true, errorTarget: 'under', clearable: false, requiredMessage: 'Transaction Type is required', autoComplete: 'on', name: 'TransactionType', flex: 1, margin: '', id: 'MyFormPanel_TransactionType', listeners: {blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'hiddenfield', fieldLabel: 'TransactionAction', label: 'TransactionAction', labelSeparator: ' ', required: false, labelWrap: true, errorTarget: 'under', clearable: false, requiredMessage: 'TransactionAction is required', autoComplete: 'on', name: 'TransactionAction', flex: 1, margin: '', id: 'MyFormPanel_TransactionAction', listeners: {blur: function(cmp){if(cmp.validate){cmp.validate();}}} }, {xtype: 'hiddenfield', fieldLabel: 'IsPaymentPlanFlow', label: 'IsPaymentPlanFlow', labelSeparator: ' ', required: false, labelWrap: true, errorTarget: 'under', clearable: false, requiredMessage: 'IsPaymentPlanFlow is required', autoComplete: 'on', name: 'IsPaymentPlanFlow', flex: 1, margin: '', id: 'MyFormPanel_IsPaymentPlanFlow', listeners: {blur: function(cmp){if(cmp.validate){cmp.validate();}}} }] }, {xtype: 'container', flex: 1, scrollable: null, id: 'MyFormPanel_container_4', items: [ {xtype: 'container', layout: {type: 'hbox', pack: 'start', align: 'bottom'}, flex: 1, cls: 'buttonContainer', scrollable: null, id: 'MyFormPanel_container_5', items: [ {xtype: 'button', text: 'Cancel', flex: 1, margin: '', ariaRole: 'button', cls: 'noprint', id: 'MyFormPanel_button_Cancel', listeners: {tap: function(cmp, e, options) { InstaMed.getNavigationView().back(); }} }, {xtype: 'spacer', flex: 1, id: 'MyFormPanel_spacer_2' }, {xtype: 'button', text: 'Send', name: 'Submit', ui: 'action', flex: 1, margin: '', ariaRole: 'button', cls: 'action noprint', id: 'MyFormPanel_button_Send', listeners: {tap: function(cmp, e, options) { var cmpForm = InstaMed.findParentForm(cmp); InstaMed.submitForm(cmpForm,function(cmp, e, options) { InstaMed.getNavigationView().back(); }); }} }] }] }] }] }, {xtype: 'container', name: 'NavAPCTerms', layout: {type: 'vbox', pack: 'start'}, scrollable: 'true', id: 'NavAPCTerms', items: [ {xtype: 'container', docked: 'top', scrollable: null, id: 'NavAPCTerms_container', items: [ {xtype: 'instamedNavigationBar', name: 'headerBar', layout: {type: 'hbox'}, hidden: false, cls: 'im-ignore-custom-colors im-ignore-background', scrollable: null, id: 'NavAPCTerms_headerBar', items: [ {xtype: 'spacer', id: 'NavAPCTerms_spacer', plugins: 'responsive', responsiveConfig: {'width > 1272':{flex : 1,},'width <= 1272':{flex :0,},} }, {xtype: 'titlebar', title: '<a href=\\"../../Form/PaymentPortal/Start\\"> <img src=\\"https://cdn.instamed.com/V_2024_March/Content/Images/General/instamed-tagged-white.png?id=AFCURGENT149\\" alt=\\"InstaMed a J.P. Morgan company logo\\" style=\\"height: 40px\\">', maxWidth: 1272, cls: 'largeTwelveColumn mediumTwelveColumn smallTwelveColumn xsmallTwelveColumn im-ignore-custom-colors im-ignore-background', scrollable: null, id: 'NavAPCTerms_titlebar', plugins: 'responsive', responsiveConfig: {'width >= 1272':{title :'',},'width < 1272':{title : ' ',},}, items: [ {xtype: 'button', accessibleText: 'Back', iconCls: 'x-ma ma-arrow-back', align: 'left', name: 'TitleBarNavigationViewBack', margin: '', hidden: false, ariaRole: 'button', cls: 'x-button-icon-link-style white hiddenlg noprint', id: 'NavAPCTerms_TitleBarNavigationViewBack', plugins: 'responsive', responsiveConfig: {'width > 1272':{iconCls :'',},'width <= 1272':{iconCls : 'x-ma ma-arrow-back',},}, listeners: {tap: function(cmp, e, options) { InstaMed.getNavigationView().back(); }} }, {xtype: 'container', html: ' ', align: 'left', scrollable: null, id: 'NavAPCTerms_container_1', plugins: 'responsive', responsiveConfig: {'width >= 1272':{hidden : false,},'width < 1272':{hidden :true,},} }, {xtype: 'button', name: 'HeaderTitlebarButton', ui: 'white', margin: '', hidden: true, ariaRole: 'button', cls: 'x-button-link-style im-center-header-button white noprint', id: 'NavAPCTerms_HeaderTitlebarButton' }, {xtype: 'button', text: 'Pay Any Healthcare Bill', align: 'right', name: 'PayAnyHealthcareBillButton', ui: 'white', margin: '', ariaRole: 'button', cls: 'x-button-link-style x-border hiddenxs hiddensm white noprint', id: 'NavAPCTerms_button_PayAnyHealthcareBill', listeners: {tap: function() { if(InstaMed.isLoggedIn) { window.location.href ='../../Form/PaymentPortal/Dashboard?id=AFCURGENT149&pageStep=NavFindProvider'; } else { window.location.href ='../../Form/PaymentPortal/Start?pageStep=NavFindProvider'; }}} }, {xtype: 'button', text: 'Pay Bills', iconCls: 'x-ma ma-search', iconAlign: 'top', align: 'right', name: 'PayAnyHealthcareBillIcon', margin: '', ariaRole: 'button', cls: 'x-button-icon-ontop-link-style white hiddenmd hiddenlg noprint', id: 'NavAPCTerms_button_PayBills', listeners: {tap: function() { if(InstaMed.isLoggedIn) { window.location.href ='../../Form/PaymentPortal/Dashboard?pageStep=NavFindProvider'; } else { window.location.href ='../../Form/PaymentPortal/Start?pageStep=NavFindProvider'; }}} }, {xtype: 'button', accessibleText: 'Log In or Sign Up', iconCls: 'x-ma ma-account-circle', align: 'right',menu:[{xtype: 'menuitem', text: 'Log In', handler: function() { PerformAction({}, PatientPortalLoginController.redirectToLogin,null); }, id: 'menuitem_LogIn_14'},{xtype: 'menuitem', text: 'Sign Up', handler: function() { PerformAction({}, SignUpController.redirectToSignUp,null); }, id: 'menuitem_SignUp_14'},], name: 'LoginOrSignUpProfileIcon', margin: '', ariaRole: 'button', cls: 'x-button-icon-link-style white noprint', id: 'NavAPCTerms_button_LoginOrSignUpProfileIcon', plugins: 'responsive', responsiveConfig: {'!InstaMed.isLoggedIn & width > 960':{hidden: true,},'!InstaMed.isLoggedIn && width <= 960':{hidden: false,},}, listeners: {hiddenchange: function() { Ext.ComponentQuery.query('[name=LoginOrSignUpProfileIcon]')[0].getMenu().hide(); }} }, {xtype: 'button', text: '', align: 'right',menu:[{xtype: 'menuitem', text: 'Dashboard', handler: function(){ window.location.href='../../Form/PaymentPortal/Dashboard'; }, id: 'menuitem_Dashboard_28'},{xtype: 'menuitem', text: 'Help', handler: function() { window.open('https://help.instamed.com/patients/s/?dc_label=Patients')}, id: 'menuitem_Help_28'},{xtype: 'menuitem', text: 'Log Out', handler: function(){ window.location.href='../../Form/PaymentPortal/Logout?id=AFCURGENT149'; }, id: 'menuitem_LogOut_28'},], name: 'Profile', ui: 'white', margin: '', hidden: true, ariaRole: 'button', cls: 'x-button-link-style white noprint', id: 'NavAPCTerms_button_Profile', plugins: 'responsive', responsiveConfig: {'InstaMed.isLoggedIn & width > 960':{hidden: false,},'InstaMed.isLoggedIn && width <= 960':{hidden: true,},}, listeners: {hiddenchange: function() { Ext.ComponentQuery.query('[name=Profile]')[0].getMenu().hide(); }} }, {xtype: 'container', align: 'right', name: 'LoginOrSignUpContainer', layout: {type: 'hbox'}, scrollable: null, id: 'NavAPCTerms_LoginOrSignUpContainer', plugins: 'responsive', responsiveConfig: {'!InstaMed.isLoggedIn & width > 960':{hidden: false,},'!InstaMed.isLoggedIn && width <= 960':{hidden: true,},}, items: [ {xtype: 'button', text: 'Log In', align: 'right', name: 'LoginForDualLogin', ui: 'white', margin: '', hidden: false, ariaRole: 'button', cls: 'x-button-link-style hiddenxs hiddensm white noprint', id: 'NavAPCTerms_button_LoginForDualLogin', listeners: {tap: function() { PerformAction({}, PatientPortalLoginController.redirectToLogin,null); }} }, {xtype: 'label', html: 'or', align: 'right', name: 'Or', ui: 'body1-white', cls: 'hiddenxs hiddensm body1-white', id: 'NavAPCTerms_Or' }, {xtype: 'button', text: 'Sign Up', align: 'right', name: 'SignUpForDualLogin', ui: 'white', margin: '', ariaRole: 'button', cls: 'x-button-link-style hiddenxs hiddensm white noprint', id: 'NavAPCTerms_button_SignUpForDualLogin', listeners: {tap: function() { PerformAction({}, SignUpController.redirectToSignUp,null); }} }] }, {xtype: 'button', accessibleText: 'Profile', iconCls: 'x-ma ma-account-circle', align: 'right',menu:[{xtype: 'menuitem', text: 'Dashboard', handler: function(){ window.location.href='../../Form/PaymentPortal/Dashboard'; }, id: 'menuitem_Dashboard_29'},{xtype: 'menuitem', text: 'Help', handler: function() { window.open('https://help.instamed.com/patients/s/?dc_label=Patients')}, id: 'menuitem_Help_29'},{xtype: 'menuitem', text: 'Log Out', handler: function(){ window.location.href='../../Form/PaymentPortal/Logout?id=AFCURGENT149'; }, id: 'menuitem_LogOut_29'},], name: 'ProfileIcon', margin: '', hidden: true, ariaRole: 'button', cls: 'x-button-icon-link-style white noprint', id: 'NavAPCTerms_button_ProfileIcon', plugins: 'responsive', responsiveConfig: {'InstaMed.isLoggedIn & width > 960':{hidden: true,},'InstaMed.isLoggedIn && width <= 960':{hidden: false,},}, listeners: {hiddenchange: function() { Ext.ComponentQuery.query('[name=ProfileIcon]')[0].getMenu().hide(); }} }] }, {xtype: 'spacer', id: 'NavAPCTerms_spacer_1', plugins: 'responsive', responsiveConfig: {'width > 1272':{flex : 1,},'width <= 1272':{flex :0,},} }] }] }, {xtype: 'container', layout: {type: 'hbox'}, cls: 'x-subheader-container', scrollable: null, id: 'NavAPCTerms_container_2', items: [ {xtype: 'spacer', id: 'NavAPCTerms_spacer_2', plugins: 'responsive', responsiveConfig: {'width > 1272':{flex : 1,},'width <= 1272':{flex :0,},} }, {xtype: 'container', maxWidth: 1272, layout: {type: 'hbox'}, cls: 'largeTwelveColumn mediumTwelveColumn smallTwelveColumn xsmallTwelveColumn x-subheader-panel ', scrollable: null, id: 'NavAPCTerms_container_3', items: [ {xtype: 'image', src: '../../ContentHandler.aspx?URL=/Images/Database/326332D5-86DA-4881-BE6F-8DE62B1DD7E0&id=AFCURGENT149&crop=true&maxWidth=150&maxHeight=64', hidden: false, cls: 'x-clickable x-button-provider-img', id: 'NavAPCTerms_image', listeners: {painted: function() { var cmp = this; cmp.el.dom.setAttribute('aria-label', 'AFC URGENT CARE - 149th Street logo'); cmp.el.dom.setAttribute('role', 'img'); cmp.el.dom.setAttribute('title', ''); },tap: function(){ window.location.href='../../Form/PaymentPortal/Default?id=AFCURGENT149'; }} }, {xtype: 'container', layout: {type: 'vbox', pack: 'center', align: 'left'}, cls: 'im-provider-header-buttons', scrollable: null, id: 'NavAPCTerms_container_4', items: [ {xtype: 'label', html: 'AFC URGENT CARE - 149th Street', name: 'SubheaderProviderName', ui: 'subheading-primary', cls: 'initial-caps font-400 im-bold-button subheading-primary', id: 'NavAPCTerms_SubheaderProviderName' }, {xtype: 'container', layout: {type: 'hbox'}, scrollable: null, id: 'NavAPCTerms_container_5', items: [ {xtype: 'container', html: '', hidden: true, cls: 'im-address-verification-icon', scrollable: null, id: 'NavAPCTerms_container_6' }, {xtype: 'label', html: '332 East 149th Street, Bronx, NY 10451', ui: 'body1-secondary', cls: 'line-height-20 body1-secondary', id: 'NavAPCTerms_label' }] }, {xtype: 'container', layout: {type: 'hbox'}, hidden: false, scrollable: null, id: 'NavAPCTerms_container_7', items: [ {xtype: 'label', html: '(347) 329-4010', ui: 'body1-primary', cls: 'body1-primary', id: 'NavAPCTerms_label_1' }] }] }] }, {xtype: 'spacer', id: 'NavAPCTerms_spacer_3', plugins: 'responsive', responsiveConfig: {'width > 1272':{flex : 1,},'width <= 1272':{flex :0,},} }] }, { xtype: 'panel', dock: 'top', frame: false, scrollable: 'true', id: 'panel_14', items: [ {xtype: 'container', maxWidth: 1272, layout: {type: 'hbox'}, cls: 'mainContent MainContentWithHeaerAndSubheader ', scrollable: null, id: 'container_46', items: [ {xtype: 'container', flex: 1, scrollable: null, id: 'container_47', items: [ { xtype: 'form', preventHeader: true, bodyCls: 'mypanel', api: { }, name: 'MyFormPanel', itemId: 'MyFormPanel', cls: 'col-large-offSet-3 col-medium-offSet-3 col-small-offSet-1 smallTenColumn xsmallTwelveColumn mediumSixColumn largeSixColumn ', scrollable: null, id: 'MyFormPanel_3', items: [ {xtype: 'errorbox', name: 'ValidationSummary', ui: 'ErrorBox', hidden: true, cls: 'ErrorBox', id: 'ValidationSummary_17' }, {xtype: 'instamedHeading1', text: 'Payment Plan Authorization', id: 'MyFormPanel_instamedHeading1_1' }, {xtype: 'container', html: '

Consent and Authorized Amount. By clicking \"Confirm\" below, I authorize my Service Provider to use my payment information provided above to electronically debit the specified bank account for the amount of my requested monthly payments and remit my payments to the designated healthcare provider.These payments will debit in the amounts and on the schedule described above. If a transfer date falls on a weekend or holiday, it may process on the next business day, or shortly thereafter. \"Service Provider\" means AFC URGENT CARE - 149th Street and all its affiliated and related organizations.I agree that it is my responsibility to maintain sufficient funds in my account until each transaction I authorize processes. I acknowledge that I am also responsible for all fees charged by my financial institution associated with the transactions authorized. If a payment is rejected due to insufficient funds, I agree that AFC URGENT CARE - 149th Street may attempt to process the transaction again and may debit a returned item fee. I acknowledge that I will be liable for any fees, including insufficient funds or returned entry fees. I also authorize AFC URGENT CARE - 149th Street to electronically debit or credit my account to correct any erroneous transfers.
Duration of Authorization; Termination and Modification.I understand that this authorization is valid and will remain in full force and effect until I notify Service Provider that I wish to revoke this authorization. To revoke or modify this authorization, please contact our agent InstaMed’s customer service at (866) 467-8263. I understand that Service Provider requires at least three (3) business days’ prior notice in order to update or cancel this authorization. This authorization will remain in effect until I terminate it. I understand that I have the right to terminate or modify this authorization, including updating my payment method, by logging into www.pay.instamed.com and modifying or discontinuing the payments or by notifying my Service Provider in writing to 332 East 149th Street, Bronx, NY 10451 or calling (347) 329-4010. I understand that the termination of this authorization in no way relieves me of the obligation to fulfill my obligations to my Service Provider. My request to terminate or update this authorization will be effective only after my Service Provider has had a reasonable opportunity to act upon my request, at least three (3) business days.
Transactions and Accounts.I authorize my debit / credit card issuer and / or financial institution (bank) to honor transactions processed by this authorization. I certify that I am an owner of or authorized signer for the debit / credit card or the designated bank account with the Account Number and Routing Number listed under the ”Payment Method” on the “Review & Confirm” page. I acknowledge that a transaction involving an ACH debit from my bank account is subject to the Rules and Operating Guidelines of National Automated Clearing House Association and charge to my card is subject to the card brand rules and any agreement between me and my card issuer.
Acknowledgement.I understand that I should read this authorization carefully and keep a copy for my records. To receive a copy of this authorization for no charge I may contact my Service Provider at the address or phone number provided in Section 2 above.
Communications to be Provided Electronically.By enrolling, I also consent that, now and in the future, any information, notices, and disclosures in connection with this authorization may be provided to you electronically in lieu of providing such communications being provided on paper.
Updating Contact Information. I can change my contact information by configuring my account settings on this website or by writing to or calling my Service Provider using the information provided in Section 2 above.
Online and Mobile E-Sign Disclosure and Consent. I acknowledge the following information is being provided by Service Provider:
1. Definitions for purposes of Section 7.
  \t\t
  - “Communication” is defined in Section 7(b) below.
  - “Electronic Delivery” is the act of delivering Communications using electrical, digital, magnetic, wireless, optical, electromagnetic, or similar electronic means as set forth in Section 7(d) below, including through our websites or mobile applications.
  - “We,” “us,” and “our,” refer to the entity that provides you one or more Services and such entity’s affiliates and subsidiaries or our agents, assignees or service providers.
2. Consent and Scope of Communications to be Provided Electronically.
  \t\tWe are required by law, regulation or agreement to give you certain information “in writing”. With your consent, we can provide this information to you by Electronic Delivery instead. We also need your general consent to use electronic records and signatures in our relationship with you.
  You agree that for all Communications for Services we may use Electronic Delivery and, at our discretion, terminate paper delivery of Communications to you unless and until you withdraw your consent to this Section 7 as described in Section 7(f) below. This Section 7 applies to all Communications relating to such Services.
  “Communications” include, but are not limited to, the following:
  - All legal, regulatory or other disclosures associated with a Service;
  - All documentation or communications relevant to a Service, including agreements, amendments, policies and procedures (including but not limited to our privacy policy), terms and conditions, authorizations, confirmations of transactions, updates, notices, responses to claims, and transaction history;
  - Marketing materials; and
  - Any other document or other information required to be provided “in writing” or that we otherwise provide to you, or that you sign or submit or agree to at our request, in connection with Services or your relationship with us.
3. Delivery.
  Except as otherwise provided in this Section 7, physical delivery of Communications is not available for these Services. We reserve the right, but assume no obligation, to provide paper copies of any Communication that you have authorized us to provide via Electronic Delivery.
  To withdraw your consent to receive Communications by Electronic Delivery, you must follow the instructions set forth in the section titled “How to Withdraw Consent” in Section 7(f) below. Sometimes you are required to provide us with a written notice by law or under our agreement with you. Those notices must be provided to us on paper unless we tell you how to deliver the notice to us electronically.
4. Method of Electronic Delivery.
  All Communications (including alerts that Communications have been provided or posted) that we provide to you electronically will be provided by one or more of the following methods:
  - electronic messaging (such as e-mail, or SMS text or push notification to your mobile device);
  - by access to a web site, including our mobile websites or websites of third party service providers who we engage to deliver Communications through Electronic Delivery, that we will designate in a notice we send to you via electronic messaging at the time the information is available or that we will generally designate in advance for such purpose;
  - via our mobile applications; or
  - by requesting you download a Hyper Text Markup Language (“HTML”) file or Portable Document Format (“PDF”) or other specified electronic file containing the Communication.
  Communications delivered by e-mail will be sent to your e-mail address reflected in our records. You represent that any e-mail address you provide to us for Electronic Delivery purposes belongs to you or to a person who has authority for Services. You can update your email address on file with us by calling (866) 467-8263. You should print, download or otherwise retain a copy of this Section 7 and all other Communications provided by Electronic Delivery.
5. Hardware and Software Requirements.
  In order to access, view, print and retain electronic Communications, you must have:
  - Access to a device (e.g., computer, smartphone, mobile device, tablet, etc.) suitable for connecting to the internet, or downloading our mobile apps with the Current Version (as defined below) of (i) an operating system, such as Windows, Mac OS, iOS or Android, and (ii) a web browser, such as Chrome, Safari or Firefox, that we support;
  - A connection to the internet;
  - Local electronic storage capacity to retain Communications and/or a printer to print them;
  - A valid e-mail account and software to access it; li>
  - Software that enables you to view and display files in HTML and PDF format.
  By “Current Version,” we mean a version of the software that is currently being supported by its publisher. From time to time, we may offer services or features that require that your internet browser be configured in a particular way, such as permitting the use of cookies. If we detect that your Internet browser is not properly configured, we may provide you with a notice and advice on how to update your configuration. We reserve the right to discontinue support of a Current Version of software or an operating system if, in our sole opinion, it suffers from a security flaw or other flaw that makes it unsuitable for use.
  If our hardware or software requirements change, and that change would create a material risk that you would not be able to access or retain electronic Communications, we will give you notice of the revised hardware or software requirements. Continuing to use the Services after receiving notice of the change is reaffirmation of your consent with respect to other Communications.
6. How to Withdraw Consent.
  We will not impose any fee to process the withdrawal of your consent to receive Communications by Electronic Delivery. However, if you withdraw consent, your access to and use of the Services or certain features of the Services will be terminated. Any withdrawal of your consent to receive Communications by Electronic Delivery will be effective only after we have a reasonable period of time to process your withdrawal.
  At our option, we may treat the provision of an invalid e-mail address, or the subsequent malfunction of a previously valid e-mail address, as a withdrawal of your consent to receive Communications by Electronic Delivery.
  You may withdraw your consent to receive Electronic Delivery of Communications by calling us at (866) 467-8263.
7. Requesting Paper Copies.
  For Communications scheduled for Electronic Delivery, you should not expect to receive a paper copy of any Communication unless you request it. You can obtain a paper copy of an electronic Communication by printing it yourself or by requesting that we mail you a paper copy, provided that such request is made within a reasonable time after we first provided the Communication to you by Electronic Delivery. We may charge you a reasonable service charge, with prior notice of any such charge, for the delivery of paper copies of any Communication provided to you electronically pursuant to this Section 7.
  To request paper copies of electronic Communications, call us at (866) 467-8263.
8. Federal Law.
  You acknowledge and agree that your consent to this Section 7 is provided in connection with a transaction affecting interstate commerce, that it is subject to the federal Electronic Signatures in Global and National Commerce Act (the “E-SIGN Act”), and that you and we both intend that the E-SIGN Act apply to the fullest extent permitted by law.
9. Termination/Changes.
  We reserve the right, in our sole discretion, to discontinue providing you with electronic Communications, or to terminate or change the terms and conditions on which we provide electronic Communications. We will provide you with notice of any such termination or change as required by law.
10. Acceptance and Consent.
  By consenting to this Section 7, you agree to the following statements:
  - I have read, understand and agree to be bound by the terms and conditions contained in this Section 7, and consent to receive Communications and execute documents via Electronic Delivery according to the process described herein;
  - I am able to download and review files in HTML or PDF format, and I have internet access and can send and receive emails with links to websites;
  - Certain Communications may be delivered to me in paper form and in the future some or all of these Communications may be made available for me to view electronically in accordance with this Section 7;
  - My consent to receive Communications electronically does not automatically expire and is not limited as to duration;
  - I may incur costs, including but not limited to online time and other charges from my internet service provider or telephone carrier in accessing and/or viewing Communications;
  - I may terminate or suspend Electronic Delivery at any time at my discretion and I understand that this will terminate my access to the Site; and
  - We will not be liable for any loss, liability, cost, expense, or claim for acting upon this authorization or arising from my use of the product or services provided pursuant to this Section 7.

', name: 'APAuthTextLabel', cls: 'im-legal-text', scrollable: null, id: 'MyFormPanel_APAuthTextLabel', listeners: {painted: function(cmp, e, options){ var paymentPlanData = Ext.StoreManager.get('PaymentInformationReviewAndConfirmStore').getData().items[0].data; var frequency = document.getElementById("paymentPlanFrequency"); frequency.text = " " + paymentPlanData.Duration + " "; }} }, {xtype: 'container', layout: {type: 'hbox', pack: 'start', align: 'bottom'}, cls: 'buttonContainer', scrollable: null, id: 'MyFormPanel_container_6', items: [ {xtype: 'spacer', id: 'MyFormPanel_spacer_3' }, {xtype: 'button', text: 'Back', name: 'PatientPaymentBack', ui: 'secondary', margin: '', ariaRole: 'button', cls: 'secondary noprint', id: 'MyFormPanel_button_Back_2', listeners: {tap: function(cmp, e, options) { InstaMed.getNavigationView().back(); }} }] }] }] }] }] }, {xtype: 'spacer', flex: 1, id: 'spacer_42' }, {xtype: 'container', layout: {type: 'hbox'}, hidden: false, cls: 'x-panel-footer im-powered-by', scrollable: null, id: 'container_48', items: [ {xtype: 'spacer', id: 'spacer_43' }, {xtype: 'container', maxWidth: 1272, layout: {type: 'hbox'}, cls: 'largeTwelveColumn mediumTwelveColumn ', scrollable: null, id: 'NavAPCTerms_container_8', items: [ {xtype: 'container', name: 'poweredbylogo', cls: 'hidden hiddenxs hiddensm', scrollable: null, id: 'NavAPCTerms_poweredbylogo' }, {xtype: 'container', cls: 'copyrightContainer hiddenxs hiddensm', scrollable: null, id: 'NavAPCTerms_container_9', items: [ {xtype: 'spacer', cls: 'hiddenmd hiddenlg', id: 'NavAPCTerms_spacer_4' }, {xtype: 'label', html: '© 2024 InstaMed. 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All Rights Reserved.', name: 'copyrightFooter', ui: 'body1-primary', cls: 'margin-bottom-10 body1-primary', id: 'NavAPCTerms_copyrightFooter_1' }, {xtype: 'spacer', cls: 'hiddenmd hiddenlg', id: 'NavAPCTerms_spacer_11' }] }, {xtype: 'spacer', id: 'NavAPCTerms_spacer_12' }] }, {xtype: 'container', layout: {type: 'hbox', pack: 'center'}, cls: 'x-center-helper', scrollable: null, id: 'NavAPCTerms_container_15', items: [ {xtype: 'spacer', id: 'NavAPCTerms_spacer_13' }, {xtype: 'container', cls: 'linkButtonContainer ', scrollable: null, id: 'NavAPCTerms_container_16', items: [ {xtype: 'button', text: 'Security', iconCls: 'x-ma ma-lock-outline', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavAPCTerms_button_Security_1', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/security/','open-window');}} }, {xtype: 'button', text: 'Privacy', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavAPCTerms_button_Privacy_1', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/privacy-statement/','open-window');}} }, {xtype: 'button', text: 'Terms', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavAPCTerms_button_Terms_1', listeners: {tap: function() { InstaMed.popupNewWindow('https://www.instamed.com/terms-of-use/','open-window');}} }, {xtype: 'button', text: 'Help', ui: 'grey', margin: '', ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavAPCTerms_button_Help_1', listeners: {tap: function() { InstaMed.popupNewWindow('../../Form/PaymentPortal/ContactUs?id=AFCURGENT149','open-window');}} }] }, {xtype: 'spacer', id: 'NavAPCTerms_spacer_14' }] }, {xtype: 'container', layout: {type: 'hbox', pack: 'center'}, cls: 'x-center-helper', scrollable: null, id: 'NavAPCTerms_container_17', items: [ {xtype: 'spacer', id: 'NavAPCTerms_spacer_15' }, {xtype: 'container', scrollable: null, id: 'NavAPCTerms_container_18', items: [ {xtype: 'button', text: 'English', align: 'right',menu:[{xtype: 'menuitem', text: 'English', handler: function(cmp) { PerformAction({Language:'en'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'en', cls: 'hiddenmd hiddenlg', id: 'menuitem_en_29'},{xtype: 'menuitem', text: 'Español', handler: function(cmp) { PerformAction({Language:'es'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'es', cls: 'hiddenmd hiddenlg', id: 'menuitem_es_29'},{xtype: 'menuitem', text: 'Français', handler: function(cmp) { PerformAction({Language:'fr'}, PatientPortalLoginController.changeLanguage,cmp); }, name: 'fr', cls: 'hiddenmd hiddenlg', id: 'menuitem_fr_29'},], name: 'ForeignLanguages', ui: 'grey', margin: '', hidden: false, ariaRole: 'button', cls: 'x-button-link-style grey noprint', id: 'NavAPCTerms_button_ForeignLanguages_1' }] }, {xtype: 'spacer', id: 'NavAPCTerms_spacer_16' }] }] }] }, {xtype: 'spacer', id: 'spacer_44' }] }] }, { xtype: 'window', title: 'Payment Plan Details', titleAlign: 'center', itemId: 'PaymentPlanPaymentsBreakdownWindow', flex: 1, defaultFocus: 'button', closable: true, modal: true, draggable: false, constrainHeader: true, constrainTo: 'mainBorderPanel', closeAction: 'hide', width: 700, name: 'PaymentPlanPaymentsBreakdownWindow', ui: 'medium', flex: 1, cls: 'medium', id: 'PaymentPlanPaymentsBreakdownWindow', listeners: {show: function(cmp) { Ext.each(Ext.DomQuery.select('.x-panel-body', Ext.DomQuery.selectNode('.x-window[id=PaymentPlanPaymentsBreakdownWindow]')), function(p) { Ext.get(p.id).scrollTo('top', 0); }); }}, items: [ { xtype: 'form', preventHeader: true, bodyCls: 'mypanel', api: { }, name: 'MyFormPanel', ui: 'flat', itemId: 'MyFormPanel', flex: 1, cls: 'flat', scrollable: null, id: 'MyFormPanel_4', items: [ {xtype: 'errorbox', name: 'ValidationSummary', ui: 'ErrorBox', flex: 1, hidden: true, cls: 'ErrorBox', id: 'ValidationSummary_18' }, {xtype: 'container', flex: 1, scrollable: null, id: 'MyFormPanel_container_7', items: [ {xtype: 'dataviewlite', tpl: '\r\n \r\n

\r\n

\r\n \r\n {Description}\r\n \r\n \r\n {Amount}\r\n \r\n \r\n \r\n {Description}\r\n \r\n \r\n {Amount}\r\n \r\n \r\n \r\n

\r\n ', itemSelector: '.im-dataview-tile-payment-plan', deferInitialRefresh: false,store: Ext.data.StoreManager.lookup('PaymentPlanPaymentsBreakdownStore'), name: 'PaymentPlanPaymentsBreakdownDataView', flex: 1, id: 'MyFormPanel_PaymentPlanPaymentsBreakdownDataView' }] }, {xtype: 'container', layout: {type: 'hbox', pack: 'start', align: 'bottom'}, flex: 1, cls: 'buttonContainer', scrollable: null, id: 'MyFormPanel_container_8', items: [ {xtype: 'spacer', flex: 1, id: 'MyFormPanel_spacer_4' }, {xtype: 'button', text: 'Close', ui: 'secondary', flex: 1, margin: '', ariaRole: 'button', cls: 'secondary noprint', id: 'MyFormPanel_button_Close', listeners: {tap: function(cmp, e, options) { InstaMed.getNavigationView().back(); }} }] }] }] }, { xtype: 'window', title: 'Paperless Statements', titleAlign: 'center', itemId: 'EStatementEnrollmentInfo', flex: 1, defaultFocus: 'button', closable: true, modal: true, draggable: false, constrainHeader: true, constrainTo: 'mainBorderPanel', closeAction: 'hide', name: 'EStatementEnrollmentInfo', ui: 'medium', flex: 1, cls: 'medium', id: 'EStatementEnrollmentInfo', listeners: {painted: function(cmp, eOpts){ var myHeight = cmp.getSize().height; var windowHeight = Ext.getBody().getViewSize().height; var yPos = Math.max((windowHeight-myHeight)/2, 0); cmp.setY(yPos); },show: function(cmp) { Ext.each(Ext.DomQuery.select('.x-panel-body', Ext.DomQuery.selectNode('.x-window[id=EStatementEnrollmentInfo]')), function(p) { Ext.get(p.id).scrollTo('top', 0); }); }}, items: [ {xtype: 'label', html: 'View current and past statements from your phone, tablet, or computer anytime and save paper too. You can choose to receive paper statements again after enrolling in paperless statements by visiting your preferences.', ui: 'body1-secondary', flex: 1, cls: 'body1-secondary', id: 'label_1' }, {xtype: 'container', layout: {type: 'hbox', pack: 'start', align: 'bottom'}, flex: 1, cls: 'buttonContainer im-bottom-label', scrollable: null, id: 'container_49', items: [ {xtype: 'spacer', flex: 1, id: 'spacer_45' }, {xtype: 'button', text: 'Close', name: 'btnClose', ui: 'action', flex: 1, margin: '', ariaRole: 'button', cls: 'action noprint', id: 'button_Close', listeners: {tap: function(cmp, e, options) { InstaMed.getNavigationView().back(); }} }] }] }, { xtype: 'window', title: 'Paperless Statements', titleAlign: 'center', itemId: 'EStatementEnrollmentInfo', flex: 1, defaultFocus: 'button', closable: true, modal: true, draggable: false, constrainHeader: true, constrainTo: 'mainBorderPanel', closeAction: 'hide', name: 'EStatementEnrollmentInfo', ui: 'medium', flex: 1, cls: 'medium', id: 'EStatementEnrollmentInfo_1', listeners: {painted: function(cmp, eOpts){ var myHeight = cmp.getSize().height; var windowHeight = Ext.getBody().getViewSize().height; var yPos = Math.max((windowHeight-myHeight)/2, 0); cmp.setY(yPos); },show: function(cmp) { Ext.each(Ext.DomQuery.select('.x-panel-body', Ext.DomQuery.selectNode('.x-window[id=EStatementEnrollmentInfo]')), function(p) { Ext.get(p.id).scrollTo('top', 0); }); }}, items: [ {xtype: 'label', html: 'View current and past statements from your phone, tablet, or computer anytime and save paper too. You can choose to receive paper statements again after enrolling in paperless statements by visiting your preferences.', ui: 'body1-secondary', flex: 1, cls: 'body1-secondary', id: 'label_2' }, {xtype: 'container', layout: {type: 'hbox', pack: 'start', align: 'bottom'}, flex: 1, cls: 'buttonContainer im-bottom-label', scrollable: null, id: 'container_50', items: [ {xtype: 'spacer', flex: 1, id: 'spacer_46' }, {xtype: 'button', text: 'Close', name: 'btnClose', ui: 'action', flex: 1, margin: '', ariaRole: 'button', cls: 'action noprint', id: 'button_Close_1', listeners: {tap: function(cmp, e, options) { InstaMed.getNavigationView().back(); }} }] }] }, { xtype: 'window', title: 'Mobile Phone Number', titleAlign: 'center', itemId: 'EditMobilePhoneWindow', flex: 1, defaultFocus: 'textfield', closable: true, modal: true, draggable: false, constrainHeader: true, constrainTo: 'mainBorderPanel', closeAction: 'hide', name: 'EditMobilePhoneWindow', ui: 'medium', flex: 1, cls: 'medium', id: 'EditMobilePhoneWindow', listeners: {painted: function(cmp, eOpts){ var myHeight = cmp.getSize().height; var windowHeight = Ext.getBody().getViewSize().height; var yPos = Math.max((windowHeight-myHeight)/2, 0); cmp.setY(yPos); },show: function(cmp) { Ext.each(Ext.DomQuery.select('.x-panel-body', Ext.DomQuery.selectNode('.x-window[id=EditMobilePhoneWindow]')), function(p) { Ext.get(p.id).scrollTo('top', 0); }); }}, items: [ { xtype: 'form', preventHeader: true, bodyCls: 'mypanel', api: { }, name: 'EditMobilePhoneNumber', ui: 'flat', itemId: 'EditMobilePhoneNumber', flex: 1, cls: 'flat', scrollable: null, id: 'EditMobilePhoneNumber', items: [ {xtype: 'errorbox', name: 'ValidationSummary', ui: 'ErrorBox', flex: 1, hidden: true, cls: 'ErrorBox', id: 'ValidationSummary_20' }, {xtype: 'textfield', allowBlank: false, allowOnlyWhitespace: false, maxLength: 14, maxLength: 14, enforceMaxLength: true, minLength: 10, selectOnFocus: true, autoCorrect: false, fieldLabel: 'Mobile Phone Number', label: 'Mobile Phone Number', component: {"type":"tel","pattern":null}, inputType: 'tel', labelSeparator: ' ', required: true, labelWrap: true, labelAlign: 'placeholder', errorTarget: 'under', clearable: false, requiredMessage: 'Mobile Phone Number is required', autoComplete: 'on', name: 'MobilePhoneNumber2', flex: 1, margin: '', id: 'EditMobilePhoneNumber_MobilePhoneNumber2', listeners: {action: submitOnEnter,blur: function(cmp){if(cmp.validate){cmp.validate();}},change: function(field, event, opts ){ var s = new String(field.getValue()); if(s != null && s != '') { s = s.replace(/[-,()\s]/g,'');var newValue='(';newValue+=s.substring(0,3);if(s.length>3){newValue+=') ';}newValue+=s.substring(3,6);if(s.length>6){newValue+='-';}newValue+=s.substring(6,10); if(isNaN(parseInt(newValue.substring(1,3)))){ newValue = ''; } field.setValue(newValue); if(InstaMed.isResponsive){ field.setInputValue(newValue); } } }} }, {xtype: 'container', layout: {type: 'hbox', pack: 'start', align: 'bottom'}, flex: 1, cls: 'buttonContainer', scrollable: null, id: 'EditMobilePhoneNumber_container', items: [ {xtype: 'spacer', flex: 1, id: 'EditMobilePhoneNumber_spacer' }, {xtype: 'button', text: 'Cancel', ui: 'secondary', flex: 1, margin: '', ariaRole: 'button', cls: 'secondary noprint', id: 'EditMobilePhoneNumber_button_Cancel', listeners: {tap: function(){ windowCmp = Ext.ComponentQuery.query('[name=EditMobilePhoneWindow]')[0].hide() }} }, {xtype: 'button', text: 'Verify', name: 'Submit', ui: 'secondary', flex: 1, margin: '', ariaRole: 'button', cls: 'secondary noprint', id: 'EditMobilePhoneNumber_button_Verify', listeners: {tap: function() { PerformAction({MobilePhoneNumber2:InstaMed.getValue('MobilePhoneNumber2'),EnableTwoStepVerification:Ext.ComponentQuery.query("[name='EnableTwoStepVerification']")[0].isChecked()}, TextMessageEnrollmentController.updateMobilePhoneNumberFromPopUp,null); }} }] }] }] }, { xtype: 'window', title: 'Inactivity Alert', titleAlign: 'center', itemId: 'NavPageIdleTimeoutForm', flex: 1, defaultFocus: 'button', closable: true, modal: true, draggable: false, constrainHeader: true, constrainTo: 'mainBorderPanel', closeAction: 'hide', name: 'NavPageIdleTimeoutForm', maxWidth: 400, flex: 1, id: 'NavPageIdleTimeoutForm', listeners: {beforeshow: function(){ InstaMed.query("Logout") && InstaMed.query("Logout").setVisible(InstaMed.isLoggedIn); if(!InstaMed.isSSO){ InstaMed.query("IdleTimerNotification") && InstaMed.query("IdleTimerNotification").setHtml && InstaMed.query("IdleTimerNotification").setHtml(InstaMed.isLoggedIn ? "You have been idle for 12 minutes. If you do not select Continue or you make no selection in 3 minutes and 0 seconds, you will be automatically logged out.":"You have been idle for 12 minutes. If you do not select Continue or you make no selection in 3 minutes and 0 seconds, your session will be refreshed and you may lose any unprocessed information."); InstaMed.query("IdleTimerNotification") && InstaMed.query("IdleTimerNotification").setTitle && InstaMed.query("IdleTimerNotification").setTitle(InstaMed.isLoggedIn ? "Automatic Logout":"Inactivity Alert"); } },show: function(cmp) { Ext.each(Ext.DomQuery.select('.x-panel-body', Ext.DomQuery.selectNode('.x-window[id=NavPageIdleTimeoutForm]')), function(p) { Ext.get(p.id).scrollTo('top', 0); }); }}, items: [ { xtype: 'form', preventHeader: true, bodyCls: 'mypanel', api: { submit: IdleTimerController.submit }, defaultSubmitButton: 'btnContinue', name: 'MyFormPanel', ui: 'flat', itemId: 'MyFormPanel', flex: 1, cls: 'flat', scrollable: null, id: 'MyFormPanel_6', items: [ {xtype: 'errorbox', name: 'ValidationSummary', ui: 'ErrorBox', flex: 1, hidden: true, cls: 'ErrorBox', id: 'ValidationSummary_21' }, {xtype: 'label', html: 'You have been idle for 12 minutes. If you do not select Continue or you make no selection in 3 minutes and 0 seconds, your session will be refreshed and you may lose any unprocessed information.', name: 'IdleTimerNotification', flex: 1, id: 'MyFormPanel_IdleTimerNotification' }, {xtype: 'container', flex: 1, scrollable: null, id: 'MyFormPanel_container_11', items: [ {xtype: 'container', layout: {type: 'hbox', pack: 'start', align: 'bottom'}, flex: 1, cls: 'buttonContainer', scrollable: null, id: 'MyFormPanel_container_12', items: [ {xtype: 'spacer', flex: 1, id: 'MyFormPanel_spacer_6' }, {xtype: 'button', text: 'Logout', name: 'Logout', ui: 'secondary', flex: 1, margin: '', hidden: true, ariaRole: 'button', cls: 'secondary noprint', id: 'MyFormPanel_button_Logout', listeners: {tap: function() { LogoutTimer.logOut(); }} }, {xtype: 'button', text: 'Continue', name: 'btnContinue', ui: 'secondary', flex: 1, margin: '', ariaRole: 'button', cls: 'secondary noprint', id: 'MyFormPanel_button_Continue', listeners: {tap: function(cmp, newValue, oldValue, eOpts) {LogoutTimer.resetMainTimer(); myForm = InstaMed.findParentForm(cmp);PerformAction(myForm.getValues(),IdleTimerController.submit,cmp);}} }] }] }] }] }] }});Ext.Loader.setConfig({ enabled: false});Ext.application({ name: 'MyApp', launch: function() { Ext.create('MyApp.view.NavigationView', {fullscreen: true}); }});LogoutTimer && setTimeout(LogoutTimer.reinitiateMainTimer,5000);}