{% extends 'base.html.twig' %}

{% block title %}Insurance — Patient Insurance Tracking{% endblock %}

{% block content %}
	<div class="kt-container kt-grid__item kt-grid__item--fluid">
		<div class="kt-portlet kt-portlet--mobile">
			<div class="kt-portlet__head kt-portlet__head--lg">
				<div class="kt-portlet__head-label">
					<h3 class="kt-portlet__head-title">Insurance &mdash; Patient Insurance Tracking</h3>
				</div>

				<div class="kt-portlet__head-toolbar">
					<a href="{{ path(back_url) }}" class="btn btn-clean btn-icon-sm"><i class="la la-long-arrow-left"></i>Back</a>
				</div>
			</div> 

			<div class="kt-portlet__body table-responsive">
				<div class="row p-2">
					<div class="col-sm-3">
						<input type="text" placeholder="From date" class="form-control">
					</div>
					<div class="col-sm-3">
						<input type="text" placeholder="To date" class="form-control">
					</div>
					<div class="col-sm-2">
						<select class="form-control">
							<option>All</option>
							<option>State</option>
							<option>District</option>
							<option>Sub District</option>
							<option>Family Head ID/Family Member ID</option>
							<option>ABHA No.</option>
							<option>Unique ID No.</option>
							<option>ADHAR No.</option>
							<option>Name</option>
							<option>Age</option>
							<option>M/F</option>
							<option>Address</option>
							<option>Mobile Number</option>
							<option>Registration</option>
							<option>Pre authentication</option>
							<option>Reports Submission</option>
							<option>ClaimRequest</option>
							<option>Discharge</option>
							<option>Initiated for Insurance Claim</option>
						</select>
					</div>
					<div class="col-sm-2">
						<input type="text" placeholder="keyword" class="form-control">
					</div>
					<div class="col-sm-2">
						<button type="button" class="btn btn-brand btn-bold btn-sm" role="button">Submit</button>
						<button type="button" class="btn btn-brand btn-bold btn-sm" role="button">Reset</button>
					</div>
				</div>
				<table class="table table-striped table-bordered">
					<thead>
					<tr>
						<th>Sr.</th>
						<th>State/District/SubDistrict</th>
						<th>Insurance Scheme</th>
						<th>Package</th>
						<th>MRD No</th>
						<th>Photo</th>
						<th>Patient Name</th>
						<th>ABHA No.</th>
						<th>Unique ID No.</th>
						<th>ADHAR No.</th>
						<th>Name</th>
						<th>Age</th>
						<th>M/F</th>
						<th>Address</th>
						<th>Mobile Number</th>
						<th>E-Mail Address</th>
						<th>Emergency Contact 1 </th>
						<th>Name</th>
						<th>Contact No </th>
						<th>Relation</th>
						<th>Emergency Contact 2 </th>
						<th>Relation</th>
						<th>Schame type</th>
						<th>Select and Navigate</th>
						<th>History of Hospital Visited</th>
						<th>Popup</th>
						<th>Balance of Claim amount</th>
					</tr>
					</thead>

					<tbody>
					<tr>
						<td>1</td>
						<td>GUJ/AMD/AMD</td>
						<td>LIC General inc.</td>
						<td>XYZ</td>
						<td>abc123</td>
						<td>Images</td>
						<td>ABC</td>
						<td>RKTPL152MKLO1230/125630</td>
						<td>AI123</td>
						<td>XXXX-XXXX-2363</td>
						<td>Loren inspum</td>
						<td>23</td>
						<td>Male</td>
						<td>Loren inspum</td>
						<td>1231231230</td>
						<td>xyz@xyz.com</td>
						<td>1231231230</td>
						<td>9639639630</td>
						<td>XYZ</td>
						<td>1231231230</td>
						<td>XYZ</td>
						<td>BPL</td>
						<td>Yes</td>
						<td>Yes</td>
						<td>Yes</td>
						<td>Yes</td>
						<td>100000</td>
					</tr>

					<tr>
						<td>2</td>
						<td>GUJ/JND/KSD</td>
						<td>Tata AIG</td>
						<td>XYZ</td>
						<td>abc123</td>
						<td>Images</td>
						<td>ABC</td>
						<td>RKTPL152MKLO1230/125630</td>
						<td>AI123</td>
						<td>XXXX-XXXX-2363</td>
						<td>Loren inspum</td>
						<td>23</td>
						<td>Male</td>
						<td>Loren inspum</td>
						<td>1231231230</td>
						<td>xyz@xyz.com</td>
						<td>1231231230</td>
						<td>9639639630</td>
						<td>XYZ</td>
						<td>1231231230</td>
						<td>XYZ</td>
						<td>PMJAY</td>
						<td>Yes</td>
						<td>Yes</td>
						<td>Yes</td>
						<td>Yes</td>
						<td>100000</td>
					</tr>

					<tr>
						<td>3</td>
						<td>GUJ/AMD/AMD</td>
						<td>HDFC ARGO</td>
						<td>XYZ</td>
						<td>abc123</td>
						<td>Images</td>
						<td>ABC</td>
						<td>RKTPL152MKLO1230/125630</td>
						<td>AI123</td>
						<td>XXXX-XXXX-2363</td>
						<td>Loren inspum</td>
						<td>23</td>
						<td>Male</td>
						<td>Loren inspum</td>
						<td>1231231230</td>
						<td>xyz@xyz.com</td>
						<td>1231231230</td>
						<td>9639639630</td>
						<td>XYZ</td>
						<td>1231231230</td>
						<td>XYZ</td>
						<td>Chiranjeevi</td>
						<td>Yes</td>
						<td>Yes</td>
						<td>Yes</td>
						<td>Yes</td>
						<td>100000</td>
					</tr>

					</tbody>
				</table>
			</div>
		</div>
	</div>
{% endblock %}