@extends('admin.layouts.master')
@section('content')
    <style>
        #upload {
            display: none;
        }

        .card .card-header {
            background: #fff;
        }

        h1,
        h2,
        h3,
        h4,
        h5,
        h6 {
            color: white;
        }

        label {
            color: white !important;
        }

        .card {

            box-shadow: 0px 10px 20px 0px !important;

        }

    </style>
    <style>
        .card .card-header {
            background: #fff;
        }

        h1,
        h2,
        h3,
        h4,
        h5,
        h6 {
            color: white;
        }

        label {
            color: white !important;
        }

        .card {
            background: transparent;
            box-shadow: 0px 10px 20px 0px !important;
        }

        .text-small {
            color: white;
        }

        a {
            color: #fff
        }

        /* Chrome, Safari, Edge, Opera */
        input::-webkit-outer-spin-button,
        input::-webkit-inner-spin-button {
            -webkit-appearance: none;
            margin: 0;
        }

        /* Firefox */
        input[type=number] {
            -moz-appearance: textfield;
        }

        #upload {
            display: none;
        }



        li {
            color: white;
        }

    </style>
    <section class="section">
        <div class="container mt-5">
            <div class="row">
                <div class="col-12 ">
                    <div class="card card-primary">
                        <div class="card-header">
                            <img src="{{ asset('user/assets/img/logo.png') }}" class="img-responsive mx-auto">
                        </div>
                        <div class="card-body">
                            <div class="text-center">
                                <h5>Facility Provider NPI</h5>
                            </div>

                            <form action="{{route('admin.fpn.add.process')}}"
                                method="POST">
                                @csrf
                            <div class="row">
                                <div class="form-group col-md-6">
                                    <label for="org">Account</label>
                                    <select name="org" id="" class="form-control">
                                        @foreach ($organizations as $organization)
                                            <option value="{{$organization->id}}" {{$organization->id==old('org')?'checked':''}}>{{$organization->name}}</option>
                                        @endforeach
                                    </select>
                                    @if ($errors->has('org'))
                                        <div class="text-danger">{{ $errors->first('org') }}</div>
                                    @endif
                                </div>
                           
                            
                                <div class="form-group col-md-6">
                                    <label for="facility">Facility</label>
                                    <input id="facility" type="text" class="form-control" name="facility"
                                        value="{{old('facility', '' )}}" required>
                                    @if ($errors->has('facility'))
                                        <div class="text-danger">{{ $errors->first('facility') }}</div>
                                    @endif
                                </div>
                            </div>
                            <div class="row">
                                <div class="form-group col-md-6">
                                    <label for="provider">Provider</label>
                                    <input id="provider" type="text" class="form-control" name="provider"
                                    value="{{old('provider', '')}}">
                                    @if ($errors->has('provider'))
                                        <div class="text-danger">{{ $errors->first('provider') }}</div>
                                    @endif
                                </div>
                            
                            
                                <div class="form-group col-md-6">
                                    <label for="npi">NPI</label>
                                    <input id="npi" type="number" class="form-control" name="npi"
                                    value="{{old('npi', '')}}">
                                    @if ($errors->has('npi'))
                                        <div class="text-danger">{{ $errors->first('npi') }}</div>
                                    @endif
                                </div>
                            </div>
                                <div class="form-group">
                                    <button type="submit" class="btn btn-primary btn-lg btn-block">
                                        Add
                                    </button>
                                </div>
                            </form>
                        </div>
                    </div>
                </div>
            </div>
        </div>
    </section>
@endsection
<script src="https://code.jquery.com/jquery-3.6.0.js" integrity="sha256-H+K7U5CnXl1h5ywQfKtSj8PCmoN9aaq30gDh27Xc0jk=" crossorigin="anonymous"></script>
@push('scripts')
@endpush