{% set absUrl = app.request.getSchemeAndHttpHost() ~ app.request.baseUrl|replace({'/app_dev.php': ''}) %}
{% set userData = app.session.get('userData') %}
<!DOCTYPE html>
<html class="no-js" lang="en" dir="ltr">
<head>
	<meta charset="utf-8">
	<meta http-equiv="x-ua-compatible" content="ie=edge">
	<meta name="viewport" content="width=device-width, initial-scale=1.0">
	<title>DSRC Letter</title>
</head>
<body style="font-family:'Arial'; font-size:18px;">
{% if patientLetter.patientReferringProvider %}
    {% set rp = patientLetter.patientReferringProvider.referringProvider %}
    {% set patient = patientLetter.patient %}
    {% set receiverFullName = patientLetter.patientReferringProvider.referringProvider.honorific ~ ' ' ~ patientLetter.patientReferringProvider.referringProvider.fullName|title %}
    {% if patientLetter.patientReferringProvider.referringProvider.phoneNo is null or patientLetter.patientReferringProvider.referringProvider.phoneNo == '' %}
        {% set receiverPhone = '' %}
        {% for prhf in patient.patientReferringHealthFacilities %}
            {% for rhfp in rp.referringHealthFacilityProviders %}
                {% if prhf.referringHealthFacility.id == rhfp.referringHealthFacility.id %}
                    {% set receiverPhone = prhf.referringHealthFacility.phoneNo %}
                {% endif %}
            {% endfor %}
        {% endfor %}
    {% else %}
        {% set receiverPhone = patientLetter.patientReferringProvider.referringProvider.phoneNo %}
    {% endif %}
    {% if patientLetter.patientReferringProvider.referringProvider.faxNo is null or patientLetter.patientReferringProvider.referringProvider.faxNo == '' %}
        {% set receiverFax = '' %}
        {% for prhf in patient.patientReferringHealthFacilities %}
            {% for rhfp in rp.referringHealthFacilityProviders %}
                {% if prhf.referringHealthFacility.id == rhfp.referringHealthFacility.id %}
                    {% set receiverFax = prhf.referringHealthFacility.faxNo %}
                {% endif %}
            {% endfor %}
        {% endfor %}
    {% else %}
        {% set receiverFax = patientLetter.patientReferringProvider.referringProvider.faxNo %}
    {% endif %}
{% endif %}
{% if patientLetter.patientReferringHealthFacility %}
    {% set receiverFullName = patientLetter.patientReferringHealthFacility.referringHealthFacility.description %}
    {% set receiverPhone = patientLetter.patientReferringHealthFacility.referringHealthFacility.phoneNo is null ? patientLetter.patientReferringHealthFacility.referringHealthFacility.phoneNoTwo : patientLetter.patientReferringHealthFacility.referringHealthFacility.phoneNo %}
    {% set receiverFax = patientLetter.patientReferringHealthFacility.referringHealthFacility.faxNo is null ? patientLetter.patientReferringHealthFacility.referringHealthFacility.faxNoTwo : patientLetter.patientReferringHealthFacility.referringHealthFacility.faxNo %}
{% endif %}
{% if patientLetter.patientInsurance %}
    {% set receiverFullName = patientLetter.patientInsurance.insurance.description %}
    {% set receiverPhone = patientLetter.patientInsurance.insurance.phoneNo is null ? patientLetter.patientInsurance.insurance.phoneNoTwo : patientLetter.patientInsurance.insurance.phoneNo %}
    {% set receiverFax = patientLetter.patientInsurance.insurance.faxNo is null ? patientLetter.patientInsurance.insurance.faxNoTwo : patientLetter.patientInsurance.insurance.faxNo %}
{% endif %}
{% set patientFullName = patientLetter.patient.fullName %}
{% set patientFirstName = patientLetter.patient.firstName %}
{% set patientLastName = patientLetter.patient.lastName %}
{% set patient = patientLetter.patient %}

{% set faxCoverCustomBody = patientLetter.faxCoverCustomBody|replace({
		'{{RECEVIER-FULLNAME}}' :  receiverFullName,
		'{{PATIENT-FULLNAME}}' : patientFullName,
		'{{PATIENT-FIRSTNAME}}' :  patientLetter.patient.firstName,
		'{{PATIENT-LASTNAME}}' :  patientLetter.patient.lastName,
		'{{USERDATA-FULLNAME}}' : userData.fullName,
		'{{DATE-TODAY}}' : 'now'|date('m/d/Y'),
		'{{DATE-CREATED}}' : patientLetter.createdAt|date('m/d/Y'),
		'{{PATIENT-PHN}}' : patientLetter.patient.personalHealthNo|default(''),
		'{{PATIENT-DOB}}' : patientLetter.patient.birthDate|date('m/d/Y'),
		'{{PATIENT-GENDER}}' : patientLetter.patient.gender == 'Male' ? 'he' : 'she',
		'{{PATIENT-GENDER2}}' : patientLetter.patient.gender == 'Male' ? 'him' : 'her',
		'{{PATIENT-GENDER3}}' : patientLetter.patient.gender == 'Male' ? 'his' : 'her',
		'{{PATIENT-GENDER4}}' : patientLetter.patient.gender == 'Male' ? 'He' : 'She'
	})
%}

<div style="width:768px; position: relative; padding:0px; margin: 0 auto; box-shadow:3px 1px 10px 1px;">
	{#<h3 style="text-align: center;  border:1px solid #6F71B3; margin-left: 60px; margin-right: 60px; box-sizing: border-box; margin-top:55px; padding-right: 40px;">{{ page_title|default('FAX FORM') }}</h3>#}
	<div style="margin-top:12px; height: 150px; width:100%;">
		<div style="width: 50%; height: 230px; float: left; box-sizing: border-box; padding-right: 5px;">
			<p style="margin-bottom: 5px;">TO:</p>
			<div style="width: 100%; height: 100%; border:1px solid #6F71B3; box-sizing: border-box; padding:10px;">
				<table>
					<tr>
						<td style="width: 15%;">Attention</td>
						<td style="width: 2%;">:</td>
						<td style="width: 83%;">{{ patientLetter.attention != '' or patientLetter.attention is not null ? patientLetter.attention : receiverFullName }}</td>
					</tr>
					<tr>
						<td style="width: 15%;">Re</td>
						<td style="width: 2%;">:</td>
						<td style="width: 83%;">{{ patientLetter.recipient != '' or patientLetter.recipient is not null ? patientLetter.recipient : patientFullName }}</td>
					</tr>
					<tr>
						<td style="width: 15%;">Date</td>
						<td style="width: 2%;">:</td>
						<td style="width: 83%;">{{ patientLetter.date != '' or patientLetter.date != null ? patientLetter.date|date('F j, Y') : patientLetter.createdAt|date('F j, Y') }}</td>
					</tr>
					<tr>
						<td style="width: 15%;">Phone</td>
						<td style="width: 2%;">:</td>
						<td style="width: 83%;">{{ patientLetter.phoneNo != '' or patientLetter.phoneNo is not null ? patientLetter.phoneNo : receiverPhone }}</td>
					</tr>
					<tr>
						<td style="width: 15%;">Fax</td>
						<td style="width: 2%;">:</td>
						<td style="width: 83%;">{{ patientLetter.faxNo != '' or patientLetter.faxNo is not null ? patientLetter.faxNo : receiverFax }}</td>
					</tr>
				</table>
			</div>
		</div>
		<div style="width: 50%; height: 150px; float: right; box-sizing: border-box; padding-left: 5px;">
			<p style="margin-bottom: 5px;">FROM:</p>
			<div style="width: 100%; height: 100%; border:1px solid #6F71B3; box-sizing: border-box; padding:10px;">
				<table>
					<tr>
						<td style="width: 40%;">Name</td>
						<td style="width: 60%;">: {{ patientLetter.name != '' or patientLetter.name is not null ? patientLetter.name : userData.fullName }}</td>
					</tr>
					<tr>
						<td style="width: 45%;"># of Pages (incl. cover)</td>
						{#<td style="width: 60%;">: {{ patientLetter.page != '' or patientLetter.page is not null ? patientLetter.page : '2' }}</td>#}
						<td style="width: 55%;">: {{ patientLetter.estimatedPage }}</td>
					</tr>
					<tr>
						<td style="width: 40%;">CC</td>
						{#<td style="width: 60%;">: {{ patientLetter.carbonCopy != '' or patientLetter.carbonCopy is not null ? patientLetter.carbonCopy : '_______' }}</td>#}
						<td style="width: 60%;">: {{ patientLetter.getPatientLetterCcDescAsString }}</td>
					</tr>
				</table>
			</div>
		</div>
	</div>
	{% set faxCoverSelection = patientLetter.faxCoverSelection|split(',') %}
	<div style="width:49.5%; height: 70px; margin-top: 51px; box-sizing: border-box; padding:15px; float: right">
		<div style="width: 100%; height: 100%;">
			<input type="checkbox" id="urgent" style="height: 18px; width:18px;" {{ 1 in faxCoverSelection ? 'checked' : '' }}><label style="font-size: 11px; margin-right:40px;"><strong>Urgent</strong></label>
			<input type="checkbox" id="urgent" style="height: 18px; width:18px;" {{ 2 in faxCoverSelection ? 'checked' : '' }}><label style="font-size: 11px; margin-right:40px;"><strong>For Review</strong></label>
			{#<input type="checkbox" id="urgent" style="height: 18px; width:18px;" {{ 3 in faxCoverSelection ? 'checked' : '' }}><label style="font-size: 18px; margin-right:40px;"><strong>Please Comment</strong></label>#}
			<input type="checkbox" id="urgent" style="height: 18px; width:18px;" {{ 4 in faxCoverSelection ? 'checked' : '' }}><label style="font-size: 11px; margin-right:40px;"><strong>Please Reply</strong></label>
		</div>
	</div>
	<div style="width: 100%; height: 500px; margin-top:11px; border: 1px solid #6F71B3; box-sizing: border-box; padding:20px; float: left;">
		{% if patientLetter.faxCoverCustomBody != '' or patientLetter.faxCoverCustomBody is not null %}
			{{ faxCoverCustomBody|raw }}
		{% endif %}
	</div>
	<div style="width: 100%; height: auto; float: left;">
		<p style="font-size: 13px;">This Facsimile transmission contains information which is confidential and/or privileged. This information is intended for use only by the addressee indicated above. If you are not the intended recipient, please be advised that any disclosure, copying, distribution or use of the contents of this information is stricly prohibited, and that any misdirected or improperly received information must be returned to this company immediately. Your cooperation in phoning us of erroneous receipt is requested.</p>
	</div>
</div>
</body>
</html>