{% 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; margin-top:35px; padding-right: 40px;">Fax Cover</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 #479085; 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 #479085; 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: 40%;">Pages</td>
						{#<td style="width: 60%;">: {{ patientLetter.page != '' or patientLetter.page is not null ? patientLetter.page : '2' }}</td>#}
						<td style="width: 60%;">: {{ 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; border:1px solid #479085; 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: 600px; margin-top:11px; border: 1px solid #479085; box-sizing: border-box; padding:20px; float: left;">
		{% if patientLetter.faxCoverCustomBody != '' or patientLetter.faxCoverCustomBody is not null %}
			{{ faxCoverCustomBody|raw }}
		{% endif %}
	</div>
</div>
</body>
</html>