Changes

<input type=hidden name="post_url" value="@system. urlproviderurl@"> <input type=hidden name="codedidupdate_fieldid" value="@codedid@2704332"> <input type=hidden name="update_fieldidss_CaseID" value="99999@parent.opportunityid@"> <BRinput type=hidden name="ss_ServiceID" value="@eventid@"> <table><trinput type=hidden name="ss_CustomerID" value="ID goes here"> <th>Service</th><th><select input type=hidden name=ss_service><option "ss_Source" value=2"10">Transportation </optioninput type=hidden name="newlevelthree" value="1"> </select></thinput type=hidden name="subject" value="providername"> </tr><tr> //Referral Information<th colspaninput type="6" alignhidden name="leftdescription" classvalue="titleText001">Claim Referred By: </th> </trinput type=hidden name="statusid" value="31064"> <tr> <th aligninput type=hidden name="eventtype" value="left46852"> Address </thinput type=hidden name="appid" value="103115"> <td><textarea input type=hidden name=ss_ReferralAddress readonly"referencefield" value="2704345">@parent.client.address@ <BR> </textareadiv style="border:1px solid #1b409b; max-width:700px; min-width:550px;"> </tdtable> <th colspan="6" align="left" class="titleText001"> City Insurance company claim referred By:</th><td><textarea name=ss_ReferralCity readonly>@parent.client.city@</textarea></td> </tr> <tr> <th align="left"> Province Insurer First Name </th> <td><textarea name=ss_ReferralProvince/State ss_ReferralFirstName readonly>@parent.client.provinceReferral Contact First Name@</textarea></td> <th align="left"> Postal Code Insurer Last Name </th> <td><textarea name=ss_ReferralPostalCode ss_ReferralLastName readonly>@parent.client.postalcodeReferral Contact Last Name@</textarea></td> </tr> <tr> <th align="left"> Phone Address </th> <td><textarea name=ss_ReferralPHoneNumber ss_ReferralAddress readonly>@parent.client.phoneaddress@</textarea></td> <th align="left"> Company City </th> <td><textarea name=ss_ReferralCompany ss_ReferralCity readonly>@parent.companyclient.namecity@</textarea></td> </tr> <tr>//File Information <th colspan="6" align="left" class="titleText001">File Information Province </th></tr> <trtd> <th aligntextarea name="left">File Number (Referral)<ss_ReferralProvince/th><td><textarea name=ss_ReferralFileNumber State readonly>@parent.File Numberclient.province@</textarea></td> <th align="left"> Type of FilePostal Code </th> <td><textarea name=ss_ClaimFile ss_ReferralPostalCode readonly>@filetypeparent.combovalueclient.postalcode@</textarea></td> </tr> <tr>//Appointment Details <th align="left">LocationCountry </th> <td><textarea name=ss_AppointmentLocation ss_ReferralCountry readonly>@Location@Canada</textarea></td> </tr> <tr> <th align="left"> Date & Time Phone </th> <td><textarea name=ss_DateandTime ss_ReferralPhoneNumber readonly>@fullstartdateparent.Referral Contact Phone@</textarea></td></tr> <th align="left"> Assessment TypeFax </th> <thtd><textarea name=ss_TypeofAssessment ss_ReferralFaxNumber readonly>@typeparent.client.fax@</textarea></thtd> </tr> <tr>//Claimant Information <th colspan="6" alignalign="left" class="titleText001">Claimant Information Email </th></tr><tr> <th align="left"> Claimant First Name </th> <td><textarea name=ss_ClaimantFirstName ss_ReferralEmail readonly><!--hideifnotfound-->@parent.Claimant First NameReferral Contact Email@</textarea></td> <th align="left"> Claimant Last NameCompany </th> <td><textarea name=ss_ClaimantLastName ss_ReferralCompany readonly>@parent.Claimant Last Nameclient.name@</textarea></td> </tr> <tr> <th aligncolspan="left6"> Address </th> <td><textarea name=ss_ClaimantAddress readonly>@parent.Claimant Address@</textarea></td/tr> <th colspan="6" align="left" class="titleText001"> City Claim / Assessment Information </th><td><textarea name=ss_ClaimantCity readonly>@parent.Claimant City@</textarea></td> </tr> <tr> <th align="left"> Province <File Number (Referral)</th> <td><textarea name=ss_ClaimantProvince/State ss_ReferralFileNumber readonly>@parent.Claimant ProvinceClaim #@</textarea></td><th> </th> </tr> <tr> <th align="left"> Postal Code Arrange Appointment with Claimant/Patient</th> <td><textarea input type='hidden' name=ss_ClaimantPostalCode 'ss_ArrangeAppointmentwithClaimant' value='@arrapp.combovalue@'> <textarea readonly>@parent.Claimant Postal Codearrapp@</textarea></td><tr> <th align="left">Phone Confirm Appointment with Claimant/Patient</th> <td><textarea input type='hidden' name=ss_ClaimantPhone 'ss_ConfirmAppointmentwithClaimant' value='@conapp.combovalue@'> <textarea readonly>@parent.Claimant Phone #conapp@</textarea></td> </tr> //Appointment Details <tr> <th colspan="6" align="left" class>Location</th> <td><textarea name="titleText001"ss_AppointmentLocation readonly>Appointment Details @Location@</thtextarea></trtd> <th align="left"> Appointment location same as home addressDate & Time </th> <thtd><textarea name=ss_picsamehome ss_DateandTime readonly>@picsamehome.combovaluefullstartdate@</textarea></thtd> </tr> <tr> <th align="left"> Appointment Date and TimeDuration (hr) </th> <td><textarea name=ss_DateandTime ss_Duration readonly>@fullstartdateappduration@</textarea></td> <th align="left"> Pickup TimeAssessment Type</th> <tdth><textarea name=ss_PickupTime ss_TypeofAssessment readonly>@apppictimetype@</textarea></tdth> </tr> <tr> <th aligncolspan="left6"> Return Time</th><td><textarea name=ss_apprettime readonly>@appdate@ </textarea></tdtr> <th colspan="6" align="left" class="titleText001"> DurationPickup Details </th> </tr> <tr> <th align="left"> Pickup Time</th> <td><textarea name=ss_Duration ss_PickupTime readonly>@Assessment Durationapppictime@</textarea></td> <th align="left"> Pickup Address</trth> <!--@sslogic('@picsamehome@'!='YesNo')--><tr> <th align="left"> Address</th> <td><textarea name=ss_AppointmentLocation ss_PickupAddress readonly>@Locationpicaddress@</textarea></td> </tr><!-!--@end-->  <//Billing Detailstr> <tr> <th colspan="6" align="left" class="titleText001">Billing DetailsPickup City</th> </tr><tr> <th align!--@sslogic('@picsamehome@'="left"> Billing same as referral</th'No')--> <td><textarea name=ss_Billingsameasreferral ss_PickupCity readonly>@billsamereferral.combovaluepiccity@</textarea></td> </tr!--@end--> <th align="left"> Pickup Postal Code</th> <!--@sslogic('@billsamereferralpicsamehome@'='No')--> <trtd> <th aligntextarea name="left"ss_PickupPostalCode readonly> First Name (Billing)@piczip@</thtextarea></td> <textarea name=ss_BillingFirstName readonly!--@end-->@bilfirstname@ </textareatr> </tdtr> <th align="left"> Last Name (Billing)Pickup Apt. /Suite</th> <td><textarea name=ss_BillingLastName ss_PickupApt/Suite readonly><!--hideifnotfound-->@bilastnamePickup-Apt@</textarea></td></tr><tr> <th align="left"> Company (Billing)Pickup Buzzer Code</th> <td><textarea name=ss_BillingCompany ss_PickupBuzzer readonly><!--hideifnotfound-->@bilcompanyPickup-Buzzer@</textarea></td> </tr> <tr> <th align="left"> Address (Billing)Pickup Province/State</th> <td><textarea !--@sslogic('@picsamehome@'='No')--> <td><textarea name=ss_BillingAddress ss_PickupProvince/state readonly>@biladdresspicprovince@</textarea></td> </tr!--@end--> <tr> <th th align="left"> City (Billing)Pickup Phone</th> <!--@sslogic('@picsamehome@'='No')--> <td><textarea name=ss_BillingCity ss_PickupPhone readonly>@bilcity<!--hideifnotfound-->@Pickup-Phone@</textarea></td> <!--@end--> </tr> <tr> <th align="left"> Province CodeDoes Claimant Require a Wheelchair Accessible Vehicle?</Zip (Billing)</thth> <td><textarea input type='hidden' name=ss_BillingProvince/State 'ss_WheelchairVehicle' value='@intwheel.combovalue@'> <textarea readonly>@bilprovinceintwheel@</textarea></td> </tr><tr> <th th align="left"> Postal Code/Zip Does Claimant Require Special Needs (Billinge.g. Assistance)?</th> <td><textarea input type='hidden' name=ss_BillingPostalCode readonly>'ss_SpecialNeeds' value='@bilzipintassistance.combovalue@'> <textarea readonly>@intassistance@</textarea></td> <!--@end--/tr> //Appointment Confirmation <tr> <th colspan="6" align="left> </th> </tr> <th colspan="6" align="left" class="titleText001">Appointment ConfirmationClaimant Information </th> </tr> <tr> <th align="left"> Fax confirmation of appointmentClaimant First Name </th> <thtd><textarea name=ss_Faxconfirmationofappointment ss_ClaimantFirstName readonly>@faxconfparent.combovalueClaimant First Name@</textarea></th><th> </thtd> <th align="left"> Phone ConfirmationClaimant Last Name </th> <thtd><textarea name=ss_Phoneconfirmationofappointment ss_ClaimantLastName readonly>@phoneconfparent.combovalueClaimant Last Name@</textarea></thtd> </tr> <tr> <th align="left"> Email confirmation of web referralAddress </th> <td><textarea name=ss_Emailconfirmationofappointment ss_ClaimantAddress readonly><!--hideifnotfound-->@emailconfparent.combovalueClaimant Address@</textarea></td> </trth align="left">City </tableth> <td><textarea name=ss_ClaimantCity readonly><!--hideifnotfound-->@parent.Claimant City@</textarea></td> </tr> <tr> <th align="left"> Apt. /Suite </th> <td><textarea name=ss_ClaimantApt/Suite readonly><!--hideifnotfound-->@parent.Claimant Apt@</textarea></td> <th align="left"> Buzzer Code</th> <td><textarea name=ss_ClaimantBuzzer readonly><!--hideifnotfound-->@parent.Claimant Buzzer@</textarea></td> </tr> <tr> <th align="left"> Province </th> <td><textarea name=ss_ClaimantProvince readonly><!--hideifnotfound-->@parent.Claimant Province@</textarea></td> <th align="left"> Postal Code </th> <td><textarea name=ss_ClaimantPostalCode readonly><!--hideifnotfound-->@parent.Claimant Postal Code@</textarea></td> </tr> <tr> <th align="left"> Country </th> <td><textarea name=ss_ClaimantCountry readonly><!--hideifnotfound-->Canada</textarea></td> <th align="left"> P.O Box </th> <td><textarea name=ss_ClaimantP.O.Box readonly><!--hideifnotfound-->@parent.Claimant P.O Box@</textarea></td> </tr> <tr> <th align="left">Phone </th> <td><textarea name=ss_ClaimantPhone readonly><!--hideifnotfound-->@parent.Claimant Phone #@</textarea></td> <th align="left">Fax Number </th> <td><textarea name=ss_ClaimantFax readonly><!--hideifnotfound-->@parent.Claimant Fax #@</textarea></td> </tr> <tr> <th align="left">Policy #</th> <td><textarea name=ss_ClaimantPolicyNumber readonly>@parent.Policy #@</textarea></td> <th align="left"> Claim #</th> <td><textarea name=ss_ClaimFile readonly>@parent.Claim #@</textarea></td> </tr> <tr> <th align="left"> Date of Loss </th> <td><textarea name=ss_DateofLoss readonly>@parent.Date of Loss@</textarea></td> </tr> <tr> <th colspan="6" align="left" class="titleText001">Billing Details</th> </tr> <tr> <th align="left"> Billing Same as Insurer / Referral company</th> <td><input type='hidden' name='ss_Billingsameasreferral' value='@billsamereferral.combovalue@'> <textarea readonly>@billsamereferral@</textarea></td> </tr> <!--@sslogic('@billsamereferral@'='No')--> <tr> <th align="left"> First Name (Billing)</th> <td><textarea name=ss_BillingFirstName readonly>@bilfirstname@</textarea></td> <th align="left"> Last Name (Billing)</th> <td><textarea name=ss_BillingLastName readonly>@bilastname@</textarea></td> </tr> <tr> <th align="left"> Company (Billing)</th> <td><textarea name=ss_BillingCompany readonly>@bilcompany@</textarea></td> <th align="left"> Address (Billing)</th> <td><textarea name=ss_BillingAddress readonly>@biladdress@</textarea></td> </tr> <tr> <th align="left"> City (Billing)</th> <td><textarea name=ss_BillingCity readonly>@bilcity@</textarea></td> <th align="left"> Province Code/Zip (Billing)</th> <td><textarea name=ss_BillingProvince/state readonly>@bilprovince@</textarea></td> </tr> <tr> <th align="left"> Postal Code/Zip (Billing)</th> <td><textarea name=ss_BillingPostalCode readonly>@bilzip@</textarea></td> <th align="left"> P.O.Box(Billing) </th> <td><textarea name=ss_BillingP.O.Box readonly>@bilpobox@</textarea></td> </tr> <tr> <th align="left"> Phone (Billing)</th> <td><textarea name=ss_BillingPhone readonly>@bilphone@</textarea></td> <th align="left"> Fax(Billing)</th> <td><textarea name=ss_BillingFax readonly>@bilfax@</textarea></td> </tr> <tr> <th align="left"> Email</th> <td><textarea name=ss_BillingEmail readonly>@bilemail@</textarea></td> </tr> <!--@end--> <br> <tr> <th colspan="6"> </th> </tr> <tr> <th colspan="6" align="left" class="titleText001">Appointment Confirmation</th> </tr> <tr> <th align="left"> Fax confirmation of appointment</th> <td><input type='hidden' name='ss_Faxconfirmationofappointment' value='@faxconf.combovalue@'> <textarea readonly>@faxconf@</textarea></td> <th align="left"> Phone Confirmation</th> <td><input type='hidden' name='ss_Phoneconfirmationofappointment' value='@phoneconf.combovalue@'> <textarea readonly>@phoneconf@</textarea></td> </tr> <tr> <th align="left"> Email confirmation of appointment</th> <td><input type='hidden' name='ss_Emailconfirmationofappointment' value='@emailconf.combovalue@'> <textarea readonly>@emailconf@</textarea></td> <th align="left"> Notes</th> <th><textarea name=ss_Notes readonly><!--hideifnotfound-->@Service Notes@</textarea> </th> </tr> </table> </div>

</body>