{!! Form::text('doc_no')->value('INSR-'.$insurance_despatch_tracker->id)->name('doc_no')->label(trans('insurance_despatch_tracker::insurance_despatch_tracker.label.doc_no'))->placeholder(trans('insurance_despatch_tracker::insurance_despatch_tracker.placeholder.doc_no'))->disabled()->addGroupClass('form-group-sm') !!} {!! Form::date('date')->addClass('datepick') ->value($insurance_despatch_tracker->date) ->label(trans('insurance_despatch_tracker::insurance_despatch_tracker.label.date'))->disabled()->addGroupClass('form-group-sm') !!} {!! Form::text('uhid')->label(trans('insurance_despatch_tracker::insurance_despatch_tracker.label.uhid'))->placeholder(trans('insurance_despatch_tracker::insurance_despatch_tracker.placeholder.uhid'))->disabled($disableFields)->addGroupClass('form-group-sm')->required() !!} {!! Form::text('patient_name')->label(trans('insurance_despatch_tracker::insurance_despatch_tracker.label.patient_name'))->placeholder(trans('insurance_despatch_tracker::insurance_despatch_tracker.placeholder.patient_name'))->disabled($disableFields)->addGroupClass('form-group-sm')->required() !!} {!! Form::text('ip_op_no')->label(trans('insurance_despatch_tracker::insurance_despatch_tracker.label.ip_op_no'))->placeholder(trans('insurance_despatch_tracker::insurance_despatch_tracker.placeholder.ip_op_no'))->disabled($disableFields)->addGroupClass('form-group-sm')->required() !!} {!! Form::text('invoice_ref_no') ->label(trans('insurance_despatch_tracker::insurance_despatch_tracker.label.invoice_ref_no')) ->placeholder(trans('insurance_despatch_tracker::insurance_despatch_tracker.placeholder.invoice_ref_no'))->disabled($disableFields)->addGroupClass('form-group-sm')->required() !!} {!! Form::select('status')->options($status)->label(trans('insurance_despatch_tracker::insurance_despatch_tracker.label.status'))->disabled($disableFields)->addGroupClass('form-group-sm')->required() !!} {!! Form::textarea('remarks')->label(trans('insurance_despatch_tracker::insurance_despatch_tracker.label.remarks'))->placeholder(trans('insurance_despatch_tracker::insurance_despatch_tracker.placeholder.remarks'))->disabled($disableFields)->addGroupClass('form-group-sm')->required() !!}

@if (user('admin.web')->hasPermission('insurance_despatch_tracker.insurance_despatch_tracker.insurance_review') || user('admin.web')->hasPermission('insurance_despatch_tracker.insurance_despatch_tracker.insurance_file_prepare') || user('admin.web')->hasPermission('insurance_despatch_tracker.insurance_despatch_tracker.insurance_despatch')) {!! Form::textarea('review_remarks')->label(trans('insurance_despatch_tracker::insurance_despatch_tracker.label.review_remarks'))->placeholder(trans('insurance_despatch_tracker::insurance_despatch_tracker.placeholder.review_remarks'))->disabled($disableFields)->addGroupClass('form-group-sm')->required() !!} @endif @if (user('admin.web')->hasPermission('insurance_despatch_tracker.insurance_despatch_tracker.insurance_file_prepare') || user('admin.web')->hasPermission('insurance_despatch_tracker.insurance_despatch_tracker.insurance_despatch')) {!! Form::textarea('file_prepared_remarks')->label(trans('insurance_despatch_tracker::insurance_despatch_tracker.label.file_prepared_remarks'))->placeholder(trans('insurance_despatch_tracker::insurance_despatch_tracker.placeholder.file_prepared_remarks'))->disabled($disableFields)->addGroupClass('form-group-sm')->required() !!} @endif @if (user('admin.web')->hasPermission('insurance_despatch_tracker.insurance_despatch_tracker.insurance_despatch')) {!! Form::textarea('rcm_remarks')->label(trans('insurance_despatch_tracker::insurance_despatch_tracker.label.rcm_remarks'))->placeholder(trans('insurance_despatch_tracker::insurance_despatch_tracker.placeholder.rcm_remarks'))->disabled($disableFields)->addGroupClass('form-group-sm')->required() !!} {!! Form::text('pa_tpa_id')->label(trans('insurance_despatch_tracker::insurance_despatch_tracker.label.pa_tpa_id'))->placeholder(trans('insurance_despatch_tracker::insurance_despatch_tracker.placeholder.pa_tpa_id'))->disabled($disableFields)->addGroupClass('form-group-sm')->required() !!} {!! Form::text('mobile_no')->label(trans('insurance_despatch_tracker::insurance_despatch_tracker.label.mobile_no'))->placeholder(trans('insurance_despatch_tracker::insurance_despatch_tracker.placeholder.mobile_no'))->disabled($disableFields)->addGroupClass('form-group-sm')->required() !!} {!! Form::text('corp_individual')->label(trans('insurance_despatch_tracker::insurance_despatch_tracker.label.corp_individual'))->placeholder(trans('insurance_despatch_tracker::insurance_despatch_tracker.placeholder.corp_individual'))->disabled($disableFields)->addGroupClass('form-group-sm')->required() !!}

{!! Form::text('insurance_company_name')->label(trans('insurance_despatch_tracker::insurance_despatch_tracker.label.insurance_company_name'))->placeholder(trans('insurance_despatch_tracker::insurance_despatch_tracker.placeholder.insurance_company_name'))->disabled($disableFields)->addGroupClass('form-group-sm')->required() !!} {!! Form::text('policy_no')->label(trans('insurance_despatch_tracker::insurance_despatch_tracker.label.policy_no'))->placeholder(trans('insurance_despatch_tracker::insurance_despatch_tracker.placeholder.policy_no'))->disabled($disableFields)->addGroupClass('form-group-sm')->required() !!} {!! Form::text('surgery_name')->label(trans('insurance_despatch_tracker::insurance_despatch_tracker.label.surgery_name'))->placeholder(trans('insurance_despatch_tracker::insurance_despatch_tracker.placeholder.surgery_name'))->disabled($disableFields)->addGroupClass('form-group-sm')->required() !!} {!! Form::text('bills_sent_date')->addclass('datepick_bills')->label(trans('insurance_despatch_tracker::insurance_despatch_tracker.label.bills_sent_date'))->placeholder(trans('insurance_despatch_tracker::insurance_despatch_tracker.placeholder.bills_sent_date'))->disabled($disableFields)->addGroupClass('form-group-sm')->required() !!} {!! Form::text('bill_received_date')->addclass('datepick_bills')->label(trans('insurance_despatch_tracker::insurance_despatch_tracker.label.bill_received_date'))->placeholder(trans('insurance_despatch_tracker::insurance_despatch_tracker.placeholder.bill_received_date'))->disabled($disableFields)->addGroupClass('form-group-sm')->required() !!} {!! Form::textarea('package_details')->label(trans('insurance_despatch_tracker::insurance_despatch_tracker.label.package_details'))->placeholder(trans('insurance_despatch_tracker::insurance_despatch_tracker.placeholder.package_details'))->disabled($disableFields)->addGroupClass('form-group-sm')->required() !!} {!! Form::text('final_pa_amount')->label(trans('insurance_despatch_tracker::insurance_despatch_tracker.label.final_pa_amount'))->placeholder(trans('insurance_despatch_tracker::insurance_despatch_tracker.placeholder.final_pa_amount'))->disabled($disableFields)->addGroupClass('form-group-sm')->required() !!} {!! Form::text('non_medical_amount')->label(trans('insurance_despatch_tracker::insurance_despatch_tracker.label.non_medical_amount'))->placeholder(trans('insurance_despatch_tracker::insurance_despatch_tracker.placeholder.non_medical_amount'))->disabled($disableFields)->addGroupClass('form-group-sm')->required() !!}