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www.inpedsupport.ircmhealth.com Open in urlscan Pro
192.254.185.42  Public Scan

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URL: https://www.inpedsupport.ircmhealth.com/
Submission: On November 15 via api from US — Scanned from DE

Form analysis 1 forms found in the DOM

Name: EditView — POST https://www.inpedsupport.ircmhealth.com/index.php/dashboard/save_ticket

<form action="https://www.inpedsupport.ircmhealth.com/index.php/dashboard/save_ticket" method="POST" name="EditView" id="EditView" enctype="multipart/form-data">
  <div class="edit-view-pagination-mobile-container">
    <div class="edit-view-pagination edit-view-mobile-pagination">
    </div>
  </div>
  <!--                <table width="100%" cellpadding="0" cellspacing="0" border="0" class="dcQuickEdit">
                    <tbody>
                        <tr>
                            <td class="buttons">
                                 to be used for id for buttons with custom code in def files
                                <div class="buttons">
                                    <input title="Save" accesskey="a" class="button primary" type="submit" name="button" value="Save" id="SAVE">
                                </div>
                            </td>
                            <td align="right" class="edit-view-pagination-desktop-container">
                                <div class="edit-view-pagination edit-view-pagination-desktop">
                                </div>
                            </td>
                        </tr>
                    </tbody>
                </table>-->
  <div id="EditView_tabs">
    <ul class="nav nav-tabs">
    </ul>
    <div class="clearfix"></div>
    <div class="tab-content" style="padding: 0; border: 0;">
      <div class="tab-pane panel-collapse">test</div>
    </div>
    <span style="color: green; font-size: 18px;"></span>
    <span style="color: red; font-size: 18px;"></span>
    <div class="panel-content">
      <div>&nbsp;</div>
      <div class="panel panel-default">
        <div class="panel-heading ">
          <a class="collapsed" role="button" data-toggle="collapse" aria-expanded="false">
                                    <div class="col-xs-10 col-sm-11 col-md-11">
                                        BASIC
                                    </div>
                                </a>
        </div>
        <div class="panel-body panel-collapse collapse in" id="detailpanel_-1">
          <div class="tab-content">
            <!-- tab_panel_content.tpl -->
            <div class="row edit-view-row">
              <div class="col-xs-12 col-sm-6 edit-view-row-item">
                <div class="col-xs-12 col-sm-4 label"> Subject: <span class="required">*</span>
                </div>
                <div class="col-xs-12 col-sm-8 edit-view-field  yui-ac" type="relate" field="subject">
                  <input required="" type="text" name="subject" class="sqsEnabled yui-ac-input" tabindex="" id="subject" size="" value="" title="" autocomplete="off">
                </div>
                <div class="col-xs-12 col-sm-4 label">
                </div>
                <div class="col-xs-12 col-sm-4">
                  <span style="color: red; font-size: 15px;"></span>
                </div>
                <!-- [/hide] -->
              </div>
              <div class="col-xs-12 col-sm-6 edit-view-row-item">
                <div class="col-xs-12 col-sm-2 label"> Email: <span class="required">*</span>
                </div>
                <div class="col-xs-12 col-sm-8 edit-view-field " type="varchar" field="name" colspan="3">
                  <input required="" type="text" name="email" id="email" size="120" maxlength="255" value="" title="">
                </div>
                <div class="col-xs-12 col-sm-4 label">
                </div>
                <div class="col-xs-12 col-sm-4">
                  <span style="color: red; font-size: 15px;"></span>
                </div>
                <!-- [/hide] -->
              </div>
              <div class="col-xs-12 col-sm-12 edit-view-row-item">
                <div class="col-xs-12 col-sm-2 label"> Category: <span class="required">*</span>
                </div>
                <div class="col-xs-12 col-sm-8 edit-view-field " type="varchar" field="category" colspan="3">
                  <ul id="menu" style=" width: 36%;" role="menu" tabindex="0" class="ui-menu ui-widget ui-widget-content">
                    <li class="ui-menu-item">
                      <div class="menuli ui-menu-item-wrapper" data-subcatvalue="" dat-catvalu="Billing Question" aria-haspopup="true" id="ui-id-1" tabindex="-1" role="menuitem"><span class="ui-menu-icon ui-icon ui-icon-caret-1-e"></span>Billing
                        Question</div>
                      <ul style="width: 20%; display: none;" role="menu" aria-hidden="true" aria-expanded="false" class="ui-menu ui-widget ui-widget-content ui-front">
                        <li class="ui-menu-item">
                          <div class="menuli ui-menu-item-wrapper" dat-catvalu="Billing Question" data-subcatvalue="New Billing" id="ui-id-2" tabindex="-1" role="menuitem">New Billing</div>
                        </li>
                      </ul>
                    </li>
                    <li class="ui-menu-item">
                      <div class="menuli ui-menu-item-wrapper" data-subcatvalue="" dat-catvalu="Pre Auth" id="ui-id-3" tabindex="-1" role="menuitem">Pre Auth</div>
                    </li>
                    <li class="ui-menu-item">
                      <div class="menuli ui-menu-item-wrapper" data-subcatvalue="" dat-catvalu="HR" id="ui-id-4" tabindex="-1" role="menuitem">HR</div>
                    </li>
                    <li class="ui-menu-item">
                      <div class="menuli ui-menu-item-wrapper" data-subcatvalue="" dat-catvalu="Eligibility" aria-haspopup="true" id="ui-id-5" tabindex="-1" role="menuitem"><span class="ui-menu-icon ui-icon ui-icon-caret-1-e"></span>Eligibility</div>
                      <ul style="width: 20%; display: none;" role="menu" aria-hidden="true" aria-expanded="false" class="ui-menu ui-widget ui-widget-content ui-front">
                        <li class="ui-menu-item">
                          <div class="menuli ui-menu-item-wrapper" dat-catvalu="Eligibility" data-subcatvalue="Daily Limit" id="ui-id-6" tabindex="-1" role="menuitem">Daily Limit</div>
                        </li>
                      </ul>
                    </li>
                    <li class="ui-menu-item">
                      <div class="menuli ui-menu-item-wrapper" data-subcatvalue="" dat-catvalu="ircmax Billing Software" id="ui-id-7" tabindex="-1" role="menuitem">Ircmax Billing Software</div>
                    </li>
                    <li class="ui-menu-item">
                      <div class="menuli ui-menu-item-wrapper" data-subcatvalue="" dat-catvalu="Facility related" id="ui-id-8" tabindex="-1" role="menuitem">Facility related</div>
                    </li>
                  </ul>
                  <input type="hidden" value="" name="category" id="category">
                  <input type="hidden" value="" name="subcategory" id="sub_category">
                  <!--                                                <select  required="" name="category" id="category" title="">

                                                </select>-->
                </div>
                <div class="col-xs-12 col-sm-4 label">
                </div>
                <div class="col-xs-12 col-sm-4">
                  <span style="color: red; font-size: 15px;"></span>
                </div>
                <!-- [/hide] -->
              </div>
              <div class="clear"></div>
              <div class="col-xs-12 col-sm-6 edit-view-row-item">
                <div class="col-xs-12 col-sm-4 label"> Account Name:<span class="required"></span>
                </div>
                <div class="col-xs-12 col-sm-8 edit-view-field  yui-ac" type="relate" field="account_name">
                  <input type="text" name="account_name" class="sqsEnabled yui-ac-input" tabindex="" id="account_name" size="" value="" title="" autocomplete="off">
                </div>
                <div class="col-xs-12 col-sm-4 label">
                </div>
                <div class="col-xs-12 col-sm-4">
                  <span style="color: red; font-size: 15px;"></span>
                </div>
                <!-- [/hide] -->
              </div>
              <div class="col-xs-12 col-sm-6 edit-view-row-item">
                <div class="col-xs-12 col-sm-2 label"> Status:<span class="required">*</span>
                </div>
                <div class="col-xs-12 col-sm-8 edit-view-field " type="enum" field="status">
                  <select required="" name="status" id="status" title="">
                    <option label="New" value="New">New</option>
                  </select>
                </div>
                <div class="col-xs-12 col-sm-4 label">
                </div>
                <div class="col-xs-12 col-sm-4">
                  <span style="color: red; font-size: 15px;"></span>
                </div>
                <!-- [/hide] -->
              </div>
              <div class="clear"></div>
              <div class="clear"></div>
              <div class="col-xs-12 col-sm-6 edit-view-row-item">
                <div class="col-xs-12 col-sm-4 label"> Priority: <span class="required">*</span>
                </div>
                <div class="col-xs-12 col-sm-8 edit-view-field " type="enum" field="priority">
                  <select required="" name="priority" id="priority" title="">
                    <option label="Very High" value="very high">Very High</option>
                    <option label="High" value="high">High</option>
                    <option label="Medium" value="medium" selected="selected">Medium</option>
                    <option label="Low" value="low">Low</option>
                  </select>
                </div>
                <div class="col-xs-12 col-sm-4 label">
                </div>
                <div class="col-xs-12 col-sm-4">
                  <span style="color: red; font-size: 15px;"></span>
                </div>
                <!-- [/hide] -->
              </div>
              <div class="clear"></div>
              <div class="clear"></div>
              <div class="col-xs-12 col-sm-6 edit-view-row-item">
                <div class="col-xs-12 col-sm-4 label"> Deadline: </div>
                <div class="col-xs-12 col-sm-8 edit-view-field  yui-ac" type="relate" field="deadline">
                  <input required="" type="text" name="deadline" class="sqsEnabled yui-ac-input" tabindex="" id="deadline" size="" value="" title="" autocomplete="off">
                </div>
                <div class="col-xs-12 col-sm-4 label">
                </div>
                <div class="col-xs-12 col-sm-4">
                  <span style="color: red; font-size: 15px;"></span>
                </div>
                <!-- [/hide] -->
              </div>
              <div class="clear"></div>
              <div class="clear"></div>
              <div class="clear"></div>
              <div class="col-xs-12 col-sm-12 edit-view-row-item">
                <div class="col-xs-12 col-sm-2 label"> Description:<span class="required">*</span>
                </div>
                <div class="col-xs-12 col-sm-8 edit-view-field " type="text" field="description" colspan="3">
                  <textarea required="" id="description" name="description" rows="6" cols="120" title="" tabindex=""></textarea>
                </div>
                <div class="col-xs-12 col-sm-4 label">
                </div>
                <div class="col-xs-12 col-sm-4">
                  <span style="color: red; font-size: 15px;"></span>
                </div>
                <!-- [/hide] -->
              </div>
              <div class="clear"></div>
            </div>
          </div>
        </div>
      </div>
      <div class="panel panel-default">
        <div class="panel-heading ">
          <a class="" role="button" data-toggle="collapse" aria-expanded="false">
                                    <div class="col-xs-10 col-sm-11 col-md-11">
                                        Attachments
                                    </div>
                                </a>
        </div>
        <div class="panel-body panel-collapse collapse in" id="detailpanel_0">
          <div class="tab-content">
            <!-- tab_panel_content.tpl -->
            <div class="row edit-view-row">
              <div class="col-xs-12 col-sm-12 edit-view-row-item">
                <div class="col-xs-12 col-sm-2 label"> Add: </div>
                <input type="file" name="attachment" class="file">
                <div class="col-xs-12 col-sm-4 edit-view-field " type="text" field="note" colspan="3">
                  <font color="#b40a0c"><b>Maximum file size is 5 MB !</b></font>
                  <br>
                  <input type="button" value="Add Attachment" class="button" id="browse">
                  <br>
                  <span id="image_name"></span>
                </div>
              </div>
              <div class="clear"></div>
            </div>
          </div>
        </div>
      </div>
    </div>
  </div>
  <br>
  <!-- to be used for id for buttons with custom code in def files-->
  <div class="buttons">
    <input title="Save" accesskey="a" class="button primary" type="submit" name="button" value="Save" id="save">
  </div>
</form>

Text Content

CREATE

 


test
 
BASIC
Subject: *



Email: *



Category: *
 * Billing Question
   * New Billing
 * Pre Auth
 * HR
 * Eligibility
   * Daily Limit
 * Ircmax Billing Software
 * Facility related




Account Name:



Status:*
New




Priority: *
Very High High Medium Low




Deadline:






Description:*




Attachments
Add:
Maximum file size is 5 MB !