CMSgov/dpc-app

<fieldset class="ds-l-row field-group">
  <div class="ds-l-col--12 ds-l-md-col--3">
    <legend class="field-group__heading">Details</legend>
  </div>

  <div class="ds-l-col--12 ds-l-md-col--9 field-group__fields">

    <div class="field">
      <%= f.label :name, class: "ds-c-label ds-u-margin-top--0" %>
      <%= f.text_field :name, class: "ds-c-field" %>
    </div>

      <%= f.label :organization_type, class: "ds-c-label" %>
      <%= f.select :organization_type,
        organization_types_for_select,
        { include_blank: 'Please select an organization type' },
        class: "ds-c-field drop-down",
        data: { hide_follow_up: 'health_it_vendor' }
      %>

    <div class="field--follow-up" hidden>
      <div class="field">
        <%= f.label :num_providers, class: "ds-c-label" do %>
        Number of Providers
        <span class="ds-c-field__hint">You may use an approximate number.<br/>If organization is a vendor, leave blank.</span>
        <% end %>
        <%= f.number_field :num_providers,
          min: 0, class: "ds-c-field ds-c-field--small" %>
      </div>

    <% unless @organization.prod_sbx? %>
      <div class="field">
        <%= f.label :npi, "NPI", class: "ds-c-label" %>
        <%= f.text_field :npi, class: "ds-c-field" %>
      </div>
    <% end %>

    <div class="field">
      <%= f.label :vendor, "Vendor", class: "ds-c-label" %>
      <%= f.text_field :vendor, class: "ds-c-field" %>
    </div>
    </div>
  </div>
</fieldset>

<fieldset class="ds-l-row field-group">
  <div class="ds-l-col--12 ds-l-md-col--3">
    <legend class="field-group__heading">Location</legend>
  </div>

  <div class="ds-l-col--12 ds-l-md-col--9 field-group__fields">
    <%= f.fields_for :address do |ff| %>
      <%= ff.label :address_use, class: "ds-c-label ds-u-margin-top--0" %>
      <%= ff.select :address_use, address_uses_for_select, { include_blank: 'Please select address use' },  class: "ds-c-field drop-down" %>

      <%= ff.label :address_type, class: "ds-c-label" %>
      <%= ff.select :address_type, address_types_for_select, { include_blank: 'Please select address type' }, class: "ds-c-field drop-down" %>

      <%= ff.label :street, class: "ds-c-label" %>
      <%= ff.text_field :street, class: "ds-c-field" %>


      <%= ff.label :street_2, class: "ds-c-label" %>
      <%= ff.text_field :street_2, class: "ds-c-field" %>

      <%= ff.label :city, class: "ds-c-label" %>
      <%= ff.text_field :city, class: "ds-c-field" %>

      <%= ff.label :state, class: "ds-c-label" %>
      <%= ff.select :state, states_for_select, { include_blank: 'Please select' }, class: "ds-c-field drop-down" %>

      <%= ff.label :zip, class: "ds-c-label" %>
      <%= ff.text_field :zip, class: "ds-c-field ds-c-field--medium" %>
    <% end %>
  </div>
</fieldset>

<div class="ds-l-row actions ds-u-margin-top--3 field-group">
  <div class="ds-l-col--12 ds-l-md-col--3">

  </div>

  <div class="ds-l-col--12 ds-l-md-col--9 field-group__fields ds-u-border--0">
    <%= hidden_field_tag :user_id, params[:user_id] %>
    <%= f.submit locals[:button_label], class: "ds-c-button ds-c-button--primary", data: { test: "form-submit" } %>
    <%= link_to "Cancel", organizations_path, class: "ds-c-button ds-c-button--transparent" %>
  </div>
</div>