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oldJsonpFunction = jsonpArray.push.bind(jsonpArray);\n \tjsonpArray.push = webpackJsonpCallback;\n \tjsonpArray = jsonpArray.slice();\n \tfor(var i = 0; i < jsonpArray.length; i++) webpackJsonpCallback(jsonpArray[i]);\n \tvar parentJsonpFunction = oldJsonpFunction;\n\n\n \t// add entry module to deferred list\n \tdeferredModules.push([0,\"chunk-vendors\"]);\n \t// run deferred modules when ready\n \treturn checkDeferredModules();\n","import mod from \"-!../node_modules/mini-css-extract-plugin/dist/loader.js??ref--6-oneOf-1-0!../node_modules/css-loader/dist/cjs.js??ref--6-oneOf-1-1!../node_modules/vue-loader/lib/loaders/stylePostLoader.js!../node_modules/postcss-loader/src/index.js??ref--6-oneOf-1-2!../node_modules/cache-loader/dist/cjs.js??ref--0-0!../node_modules/vue-loader/lib/index.js??vue-loader-options!./App.vue?vue&type=style&index=0&lang=css&\"; export default mod; export * from 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!_vm.$v.newRequest.otherPopulationTypeDescription.$error : null}},[_vm._v(\"* Required: Please enter an Age Range\")]),_c('b-form-input',{attrs:{\"trim\":\"\",\"lazy\":\"\",\"placeholder\":_vm.otherPopulationTypeInputPlaceholder,\"disabled\":_vm.disableOtherPopulationTypeInput,\"maxlength\":\"500\"},model:{value:(_vm.$v.newRequest.otherPopulationTypeDescription.$model),callback:function ($$v) {_vm.$set(_vm.$v.newRequest.otherPopulationTypeDescription, \"$model\", $$v)},expression:\"$v.newRequest.otherPopulationTypeDescription.$model\"}})],1)],1)],1)],1),_c('b-row',[_c('b-col',{attrs:{\"cols\":\"6\"}},[_c('b-form-group',[_c('div',[_vm._v(\"Languages Spoken (other than English) \"),_c('b-form-invalid-feedback',{attrs:{\"state\":_vm.$v.newRequest.selectedLanguages.$dirty ? !_vm.$v.newRequest.selectedLanguages.$error : null}},[_vm._v(\" * Required: Please select at least 1 Language spoken\")])],1),_c('div',{staticClass:\"list-group checkbox-list-group\",staticStyle:{\"margin-top\":\"5px\",\"border\":\"1px solid rgb(206, 212, 218)\",\"border-radius\":\"0.25rem\",\"padding\":\"3px\",\"max-height\":\"380px\",\"overflow-x\":\"hidden !important\",\"overflow-y\":\"scroll\"}},_vm._l((_vm.optionsLanguages),function(language){return _c('div',{key:language.Id,staticClass:\"custom-control custom-checkbox\"},[_c('input',{directives:[{name:\"model\",rawName:\"v-model\",value:(_vm.$v.newRequest.selectedLanguages.$model),expression:\"$v.newRequest.selectedLanguages.$model\"}],staticClass:\"custom-control-input\",attrs:{\"type\":\"checkbox\",\"name\":\"languages\",\"id\":'language_' + language.Id},domProps:{\"value\":language.Id,\"checked\":Array.isArray(_vm.$v.newRequest.selectedLanguages.$model)?_vm._i(_vm.$v.newRequest.selectedLanguages.$model,language.Id)>-1:(_vm.$v.newRequest.selectedLanguages.$model)},on:{\"change\":function($event){var $$a=_vm.$v.newRequest.selectedLanguages.$model,$$el=$event.target,$$c=$$el.checked?(true):(false);if(Array.isArray($$a)){var $$v=language.Id,$$i=_vm._i($$a,$$v);if($$el.checked){$$i<0&&(_vm.$set(_vm.$v.newRequest.selectedLanguages, \"$model\", $$a.concat([$$v])))}else{$$i>-1&&(_vm.$set(_vm.$v.newRequest.selectedLanguages, \"$model\", $$a.slice(0,$$i).concat($$a.slice($$i+1))))}}else{_vm.$set(_vm.$v.newRequest.selectedLanguages, \"$model\", $$c)}}}}),_c('label',{staticClass:\"custom-control-label\",attrs:{\"for\":'language_' + language.Id}},[_vm._v(_vm._s(language.Description))])])}),0),_c('b-form-group',{staticStyle:{\"padding-top\":\"7px\",\"padding-right\":\"0px\",\"padding-bottom\":\"0px\",\"padding-left\":\"3px\"},attrs:{\"inline\":\"\"}},[_c('b-form-checkbox',{key:_vm.otherLanguage.Id,attrs:{\"value\":_vm.otherLanguage.Id,\"name\":\"otherLanguages\",\"inline\":\"\"},on:{\"change\":_vm.otherLanguageChange},model:{value:(_vm.$v.newRequest.selectedLanguages.$model),callback:function ($$v) {_vm.$set(_vm.$v.newRequest.selectedLanguages, \"$model\", $$v)},expression:\"$v.newRequest.selectedLanguages.$model\"}},[_vm._v(\" \"+_vm._s(this.otherLanguage.Description)+\" \")]),_c('b-form-invalid-feedback',{attrs:{\"state\":_vm.$v.newRequest.otherLanguageDescription.$dirty ? !_vm.$v.newRequest.otherLanguageDescription.$error : null}},[_vm._v(\"* Required: Please enter the Languages spoken.\")]),_c('b-form-input',{attrs:{\"trim\":\"\",\"lazy\":\"\",\"placeholder\":_vm.otherLanguageInputPlaceholder,\"disabled\":_vm.disableOtherLanguageInput,\"maxlength\":\"500\"},model:{value:(_vm.$v.newRequest.otherLanguageDescription.$model),callback:function ($$v) {_vm.$set(_vm.$v.newRequest.otherLanguageDescription, \"$model\", $$v)},expression:\"$v.newRequest.otherLanguageDescription.$model\"}})],1)],1)],1),_c('b-col',{attrs:{\"cols\":\"6\"}},[_c('b-form-group',[_vm._v(\" Office Hours \"),_c('b-container',{staticStyle:{\"margin-top\":\"5px\",\"border\":\"1px solid rgb(206, 212, 218)\",\"border-radius\":\"0.25rem\",\"padding\":\"5px\",\"height\":\"380px\",\"overflow-x\":\"hidden !important\",\"overflow-y\":\"hidden\"},attrs:{\"fluid\":\"\"}},[_c('b-row',[_c('b-col',{attrs:{\"cols\":\"12\"}},[_c('b-form-group',{attrs:{\"label\":\"Monday:\",\"label-cols\":\"2\",\"label-align\":\"right\",\"label-for\":\"officeHoursMonday\"}},[_c('b-form-input',{attrs:{\"id\":\"officeHoursMonday\",\"type\":\"text\",\"trim\":\"\",\"lazy\":\"\",\"placeholder\":\"\",\"maxlength\":\"100\"},model:{value:(_vm.$v.newRequest.officeHoursMonday.$model),callback:function ($$v) {_vm.$set(_vm.$v.newRequest.officeHoursMonday, \"$model\", $$v)},expression:\"$v.newRequest.officeHoursMonday.$model\"}})],1)],1)],1),_c('b-row',[_c('b-col',[_c('b-form-group',{attrs:{\"label\":\"Tuesday:\",\"label-cols\":\"2\",\"label-align\":\"right\",\"label-for\":\"officeHoursTuesday\"}},[_c('b-form-input',{attrs:{\"id\":\"officeHoursTuesday\",\"type\":\"text\",\"trim\":\"\",\"lazy\":\"\",\"placeholder\":\"\",\"maxlength\":\"100\"},model:{value:(_vm.$v.newRequest.officeHoursTuesday.$model),callback:function ($$v) {_vm.$set(_vm.$v.newRequest.officeHoursTuesday, \"$model\", $$v)},expression:\"$v.newRequest.officeHoursTuesday.$model\"}})],1)],1)],1),_c('b-row',[_c('b-col',[_c('b-form-group',{attrs:{\"label\":\"Wednesday:\",\"label-cols\":\"2\",\"label-align\":\"right\",\"label-for\":\"officeHoursWednesday\"}},[_c('b-form-input',{attrs:{\"id\":\"officeHoursWednesday\",\"type\":\"text\",\"trim\":\"\",\"lazy\":\"\",\"placeholder\":\"\",\"maxlength\":\"100\"},model:{value:(_vm.$v.newRequest.officeHoursWednesday.$model),callback:function ($$v) {_vm.$set(_vm.$v.newRequest.officeHoursWednesday, \"$model\", $$v)},expression:\"$v.newRequest.officeHoursWednesday.$model\"}})],1)],1)],1),_c('b-row',[_c('b-col',[_c('b-form-group',{attrs:{\"label\":\"Thursday:\",\"label-cols\":\"2\",\"label-align\":\"right\",\"label-for\":\"officeHoursThursday\"}},[_c('b-form-input',{attrs:{\"id\":\"officeHoursThursday\",\"type\":\"text\",\"trim\":\"\",\"lazy\":\"\",\"placeholder\":\"\",\"maxlength\":\"100\"},model:{value:(_vm.$v.newRequest.officeHoursThursday.$model),callback:function ($$v) {_vm.$set(_vm.$v.newRequest.officeHoursThursday, \"$model\", $$v)},expression:\"$v.newRequest.officeHoursThursday.$model\"}})],1)],1)],1),_c('b-row',[_c('b-col',[_c('b-form-group',{attrs:{\"label\":\"Friday:\",\"label-cols\":\"2\",\"label-align\":\"right\",\"label-for\":\"officeHoursFriday\"}},[_c('b-form-input',{attrs:{\"id\":\"officeHoursFriday\",\"type\":\"text\",\"trim\":\"\",\"lazy\":\"\",\"placeholder\":\"\",\"maxlength\":\"100\"},model:{value:(_vm.$v.newRequest.officeHoursFriday.$model),callback:function ($$v) {_vm.$set(_vm.$v.newRequest.officeHoursFriday, \"$model\", $$v)},expression:\"$v.newRequest.officeHoursFriday.$model\"}})],1)],1)],1),_c('b-row',[_c('b-col',[_c('b-form-group',{attrs:{\"label\":\"Saturday:\",\"label-cols\":\"2\",\"label-align\":\"right\",\"label-for\":\"officeHoursSaturday\"}},[_c('b-form-input',{attrs:{\"id\":\"officeHoursSaturday\",\"type\":\"text\",\"trim\":\"\",\"lazy\":\"\",\"placeholder\":\"\",\"maxlength\":\"100\"},model:{value:(_vm.$v.newRequest.officeHoursSaturday.$model),callback:function ($$v) {_vm.$set(_vm.$v.newRequest.officeHoursSaturday, \"$model\", $$v)},expression:\"$v.newRequest.officeHoursSaturday.$model\"}})],1)],1)],1),_c('b-row',[_c('b-col',[_c('b-form-group',{attrs:{\"label\":\"Sunday:\",\"label-cols\":\"2\",\"label-align\":\"right\",\"label-for\":\"officeHoursSunday\"}},[_c('b-form-input',{attrs:{\"id\":\"officeHoursSunday\",\"type\":\"text\",\"trim\":\"\",\"lazy\":\"\",\"placeholder\":\"\",\"maxlength\":\"100\"},model:{value:(_vm.$v.newRequest.officeHoursSunday.$model),callback:function ($$v) {_vm.$set(_vm.$v.newRequest.officeHoursSunday, \"$model\", $$v)},expression:\"$v.newRequest.officeHoursSunday.$model\"}})],1)],1)],1)],1)],1)],1)],1)],1),_c('hr',{staticClass:\"sectionBorder\"}),_c('h6',{staticClass:\"sectionCaption\"},[_vm._v(\"NETWORK AFFILIATIONS\")]),_c('b-container',{attrs:{\"fluid\":\"\"}},[_c('b-row',[_c('b-col',{attrs:{\"cols\":\"2\"}},[_c('b-form-group',[_c('div',[_c('b-form-invalid-feedback',{attrs:{\"state\":_vm.$v.newRequest.mhmdApplied.$dirty ? !_vm.$v.newRequest.mhmdApplied.$error : null}},[_vm._v(\"* Required\"),_c('br')]),_vm._v(\" Have you ever applied to MHMD? \")],1),_c('b-form-radio-group',{attrs:{\"id\":\"mhmdApplied\"},model:{value:(_vm.$v.newRequest.mhmdApplied.$model),callback:function ($$v) {_vm.$set(_vm.$v.newRequest.mhmdApplied, \"$model\", $$v)},expression:\"$v.newRequest.mhmdApplied.$model\"}},[_c('b-form-radio',{attrs:{\"value\":\"Y\"},on:{\"change\":_vm.mhmdAppliedChange}},[_vm._v(\"Yes\")]),_c('b-form-radio',{attrs:{\"value\":\"N\"},on:{\"change\":_vm.mhmdAppliedChange}},[_vm._v(\"No\")])],1)],1)],1),_c('b-col',{attrs:{\"cols\":\"5\",\"align-self\":\"end\"}},[_c('div',{directives:[{name:\"show\",rawName:\"v-show\",value:(_vm.mhmdAppliedYes),expression:\"mhmdAppliedYes\"}]},[_c('b-form-group',[_c('label',{attrs:{\"for\":\"mhmdApplicationStatus\"}},[_vm._v(\"If yes, please select one of the following:\")]),_c('b-form-invalid-feedback',{attrs:{\"state\":_vm.$v.newRequest.mhmdApplicationStatus.$dirty ? !_vm.$v.newRequest.mhmdApplicationStatus.$error : null}},[_vm._v(\" * Required\")]),_c('b-form-select',{attrs:{\"id\":\"mhmdApplicationStatus\",\"options\":_vm.optionsMHMDApplicationStatuses,\"state\":_vm.$v.newRequest.mhmdApplicationStatus.$dirty ? !_vm.$v.newRequest.mhmdApplicationStatus.$error : null,\"select-size\":0,\"value-field\":\"Id\",\"text-field\":\"Description\"},on:{\"change\":_vm.mhmdApplicationStatusChange},model:{value:(_vm.$v.newRequest.mhmdApplicationStatus.$model),callback:function ($$v) {_vm.$set(_vm.$v.newRequest.mhmdApplicationStatus, \"$model\", $$v)},expression:\"$v.newRequest.mhmdApplicationStatus.$model\"}})],1),_c('div',{directives:[{name:\"show\",rawName:\"v-show\",value:(_vm.mhmdApplicationStatusTermindated),expression:\"mhmdApplicationStatusTermindated\"}]},[_c('b-form-group',[_c('label',{attrs:{\"for\":\"mhmdApplicationStatus\"}},[_vm._v(\"Terminated Date\")]),_c('b-form-invalid-feedback',{attrs:{\"state\":_vm.$v.newRequest.mhmdTerminatedDate.$dirty ? !_vm.$v.newRequest.mhmdTerminatedDate.$error : null}},[_vm._v(\" * Required\")]),_c('b-form-input',{directives:[{name:\"mask\",rawName:\"v-mask\",value:({ mask: '99/99/9999', placeholder: '#', autoUnmask: false }),expression:\"{ mask: '99/99/9999', placeholder: '#', autoUnmask: false }\"}],attrs:{\"id\":\"mhmdTerminatedDate\",\"trim\":\"\",\"lazy\":\"\",\"state\":_vm.$v.newRequest.mhmdTerminatedDate.$dirty ? !_vm.$v.newRequest.mhmdTerminatedDate.$error : null},model:{value:(_vm.$v.newRequest.mhmdTerminatedDate.$model),callback:function ($$v) {_vm.$set(_vm.$v.newRequest.mhmdTerminatedDate, \"$model\", $$v)},expression:\"$v.newRequest.mhmdTerminatedDate.$model\"}})],1)],1)],1)])],1),_c('b-row',[_c('b-col',{attrs:{\"cols\":\"12\"}},[_c('b-form-group',{attrs:{\"label\":\"Other Network/IPA/PHO Affliations\",\"label-for\":\"otherIPAPHOAffiliations\"}},[_c('b-form-input',{attrs:{\"id\":\"otherIPAPHOAffiliations\",\"type\":\"text\",\"trim\":\"\",\"lazy\":\"\",\"placeholder\":\"\",\"maxlength\":\"500\"},model:{value:(_vm.$v.newRequest.otherIPAPHOAffiliations.$model),callback:function ($$v) {_vm.$set(_vm.$v.newRequest.otherIPAPHOAffiliations, \"$model\", $$v)},expression:\"$v.newRequest.otherIPAPHOAffiliations.$model\"}})],1),_c('br')],1)],1)],1),_c('hr',{staticClass:\"sectionBorder\"}),_c('h6',{staticClass:\"sectionCaption\"},[_vm._v(\"CREDENTIALING CONTACT INFORMATION\")]),_c('b-container',{attrs:{\"fluid\":\"\"}},[_c('b-row',[_c('b-col',{attrs:{\"cols\":\"4\"}},[_c('b-form-group',{attrs:{\"label\":\"Credentialing Contact\",\"label-for\":\"credentialingContactName\",\"invalid-feedback\":\"* Required\"}},[_c('b-form-input',{attrs:{\"id\":\"credentialingContactName\",\"type\":\"text\",\"trim\":\"\",\"lazy\":\"\",\"placeholder\":\"\",\"maxlength\":\"100\",\"state\":_vm.$v.newRequest.credentialingContactName.$dirty ? !_vm.$v.newRequest.credentialingContactName.$error : null},model:{value:(_vm.$v.newRequest.credentialingContactName.$model),callback:function ($$v) {_vm.$set(_vm.$v.newRequest.credentialingContactName, \"$model\", $$v)},expression:\"$v.newRequest.credentialingContactName.$model\"}})],1)],1),_c('b-col',{attrs:{\"cols\":\"4\"}},[_c('b-form-group',{attrs:{\"label\":\"Credentialing Contact E-mail Address\",\"label-for\":\"credentialingContactEmail\",\"invalid-feedback\":\"* Required: Must be a valid email address.\"}},[_c('b-form-input',{attrs:{\"id\":\"credentialingContactEmail\",\"type\":\"text\",\"trim\":\"\",\"lazy\":\"\",\"placeholder\":\"\",\"maxlength\":\"250\",\"state\":_vm.$v.newRequest.credentialingContactEmail.$dirty ? !_vm.$v.newRequest.credentialingContactEmail.$error : null},model:{value:(_vm.$v.newRequest.credentialingContactEmail.$model),callback:function ($$v) {_vm.$set(_vm.$v.newRequest.credentialingContactEmail, \"$model\", $$v)},expression:\"$v.newRequest.credentialingContactEmail.$model\"}})],1)],1),_c('b-col',{attrs:{\"cols\":\"4\"}},[_c('b-form-group',{attrs:{\"label\":\"Credentialing Contact Phone #\",\"label-for\":\"credentialingContactPhone\",\"invalid-feedback\":\"* Required\"}},[_c('b-form-input',{directives:[{name:\"mask\",rawName:\"v-mask\",value:({ mask: '(999) 999-9999', placeholder: '#', autoUnmask: false }),expression:\"{ mask: '(999) 999-9999', placeholder: '#', autoUnmask: false }\"}],attrs:{\"id\":\"credentialingContactPhone\",\"type\":\"tel\",\"trim\":\"\",\"lazy\":\"\",\"state\":_vm.$v.newRequest.credentialingContactPhone.$dirty ? !_vm.$v.newRequest.credentialingContactPhone.$error : null},model:{value:(_vm.$v.newRequest.credentialingContactPhone.$model),callback:function ($$v) {_vm.$set(_vm.$v.newRequest.credentialingContactPhone, \"$model\", $$v)},expression:\"$v.newRequest.credentialingContactPhone.$model\"}})],1)],1)],1)],1),_c('b-container',{attrs:{\"fluid\":\"\"}},[_c('b-row',[_c('b-col',{staticStyle:{\"text-align\":\"end\"},attrs:{\"cols\":\"6\"}},[_c('br'),(!_vm.requestSubmitted)?_c('b-button',{attrs:{\"type\":\"submit\",\"variant\":\"primary\"},on:{\"click\":_vm.submitForm}},[_vm._v(\"Submit\")]):_vm._e(),_vm._v(\" \"),(_vm.requestSubmitted)?_c('b-button',{attrs:{\"type\":\"submit\",\"variant\":\"primary\"},on:{\"click\":_vm.printForm}},[_vm._v(\"Print\")]):_vm._e(),_c('br'),_c('br')],1),_c('b-col',{staticStyle:{\"text-align\":\"start\"},attrs:{\"cols\":\"6\"}},[_c('vue-recaptcha',{ref:\"recaptcha\",attrs:{\"size\":\"normal\",\"sitekey\":\"6Le78xIUAAAAAB5HNSsND1LJLg_61mLDHF2vrRej\",\"loadRecaptchaScript\":true},on:{\"verify\":_vm.onVerify,\"expired\":_vm.onExpired,\"error\":_vm.onError}})],1)],1)],1)],1)}\nvar staticRenderFns = []\n\nexport { render, staticRenderFns }","<template>\r\n    <div>\r\n        <span class=\"formDisclaimer\">PLEASE COMPLETE ALL OF THE FOLLOWING REQUIRED FIELDS. INCOMPLETE FORMS WILL NOT BE CONSIDERED.</span>\r\n        <hr class=\"titleBorder\">        \r\n        <h6 class=\"sectionCaption\">CONTACT INFORMATION</h6>\r\n        <b-container fluid>\r\n            <!-- Contact Information : Name / Phone / Fax / Email -->\r\n            <b-row>\r\n                <b-col cols=\"5\">\r\n                    <b-form-group\r\n                        label=\"Name\"\r\n                        label-for=\"contactName\"\r\n                        invalid-feedback=\"* Required\">\r\n                        <b-form-input id=\"contactName\" type=\"text\" trim lazy placeholder=\"\" maxlength=\"100\" \r\n                            v-model=\"$v.newRequest.contactName.$model\"                            \r\n                            :state=\"$v.newRequest.contactName.$dirty ? !$v.newRequest.contactName.$error : null\">\r\n                        </b-form-input>\r\n                    </b-form-group>\r\n                </b-col>\r\n\r\n                <b-col cols=\"7\">\r\n                    <b-form-group\r\n                        label=\"Email\"\r\n                        label-for=\"contactEmail\"\r\n                        invalid-feedback=\"* Required: Must be a valid email address.\">\r\n                        <b-form-input id=\"contactEmail\" type=\"text\" trim lazy placeholder=\"\" maxlength=\"250\" \r\n                            v-model=\"$v.newRequest.contactEmail.$model\"\r\n                            :state=\"$v.newRequest.contactEmail.$dirty ? !$v.newRequest.contactEmail.$error : null\"></b-form-input>\r\n                    </b-form-group>\r\n                </b-col>\r\n            </b-row>\r\n\r\n            <b-row>\r\n                <b-col cols=\"3\">\r\n                    <b-form-group\r\n                        label=\"Phone\"\r\n                        label-for=\"contactPhone\"\r\n                        invalid-feedback=\"* Required\">\r\n                        <b-form-input id=\"contactPhone\" type=\"tel\" trim lazy v-mask=\"{ mask: '(999) 999-9999', placeholder: '#', autoUnmask: false }\"\r\n                            v-model=\"$v.newRequest.contactPhone.$model\"\r\n                            :state=\"$v.newRequest.contactPhone.$dirty ? !$v.newRequest.contactPhone.$error : null\"></b-form-input>\r\n                    </b-form-group>\r\n                </b-col>\r\n\r\n                <b-col cols=\"3\">\r\n                    <b-form-group\r\n                        label=\"Fax\"\r\n                        label-for=\"contactFax\"\r\n                        invalid-feedback=\"Must be in (###) ###-#### format.\">\r\n                        <b-form-input id=\"contactFax\" type=\"tel\" trim lazy v-mask=\"{ mask: '(999) 999-9999', placeholder: '#', autoUnmask: false }\"\r\n                            v-model=\"$v.newRequest.contactFax.$model\"\r\n                            :state=\"$v.newRequest.contactFax.$dirty ? !$v.newRequest.contactFax.$error : null\"></b-form-input>\r\n                    </b-form-group>\r\n                </b-col>\r\n            </b-row>\r\n        </b-container>\r\n\r\n        <hr class=\"sectionBorder\">\r\n        <h6 class=\"sectionCaption\">PRACTICE INFORMATION</h6>        \r\n        <b-container fluid>\r\n            <!-- Provider Types -->\r\n            <b-row>\r\n                <b-col cols=\"12\">\r\n                    <div>\r\n                        <b-form-group>\r\n                            <div class=\"grp-caption\">Provider Type\r\n                                <b-form-invalid-feedback :state=\"$v.newRequest.selectedProviderType.$dirty ? !$v.newRequest.selectedProviderType.$error : null\"> * Required: Please select a Provider Type</b-form-invalid-feedback>\r\n                            </div>                           \r\n                            <b-form-radio\r\n                                name=\"providerTypes\"\r\n                                v-for=\"providerType in optionsProviderTypes\"\r\n                                v-model=\"$v.newRequest.selectedProviderType.$model\"\r\n                                :key=\"providerType.Id\"\r\n                                :value=\"providerType.Id\"\r\n                                inline\r\n                                class=\"col-4\"\r\n                                @change=\"providerTypeChange\">\r\n                            {{ providerType.Description }}\r\n                            </b-form-radio>\r\n                        </b-form-group>\r\n                        <!-- <div v-if=\"showSelectedRecapSection\">Selected: <strong>{{ this.newRequest.selectedProviderType }}</strong></div> -->\r\n\r\n                        <!-- AssociatedWithCurrentlyContractedEntity  -->\r\n                        <b-form-group\r\n                            v-show=\"showCurrentlyContractedInput\">\r\n                            <div>\r\n                                <b-form-invalid-feedback :state=\"$v.newRequest.associatedWithCurrentlyContractedEntity.$dirty ? !$v.newRequest.associatedWithCurrentlyContractedEntity.$error : null\"><b>* Required</b><br/></b-form-invalid-feedback>\r\n                                <span style=\"padding-right:10px;\">{{ this.currentlyContractedQuestion }}</span>\r\n                                <b-form-radio-group\r\n                                    id=\"associatedWithCurrentlyContractedEntity\"\r\n                                    v-model=\"$v.newRequest.associatedWithCurrentlyContractedEntity.$model\"\r\n                                    style=\"display: inline-block;\">\r\n                                    <b-form-radio value=\"Y\">Yes</b-form-radio>\r\n                                    <b-form-radio value=\"N\">No</b-form-radio>\r\n                                </b-form-radio-group>\r\n                            </div>\r\n                        </b-form-group>\r\n                        <br/>\r\n                    </div>\r\n                </b-col>            \r\n            </b-row>\r\n\r\n            <!-- Practice Types -->\r\n            <b-row>\r\n                <b-col cols=\"12\">\r\n                    <div v-show=\"showPracticeTypes\">\r\n                        <b-form-group>\r\n                            <div class=\"grp-caption\">Practice Type\r\n                                <b-form-invalid-feedback :state=\"$v.newRequest.selectedPracticeType.$dirty ? !$v.newRequest.selectedPracticeType.$error : null\"> * Required: Please select a Practice Type</b-form-invalid-feedback>\r\n                            </div>\r\n                            <b-form-radio\r\n                                v-for=\"practiceType in optionsPracticeTypes\"\r\n                                v-model=\"$v.newRequest.selectedPracticeType.$model\"\r\n                                :key=\"practiceType.Id\"\r\n                                :value=\"practiceType.Id\"\r\n                                name=\"practiceTypes\"\r\n                                inline\r\n                                class=\"col-3\"\r\n                                @change=\"otherPracticeTypeChange\">\r\n                                    {{ practiceType.Description }}\r\n                            </b-form-radio>\r\n                            <b-form-group>\r\n                                <b-form-radio\r\n                                    v-model=\"$v.newRequest.selectedPracticeType.$model\"\r\n                                    :key=\"otherPracticeType.Id\"\r\n                                    :value=\"otherPracticeType.Id\"\r\n                                    name=\"practiceTypes\"\r\n                                    inline\r\n                                    @change=\"otherPracticeTypeChange\">\r\n                                        {{ this.otherPracticeType.Description }}\r\n                                </b-form-radio>\r\n                                <b-form-invalid-feedback :state=\"$v.newRequest.otherPracticeTypeDescription.$dirty ? !$v.newRequest.otherPracticeTypeDescription.$error : null\">* Required: Please enter the Practice Type.</b-form-invalid-feedback>\r\n                                <b-form-input trim lazy v-model=\"$v.newRequest.otherPracticeTypeDescription.$model\" :placeholder=\"otherPracticeTypeInputPlaceholder\" :disabled=\"disableOtherPracticeTypeInput\" maxlength=\"500\"></b-form-input>\r\n                            </b-form-group>\r\n                        </b-form-group>\r\n                        <!-- <div v-if=\"showSelectedRecapSection\">Selected: <strong>{{ this.newRequest.selectedPracticeType }}</strong><br/><br/></div> -->\r\n                    </div>\r\n                </b-col>            \r\n            </b-row>\r\n\r\n            <!-- Facility Types -->\r\n            <b-row>\r\n                <b-col cols=\"12\">\r\n                    <div v-show=\"showFacilityTypes\">\r\n                        <b-form-group>\r\n                            <div class=\"grp-caption\">Facility/Ancillary Provider Type\r\n                                <b-form-invalid-feedback :state=\"$v.newRequest.selectedFacilityType.$dirty ? !$v.newRequest.selectedFacilityType.$error : null\"> * Required: Please select a Facility/Ancillary Type</b-form-invalid-feedback>\r\n                            </div>\r\n                            <b-form-radio\r\n                                v-for=\"facilityType in optionsFacilityTypes\"\r\n                                v-model=\"$v.newRequest.selectedFacilityType.$model\"\r\n                                :key=\"facilityType.Id\"\r\n                                :value=\"facilityType.Id\"\r\n                                name=\"facilityTypes\"\r\n                                inline\r\n                                class=\"col-3\"\r\n                                @change=\"otherFacilityTypeChange\">\r\n                                    {{ facilityType.Description }}<span class=\"facility-additional-details-indicator\" v-if=\"facilityType.EnableAdditionalDetails\"> **</span>\r\n                            </b-form-radio>\r\n                            <b-form-group>\r\n                                <b-form-radio\r\n                                v-model=\"$v.newRequest.selectedFacilityType.$model\"\r\n                                :key=\"otherFacilityType.Id\"\r\n                                :value=\"otherFacilityType.Id\"\r\n                                name=\"facilityTypes\"\r\n                                inline\r\n                                @change=\"otherFacilityTypeChange\">\r\n                                    {{ this.otherFacilityType.Description }}\r\n                                </b-form-radio>\r\n                                <b-form-invalid-feedback :state=\"$v.newRequest.otherFacilityTypeDescription.$dirty ? !$v.newRequest.otherFacilityTypeDescription.$error : null\">* Required: Please enter the Facility Type.</b-form-invalid-feedback>\r\n                                <b-form-input trim lazy v-model=\"$v.newRequest.otherFacilityTypeDescription.$model\" :placeholder=\"otherFacilityTypeInputPlaceholder\" :disabled=\"disableOtherFacilityTypeInput\" maxlength=\"500\"></b-form-input>\r\n                            </b-form-group>\r\n                        </b-form-group>\r\n                        <!-- <div v-if=\"showSelectedRecapSection\">Selected: <strong>{{ this.newRequest.selectedFacilityType }}</strong><br/><br/></div> -->\r\n\r\n                        <!-- Service Areas -->\r\n                        <b-form-group\r\n                            v-show=\"showServiceAreasinput\"\r\n                            label-for=\"serviceAreas\"\r\n                            label=\"Service Areas (For Home Health; mobile providers and mail-order DME providers ONLY):\"\r\n                            invalid-feedback=\"* Required if any Facility/Ancillary Provider Types were selected with the ** indicator.\"\r\n                            :state=\"$v.newRequest.serviceAreas.$dirty ? !$v.newRequest.serviceAreas.$error : null\">\r\n                            <b-form-input id=\"serviceAreas\" type=\"text\" trim lazy v-model=\"$v.newRequest.serviceAreas.$model\" placeholder=\"\" maxlength=\"500\"></b-form-input>\r\n                        </b-form-group>\r\n                    </div>\r\n                </b-col>            \r\n            </b-row>\r\n        </b-container>\r\n\r\n\r\n        <hr class=\"sectionBorder\">\r\n        <h6 class=\"sectionCaption\">DEMOGRAPHIC INFORMATION</h6>\r\n        <b-container fluid>\r\n            <!-- Practitioner Name / Tax ID / NPI / CAQH -->\r\n            <b-row>\r\n                <b-col v-show=\"showPracticeTypes\" cols=\"6\">\r\n                    <b-form-group\r\n                        label=\"Practitioner Name\"\r\n                        label-for=\"practitionerName\">\r\n                        <b-form-input id=\"practitionerName\" type=\"text\" trim lazy placeholder=\"\" maxlength=\"250\"\r\n                            v-model=\"$v.newRequest.practitionerName.$model\" >\r\n                        </b-form-input>\r\n                    </b-form-group>\r\n                </b-col>\r\n\r\n                <b-col cols=\"2\">\r\n                    <b-form-group\r\n                        label=\"Tax ID #\"\r\n                        label-for=\"taxId\"\r\n                        invalid-feedback=\"* Required: Must be in ##-####### format.\">\r\n                        <b-form-input id=\"taxId\" type=\"text\" trim lazy v-mask=\"{ mask: '99-9999999', placeholder: '#', autoUnmask: false }\"\r\n                            v-model=\"$v.newRequest.taxId.$model\"\r\n                            :state=\"$v.newRequest.taxId.$dirty ? !$v.newRequest.taxId.$error : null\">\r\n                        </b-form-input>\r\n                    </b-form-group>\r\n                </b-col>\r\n\r\n                <b-col cols=\"2\">\r\n                    <b-form-group\r\n                        label=\"NPI #\"\r\n                        label-for=\"npi\"\r\n                        invalid-feedback=\"* Required: Must be in ########## format.\">\r\n                        <b-form-input id=\"npi\" type=\"text\" trim lazy v-mask=\"{ mask: '9999999999', placeholder: '#', autoUnmask: false }\"\r\n                            v-model=\"$v.newRequest.npi.$model\"\r\n                            :state=\"$v.newRequest.npi.$dirty ? !$v.newRequest.npi.$error : null\">\r\n                        </b-form-input>\r\n                    </b-form-group>\r\n                </b-col>\r\n\r\n                <b-col cols=\"2\">\r\n                    <b-form-group\r\n                        label=\"CAQH #\"\r\n                        label-for=\"caqh\"\r\n                        invalid-feedback=\"* Must be in ######## format.\">\r\n                        <b-form-input id=\"caqh\" type=\"text\" trim lazy v-mask=\"{ mask: '99999999', placeholder: '#', autoUnmask: false }\"\r\n                            v-model=\"$v.newRequest.caqh.$model\"\r\n                            :state=\"$v.newRequest.caqh.$dirty ? !$v.newRequest.caqh.$error : null\">\r\n                        </b-form-input>\r\n                    </b-form-group>\r\n                </b-col>                \r\n            </b-row>\r\n\r\n            <!-- Business Phone / Extension / Business Fax / Business Email -->\r\n            <b-row>\r\n                <b-col cols=\"3\">\r\n                    <b-form-group\r\n                        label=\"Business Phone\"\r\n                        label-for=\"businessPhone\"\r\n                        invalid-feedback=\"* Required\">\r\n                        <b-form-input id=\"businessPhone\" type=\"tel\" trim lazy v-mask=\"{ mask: '(999) 999-9999', placeholder: '#', autoUnmask: false }\"\r\n                            v-model=\"$v.newRequest.businessPhone.$model\" \r\n                            :state=\"$v.newRequest.businessPhone.$dirty ? !$v.newRequest.businessPhone.$error : null\">\r\n                        </b-form-input>\r\n                    </b-form-group>\r\n                </b-col>\r\n\r\n                <b-col cols=\"2\">\r\n                    <b-form-group\r\n                        label=\"Extension\"\r\n                        label-for=\"businessPhoneExtension\">\r\n                        <b-form-input id=\"businessPhoneExtension\" type=\"text\" trim lazy placeholder=\"\" maxlength=\"6\"\r\n                            v-model=\"$v.newRequest.businessPhoneExtension.$model\" >\r\n                        </b-form-input>\r\n                    </b-form-group>                    \r\n                </b-col>\r\n                \r\n                <b-col cols=\"3\">\r\n                    <b-form-group\r\n                        label=\"Business Fax\"\r\n                        label-for=\"businessFax\"\r\n                        invalid-feedback=\"Must be in (###) ###-#### format.\">\r\n                        <b-form-input id=\"businessFax\" type=\"tel\" trim lazy v-mask=\"{ mask: '(999) 999-9999', placeholder: '#', autoUnmask: false }\"\r\n                            v-model=\"$v.newRequest.businessFax.$model\"\r\n                            :state=\"$v.newRequest.businessFax.$dirty ? !$v.newRequest.businessFax.$error : null\">\r\n                        </b-form-input>\r\n                    </b-form-group>\r\n                </b-col>\r\n\r\n                <b-col cols=\"4\">\r\n                    <b-form-group\r\n                        label=\"Business Email\"\r\n                        label-for=\"businessEmail\"\r\n                        invalid-feedback=\"Must be a valid email address.\">\r\n                        <b-form-input id=\"businessEmail\" type=\"text\"\r\n                            trim lazy v-model=\"$v.newRequest.businessEmail.$model\" placeholder=\"\" maxlength=\"250\"\r\n                            :state=\"$v.newRequest.businessEmail.$dirty ? !$v.newRequest.businessEmail.$error : null\">\r\n                        </b-form-input>\r\n                    </b-form-group>\r\n                </b-col>\r\n            </b-row>\r\n            <b-row>\r\n                <b-col cols=\"12\">\r\n                    <br/>\r\n                </b-col>\r\n            </b-row>\r\n\r\n            <!-- Specialties -->\r\n            <b-row v-show=\"showSpecialties\">\r\n                <b-col cols=\"6\">\r\n                    <div>\r\n                        <b-form-group\r\n                        label=\"Primary Specialty\"\r\n                        label-for=\"primarySpecialty\"\r\n                        invalid-feedback=\"* Required: Please select a Primary Specialty\">\r\n                            <b-form-select\r\n                                id=\"primarySpecialty\"\r\n                                v-model=\"$v.newRequest.primarySpecialty.$model\"\r\n                                :options=\"optionsSpecialties\"\r\n                                :select-size=\"0\"\r\n                                value-field=\"Id\"\r\n                                text-field=\"Description\"\r\n                                :state=\"$v.newRequest.primarySpecialty.$dirty ? !$v.newRequest.primarySpecialty.$error : null\">\r\n                                <template v-slot:first>\r\n                                    <option :value=\"null\">-- Select a Primary Specialty --</option>\r\n                                </template>\r\n                            </b-form-select>\r\n                        </b-form-group>\r\n                        <!-- <div v-if=\"showSelectedRecapSection\">Selected Primary: <strong>{{ this.newRequest.primarySpecialty }}</strong></div> -->\r\n                    </div>\r\n                </b-col>\r\n                <b-col cols=\"6\">\r\n                    <div>\r\n                        <b-form-group\r\n                            label=\"Secondary Specialty\"\r\n                            label-for=\"secondarySpecialty\">\r\n                            <b-form-select\r\n                                id=\"secondarySpecialty\"\r\n                                v-model=\"$v.newRequest.secondarySpecialty.$model\"\r\n                                :options=\"optionsSpecialties\"\r\n                                :select-size=\"0\"\r\n                                value-field=\"Id\"\r\n                                text-field=\"Description\">\r\n                                <template v-slot:first>\r\n                                    <option :value=\"null\">-- Select a Secondary Specialty (if applicable) --</option>\r\n                                </template>\r\n                            </b-form-select>\r\n                        </b-form-group>\r\n                        <!-- <div v-if=\"showSelectedRecapSection\">Selected Secondary: <strong>{{ this.newRequest.secondarySpecialty }}</strong>\r\n                            <br/><br/>\r\n                        </div> -->\r\n                    </div>\r\n                </b-col>\r\n            </b-row>\r\n            <b-row v-show=\"showSpecialties\">\r\n                <b-col cols=\"12\">\r\n                    <br/>\r\n                </b-col>\r\n            </b-row>\r\n\r\n            <!-- Business Name -->\r\n            <b-row>\r\n                <b-col cols=\"6\">\r\n                    <b-form-group\r\n                        label=\"Business Name (as it appears on the W-9)\"\r\n                        label-for=\"businessName\"\r\n                        invalid-feedback=\"* Required\">\r\n                        <b-form-input id=\"businessName\" type=\"text\" trim lazy placeholder=\"\" maxlength=\"250\"\r\n                            v-model=\"$v.newRequest.businessName.$model\"                            \r\n                            :state=\"$v.newRequest.businessName.$dirty ? !$v.newRequest.businessName.$error : null\">\r\n                        </b-form-input>\r\n                    </b-form-group>\r\n                </b-col>\r\n            </b-row>\r\n\r\n            <!-- Primary Address -->\r\n            <b-row>\r\n                <b-col cols=\"9\">\r\n                    <b-form-group\r\n                        label=\"Address\"\r\n                        label-for=\"primaryAddressAddressLine1\"\r\n                        invalid-feedback=\"* Required\">\r\n                        <b-form-input id=\"primaryAddressAddressLine1\" type=\"text\" trim lazy placeholder=\"\" maxlength=\"250\"\r\n                            v-model=\"$v.newRequest.primaryAddress.addressLine1.$model\"\r\n                            :state=\"$v.newRequest.primaryAddress.addressLine1.$dirty ? !$v.newRequest.primaryAddress.addressLine1.$error : null\">\r\n                        </b-form-input>\r\n                    </b-form-group>\r\n                </b-col>\r\n                <b-col cols=\"3\">\r\n                    <b-form-group\r\n                        label=\"Suite\"\r\n                        label-for=\"primaryAddressSuite\">\r\n                        <b-form-input id=\"primaryAddressSuite\" type=\"text\" trim lazy placeholder=\"\" maxlength=\"10\"\r\n                            v-model=\"$v.newRequest.primaryAddress.suite.$model\">\r\n                        </b-form-input>\r\n                    </b-form-group>\r\n                </b-col>\r\n            </b-row>\r\n            <b-row>\r\n                <b-col cols=\"5\">\r\n                    <b-form-group\r\n                        label=\"City\"\r\n                        label-for=\"primaryAddressCity\"\r\n                        invalid-feedback=\"* Required\">\r\n                        <b-form-input id=\"primaryAddressCity\" type=\"text\" trim lazy placeholder=\"\" maxlength=\"50\"\r\n                            v-model=\"$v.newRequest.primaryAddress.city.$model\"\r\n                            :state=\"$v.newRequest.primaryAddress.city.$dirty ? !$v.newRequest.primaryAddress.city.$error : null\">\r\n                        </b-form-input>\r\n                    </b-form-group>\r\n                </b-col>\r\n                <b-col cols=\"2\">\r\n                    <b-form-group\r\n                        label=\"State\"\r\n                        label-for=\"primaryAddressState\"\r\n                        invalid-feedback=\"* Required\">\r\n                        <b-form-input id=\"primaryAddressState\" type=\"text\" trim lazy placeholder=\"\" maxlength=\"2\"\r\n                            v-model=\"$v.newRequest.primaryAddress.state.$model\"\r\n                            :state=\"$v.newRequest.primaryAddress.state.$dirty ? !$v.newRequest.primaryAddress.state.$error : null\">\r\n                        </b-form-input>\r\n                    </b-form-group>\r\n                </b-col>\r\n                <b-col cols=\"4\">\r\n                    <b-form-group\r\n                        label=\"Zip Code\"\r\n                        label-for=\"primaryAddressZipcode\"\r\n                        invalid-feedback=\"Must be in #####-#### format.\">\r\n                        <b-form-input id=\"primaryAddressZipcode\" type=\"text\" trim lazy v-mask=\"{ mask: '99999-9999', placeholder: '#', autoUnmask: true }\"\r\n                            v-model=\"$v.newRequest.primaryAddress.zipcode.$model\"\r\n                            :state=\"$v.newRequest.primaryAddress.zipcode.$dirty ? !$v.newRequest.primaryAddress.zipcode.$error : null\">\r\n                        </b-form-input>\r\n                    </b-form-group>\r\n                </b-col>                \r\n            </b-row>\r\n            <b-row>\r\n                <b-col cols=\"12\">\r\n                    <br/>\r\n                </b-col>\r\n            </b-row>            \r\n\r\n            <!-- Address: New Address Button / Modal Dialog -->\r\n            <b-row>\r\n                <b-col cols=\"12\">\r\n                    <b-form-group>\r\n                        <b-button @click=\"addAddress()\">Click To Add Additional Addresses</b-button>\r\n                        \r\n                        <b-form-invalid-feedback :state=\"$v.newRequest.addresses.$dirty ? !$v.newRequest.addresses.$error : null\"> * Required: Please enter at least one address.</b-form-invalid-feedback>\r\n                        <b-modal id=\"add-address\"\r\n                            size=\"lg\"\r\n                            v-model=\"addAddressModalShowing\"\r\n                            no-close-on-esc\r\n                            no-close-on-backdrop\r\n                            hide-header-close\r\n                            @show=\"showAddressDialog\"\r\n                            @hide=\"hideAddressDialog\">\r\n                            <template v-slot:modal-header=\"{ close }\">\r\n                                <h5>Add Address</h5>\r\n                            </template>\r\n                            \r\n                            <template v-slot:default>\r\n                                <b-container fluid>\r\n                                    <!-- Address Information -->\r\n                                    <b-row>\r\n                                        <b-col cols=\"9\">\r\n                                            <b-form-group\r\n                                                label=\"Address\"\r\n                                                label-for=\"address\"\r\n                                                invalid-feedback=\"* Required\">\r\n                                                <b-form-input id=\"address\" type=\"text\" trim lazy placeholder=\"\" maxlength=\"250\"\r\n                                                    v-model=\"$v.newAddress.addressLine1.$model\"\r\n                                                    :state=\"$v.newAddress.addressLine1.$dirty ? !$v.newAddress.addressLine1.$error : null\">\r\n                                                </b-form-input>\r\n                                            </b-form-group>\r\n                                        </b-col>\r\n                                        <b-col cols=\"3\">\r\n                                            <b-form-group\r\n                                                label=\"Suite\"\r\n                                                label-for=\"suite\">\r\n                                                <b-form-input id=\"suite\" type=\"text\" trim lazy placeholder=\"\" maxlength=\"10\"\r\n                                                    v-model=\"$v.newAddress.suite.$model\">\r\n                                                </b-form-input>\r\n                                            </b-form-group>\r\n                                        </b-col>\r\n                                    </b-row>\r\n\r\n                                    <b-row>\r\n                                        <b-col cols=\"5\">\r\n                                            <b-form-group\r\n                                                label=\"City\"\r\n                                                label-for=\"city\"\r\n                                                invalid-feedback=\"* Required\">\r\n                                                <b-form-input id=\"city\" type=\"text\" trim lazy placeholder=\"\" maxlength=\"50\"\r\n                                                    v-model=\"$v.newAddress.city.$model\"\r\n                                                    :state=\"$v.newAddress.city.$dirty ? !$v.newAddress.city.$error : null\">\r\n                                                </b-form-input>\r\n                                            </b-form-group>\r\n                                        </b-col>\r\n                                        <b-col cols=\"2\">\r\n                                            <b-form-group\r\n                                                label=\"State\"\r\n                                                label-for=\"state\"\r\n                                                invalid-feedback=\"* Required\">\r\n                                                <b-form-input id=\"state\" type=\"text\" trim lazy placeholder=\"\" maxlength=\"2\"\r\n                                                    v-model=\"$v.newAddress.state.$model\"\r\n                                                    :state=\"$v.newAddress.state.$dirty ? !$v.newAddress.state.$error : null\">\r\n                                                </b-form-input>\r\n                                            </b-form-group>\r\n                                        </b-col>\r\n                                        <b-col cols=\"4\">\r\n                                            <b-form-group\r\n                                                label=\"Zip Code\"\r\n                                                label-for=\"zipcode\"\r\n                                                invalid-feedback=\"Must be in #####-#### format.\">\r\n                                                <b-form-input id=\"zipcode\" type=\"text\" trim lazy v-mask=\"{ mask: '99999-9999', placeholder: '#', autoUnmask: true }\"\r\n                                                    v-model=\"$v.newAddress.zipcode.$model\"\r\n                                                    :state=\"$v.newAddress.zipcode.$dirty ? !$v.newAddress.zipcode.$error : null\"></b-form-input>\r\n                                            </b-form-group>\r\n                                        </b-col>                \r\n                                    </b-row>\r\n                                </b-container>\r\n                            </template>\r\n\r\n                            <template v-slot:modal-footer=\"{ ok, cancel, hide }\">\r\n                                <b-button size=\"sm\" variant=\"success\" @click=\"handleOkNewAddress\">\r\n                                    OK\r\n                                </b-button>\r\n                                <b-button size=\"sm\" variant=\"danger\" @click=\"handleCancelNewAddress\">\r\n                                    Cancel\r\n                                </b-button>\r\n                            </template>\r\n                        </b-modal>\r\n                    </b-form-group>\r\n                </b-col>\r\n            </b-row>\r\n\r\n            <!-- Address Grid -->\r\n            <b-row>\r\n                <b-col cols=\"12\">\r\n                    <b-table\r\n                        id=\"addresses\"\r\n                        striped\r\n                        hover\r\n                        :items=\"getSecondaryAddresses\"\r\n                        :fields=\"addressesFields\">\r\n                        <template v-slot:cell(actions)=\"row\">\r\n                            <b-button size=\"sm\" @click=\"editAddress(row.item, row.index, $event.target)\" class=\"mr-1\">\r\n                            Edit\r\n                            </b-button>\r\n                            <b-button size=\"sm\" @click=\"deleteAddress(row.item, row.index, $event.target)\" class=\"mr-1\">\r\n                            Delete\r\n                            </b-button>\r\n                        </template>\r\n\r\n                        <template v-slot:cell(url)=\"{ value }\">\r\n                            <b-link :href=\"value\">link</b-link>\r\n                        </template>\r\n                    </b-table>\r\n                </b-col>\r\n            </b-row>\r\n        </b-container>\r\n\r\n\r\n\r\n        <hr class=\"sectionBorder\">\r\n        <h6 class=\"sectionCaption\">SERVICE INFORMATION</h6>\r\n        <b-container fluid>\r\n            <!-- Population Types -->\r\n            <b-row>\r\n                <b-col cols=\"12\">\r\n                    <b-form-group>\r\n                        <div>Ages Served\r\n                            <b-form-invalid-feedback :state=\"\r\n                                ($v.newRequest.servesAges_0_2.$dirty\r\n                                    && $v.newRequest.servesAges_2_18.$dirty\r\n                                    && $v.newRequest.servesAges_18_Plus.$dirty\r\n                                    && $v.newRequest.servesAges_Geriatric.$dirty\r\n                                    && $v.newRequest.servesAges_Other.$dirty)\r\n                                && (!$v.newRequest.servesAges_0_2.$model\r\n                                    && !$v.newRequest.servesAges_2_18.$model\r\n                                    && !$v.newRequest.servesAges_18_Plus.$model\r\n                                    && !$v.newRequest.servesAges_Geriatric.$model\r\n                                    && !$v.newRequest.servesAges_Other.$model)\r\n                                ? false : null\"> * Required: Please select all that apply\r\n                            </b-form-invalid-feedback>\r\n                        </div>\r\n                        <b-form-group style=\"margin-bottom:0px !important;\" inline>\r\n                            <b-form-checkbox\r\n                                v-model=\"$v.newRequest.servesAges_0_2.$model\"\r\n                                name=\"servesAges_0_2\"\r\n                                inline\r\n                                class=\"col-2\">\r\n                                {{ \"0-2 Years\" }}\r\n                            </b-form-checkbox>\r\n                            <b-form-checkbox\r\n                                v-model=\"$v.newRequest.servesAges_2_18.$model\"\r\n                                name=\"servesAges_2_18\"\r\n                                inline\r\n                                class=\"col-2\">\r\n                                {{ \"2-18 Years\" }}\r\n                            </b-form-checkbox>\r\n                            <b-form-checkbox\r\n                                v-model=\"$v.newRequest.servesAges_18_Plus.$model\"\r\n                                name=\"servesAges_18_Plus\"\r\n                                inline\r\n                                class=\"col-2\">\r\n                                {{ \"18+ Years\" }}\r\n                            </b-form-checkbox>                            \r\n                            <b-form-checkbox\r\n                                v-model=\"$v.newRequest.servesAges_Geriatric.$model\"\r\n                                name=\"servesAges_Geriatric\"\r\n                                inline\r\n                                class=\"col-2\">\r\n                                {{ \"Geriatrics\" }}\r\n                            </b-form-checkbox>                            \r\n                        </b-form-group>\r\n                        <b-form-group class=\"\" inline>\r\n                                <b-form-checkbox\r\n                                    v-model=\"$v.newRequest.servesAges_Other.$model\"\r\n                                    name=\"servesAges_Other\"\r\n                                    inline\r\n                                    class=\"\"\r\n                                    @change=\"otherPopulationTypeChange\">\r\n                                    {{ \"Other\" }}\r\n                                </b-form-checkbox>\r\n                                <b-form-invalid-feedback :state=\"$v.newRequest.otherPopulationTypeDescription.$dirty ? !$v.newRequest.otherPopulationTypeDescription.$error : null\">* Required: Please enter an Age Range</b-form-invalid-feedback>\r\n                                <b-form-input trim lazy v-model=\"$v.newRequest.otherPopulationTypeDescription.$model\" :placeholder=\"otherPopulationTypeInputPlaceholder\" :disabled=\"disableOtherPopulationTypeInput\" maxlength=\"500\"></b-form-input>\r\n                        </b-form-group>                        \r\n                    </b-form-group>\r\n                    <!-- <div v-if=\"showSelectedRecapSection\">Selected: <strong>{{ this.newRequest.selectedPopulationTypes }}</strong><br/><br/></div> -->\r\n                </b-col>\r\n            </b-row>\r\n\r\n            <!-- Languages / Office Hours -->\r\n            <b-row>\r\n                <b-col cols=\"6\">\r\n                    <b-form-group>\r\n                        <div>Languages Spoken (other than English)\r\n                            <b-form-invalid-feedback :state=\"$v.newRequest.selectedLanguages.$dirty ? !$v.newRequest.selectedLanguages.$error : null\"> * Required: Please select at least 1 Language spoken</b-form-invalid-feedback>\r\n                        </div>\r\n                        <div class=\"list-group checkbox-list-group\"\r\n                            style=\"margin-top: 5px; border: 1px solid rgb(206, 212, 218); border-radius: 0.25rem; padding: 3px; max-height: 380px; overflow-x: hidden !important; overflow-y: scroll;\">\r\n                            <div v-for=\"language in optionsLanguages\" :key=\"language.Id\" class=\"custom-control custom-checkbox\">\r\n                                <input type=\"checkbox\" name=\"languages\" :value=\"language.Id\" :id=\"'language_' + language.Id\" v-model=\"$v.newRequest.selectedLanguages.$model\" class=\"custom-control-input\">\r\n                                <label class=\"custom-control-label\" :for=\"'language_' + language.Id\">{{language.Description}}</label>\r\n                            </div>\r\n                        </div>                        \r\n                        <b-form-group\r\n                            style=\"padding-top: 7px; padding-right: 0px; padding-bottom: 0px; padding-left: 3px;\"\r\n                            inline>\r\n                            <b-form-checkbox\r\n                                v-model=\"$v.newRequest.selectedLanguages.$model\"\r\n                                :key=\"otherLanguage.Id\"\r\n                                :value=\"otherLanguage.Id\"\r\n                                name=\"otherLanguages\"\r\n                                inline\r\n                                class=\"\"\r\n                                @change=\"otherLanguageChange\">\r\n                                {{ this.otherLanguage.Description }}\r\n                            </b-form-checkbox>\r\n                            <b-form-invalid-feedback :state=\"$v.newRequest.otherLanguageDescription.$dirty ? !$v.newRequest.otherLanguageDescription.$error : null\">* Required: Please enter the Languages spoken.</b-form-invalid-feedback>\r\n                            <b-form-input trim lazy v-model=\"$v.newRequest.otherLanguageDescription.$model\" :placeholder=\"otherLanguageInputPlaceholder\" :disabled=\"disableOtherLanguageInput\" maxlength=\"500\"></b-form-input>\r\n                        </b-form-group>\r\n                    </b-form-group>\r\n                    <!-- <div v-if=\"showSelectedRecapSection\">Selected: <strong>{{ this.newRequest.selectedLanguages }}</strong></div> -->\r\n                </b-col>\r\n\r\n                <b-col cols=\"6\">\r\n                    <b-form-group>\r\n                        Office Hours\r\n                        <b-container fluid style=\"margin-top: 5px; border: 1px solid rgb(206, 212, 218); border-radius: 0.25rem; padding: 5px; height: 380px; overflow-x: hidden !important; overflow-y: hidden;\">\r\n                            <b-row>\r\n                                <b-col cols=\"12\">\r\n                                    <b-form-group\r\n                                        label=\"Monday:\"\r\n                                        label-cols=\"2\"\r\n                                        label-align=\"right\"\r\n                                        label-for=\"officeHoursMonday\">\r\n                                        <b-form-input id=\"officeHoursMonday\" type=\"text\" trim lazy placeholder=\"\" maxlength=\"100\"\r\n                                            v-model=\"$v.newRequest.officeHoursMonday.$model\">\r\n                                        </b-form-input>\r\n                                    </b-form-group>\r\n                                </b-col>\r\n                            </b-row>\r\n                            <b-row>\r\n                                <b-col>\r\n                                    <b-form-group\r\n                                        label=\"Tuesday:\"\r\n                                        label-cols=\"2\"\r\n                                        label-align=\"right\"\r\n                                        label-for=\"officeHoursTuesday\">\r\n                                        <b-form-input id=\"officeHoursTuesday\" type=\"text\" trim lazy placeholder=\"\" maxlength=\"100\"\r\n                                            v-model=\"$v.newRequest.officeHoursTuesday.$model\">\r\n                                        </b-form-input>\r\n                                    </b-form-group>\r\n                                </b-col>\r\n                            </b-row>\r\n                            <b-row>\r\n                                <b-col>\r\n                                    <b-form-group\r\n                                        label=\"Wednesday:\"\r\n                                        label-cols=\"2\"\r\n                                        label-align=\"right\"\r\n                                        label-for=\"officeHoursWednesday\">\r\n                                        <b-form-input id=\"officeHoursWednesday\" type=\"text\" trim lazy placeholder=\"\" maxlength=\"100\"\r\n                                            v-model=\"$v.newRequest.officeHoursWednesday.$model\">\r\n                                        </b-form-input>\r\n                                    </b-form-group>\r\n                                </b-col>\r\n                            </b-row>\r\n                            <b-row>\r\n                                <b-col>\r\n                                    <b-form-group\r\n                                        label=\"Thursday:\"\r\n                                        label-cols=\"2\"\r\n                                        label-align=\"right\"\r\n                                        label-for=\"officeHoursThursday\">\r\n                                        <b-form-input id=\"officeHoursThursday\" type=\"text\" trim lazy placeholder=\"\" maxlength=\"100\"\r\n                                            v-model=\"$v.newRequest.officeHoursThursday.$model\">\r\n                                        </b-form-input>\r\n                                    </b-form-group>\r\n                                </b-col>\r\n                            </b-row>\r\n                            <b-row>\r\n                                <b-col>\r\n                                    <b-form-group\r\n                                        label=\"Friday:\"\r\n                                        label-cols=\"2\"\r\n                                        label-align=\"right\"\r\n                                        label-for=\"officeHoursFriday\">\r\n                                        <b-form-input id=\"officeHoursFriday\" type=\"text\" trim lazy placeholder=\"\" maxlength=\"100\"\r\n                                            v-model=\"$v.newRequest.officeHoursFriday.$model\">\r\n                                        </b-form-input>\r\n                                    </b-form-group>\r\n                                </b-col>\r\n                            </b-row>\r\n                            <b-row>\r\n                                <b-col>\r\n                                    <b-form-group\r\n                                        label=\"Saturday:\"\r\n                                        label-cols=\"2\"\r\n                                        label-align=\"right\"\r\n                                        label-for=\"officeHoursSaturday\">\r\n                                        <b-form-input id=\"officeHoursSaturday\" type=\"text\" trim lazy placeholder=\"\" maxlength=\"100\"\r\n                                            v-model=\"$v.newRequest.officeHoursSaturday.$model\">\r\n                                        </b-form-input>\r\n                                    </b-form-group>\r\n                                </b-col>\r\n                            </b-row>\r\n                            <b-row>\r\n                                <b-col>\r\n                                    <b-form-group\r\n                                        label=\"Sunday:\"\r\n                                        label-cols=\"2\"\r\n                                        label-align=\"right\"\r\n                                        label-for=\"officeHoursSunday\">\r\n                                        <b-form-input id=\"officeHoursSunday\" type=\"text\" trim lazy placeholder=\"\" maxlength=\"100\"\r\n                                            v-model=\"$v.newRequest.officeHoursSunday.$model\">\r\n                                        </b-form-input>\r\n                                    </b-form-group>\r\n                                </b-col>\r\n                            </b-row>                                                                                                                                            \r\n                        </b-container>\r\n                    </b-form-group>\r\n                </b-col>\r\n            </b-row>\r\n        </b-container>\r\n\r\n\r\n        <hr class=\"sectionBorder\">\r\n        <h6 class=\"sectionCaption\">NETWORK AFFILIATIONS</h6>\r\n        <b-container fluid>\r\n            <!-- MHMD Affiliation / Ohter IPA/PHO Affiliations -->            \r\n            <b-row>\r\n                <b-col cols=\"2\">\r\n                    <b-form-group>\r\n                        <div>\r\n                            <b-form-invalid-feedback :state=\"$v.newRequest.mhmdApplied.$dirty ? !$v.newRequest.mhmdApplied.$error : null\">* Required<br/></b-form-invalid-feedback>\r\n                            Have you ever applied to MHMD?\r\n                        </div>\r\n                        <b-form-radio-group\r\n                            id=\"mhmdApplied\"\r\n                            v-model=\"$v.newRequest.mhmdApplied.$model\">\r\n                            <b-form-radio value=\"Y\" @change=\"mhmdAppliedChange\">Yes</b-form-radio>\r\n                            <b-form-radio value=\"N\" @change=\"mhmdAppliedChange\">No</b-form-radio>\r\n                        </b-form-radio-group>\r\n                    </b-form-group>\r\n                    <!-- <div v-if=\"showSelectedRecapSection\">Selected: <strong>{{ newRequest.mhmdApplied }}</strong></div> -->\r\n                </b-col>\r\n                <b-col cols=\"5\" align-self=\"end\">\r\n                    <div v-show=\"mhmdAppliedYes\">\r\n                        <b-form-group>\r\n                            <label for=\"mhmdApplicationStatus\">If yes, please select one of the following:</label>\r\n                            <b-form-invalid-feedback :state=\"$v.newRequest.mhmdApplicationStatus.$dirty ? !$v.newRequest.mhmdApplicationStatus.$error : null\"> * Required</b-form-invalid-feedback>\r\n                            <b-form-select\r\n                                id=\"mhmdApplicationStatus\"\r\n                                v-model=\"$v.newRequest.mhmdApplicationStatus.$model\"\r\n                                :options=\"optionsMHMDApplicationStatuses\"\r\n                                :state=\"$v.newRequest.mhmdApplicationStatus.$dirty ? !$v.newRequest.mhmdApplicationStatus.$error : null\"\r\n                                :select-size=\"0\"\r\n                                value-field=\"Id\"\r\n                                text-field=\"Description\"\r\n                                @change=\"mhmdApplicationStatusChange\">\r\n                            </b-form-select>\r\n                        </b-form-group>\r\n                        <div v-show=\"mhmdApplicationStatusTermindated\">\r\n                            <b-form-group>\r\n                                <label for=\"mhmdApplicationStatus\">Terminated Date</label>\r\n                                <b-form-invalid-feedback :state=\"$v.newRequest.mhmdTerminatedDate.$dirty ? !$v.newRequest.mhmdTerminatedDate.$error : null\"> * Required</b-form-invalid-feedback>\r\n                                <b-form-input id=\"mhmdTerminatedDate\" trim lazy v-mask=\"{ mask: '99/99/9999', placeholder: '#', autoUnmask: false }\"\r\n                                    v-model=\"$v.newRequest.mhmdTerminatedDate.$model\"\r\n                                    :state=\"$v.newRequest.mhmdTerminatedDate.$dirty ? !$v.newRequest.mhmdTerminatedDate.$error : null\">\r\n                                </b-form-input>\r\n                            </b-form-group>\r\n                        </div>\r\n                        <!-- <div v-if=\"showSelectedRecapSection\">\r\n                            Selected Application Status: <strong>{{ this.newRequest.mhmdApplicationStatus }}</strong>\r\n                            <br/><br/>\r\n                        </div> -->\r\n                    </div>\r\n                </b-col>\r\n            </b-row>\r\n            \r\n            <b-row>\r\n                <b-col cols=\"12\">\r\n                    <b-form-group\r\n                        label=\"Other Network/IPA/PHO Affliations\"\r\n                        label-for=\"otherIPAPHOAffiliations\">\r\n                        <b-form-input id=\"otherIPAPHOAffiliations\" type=\"text\" trim lazy  placeholder=\"\" maxlength=\"500\"\r\n                            v-model=\"$v.newRequest.otherIPAPHOAffiliations.$model\">\r\n                        </b-form-input>\r\n                    </b-form-group>\r\n                    <br/>\r\n                </b-col>                \r\n            </b-row>\r\n        </b-container>\r\n\r\n\r\n        <hr class=\"sectionBorder\">\r\n        <h6 class=\"sectionCaption\">CREDENTIALING CONTACT INFORMATION</h6>\r\n        <b-container fluid>\r\n            <!-- Credintialing Contact / Email / Phone -->\r\n            <b-row>\r\n                <b-col cols=\"4\">\r\n                    <b-form-group\r\n                        label=\"Credentialing Contact\"\r\n                        label-for=\"credentialingContactName\"\r\n                        invalid-feedback=\"* Required\">\r\n                        <b-form-input id=\"credentialingContactName\" type=\"text\" trim lazy placeholder=\"\" maxlength=\"100\"\r\n                            v-model=\"$v.newRequest.credentialingContactName.$model\"\r\n                            :state=\"$v.newRequest.credentialingContactName.$dirty ? !$v.newRequest.credentialingContactName.$error : null\">\r\n                        </b-form-input>\r\n                    </b-form-group>\r\n                </b-col>\r\n\r\n                <b-col cols=\"4\">\r\n                    <b-form-group\r\n                        label=\"Credentialing Contact E-mail Address\"\r\n                        label-for=\"credentialingContactEmail\"\r\n                        invalid-feedback=\"* Required: Must be a valid email address.\">\r\n                        <b-form-input id=\"credentialingContactEmail\" type=\"text\" trim lazy placeholder=\"\" maxlength=\"250\"\r\n                            v-model=\"$v.newRequest.credentialingContactEmail.$model\" \r\n                            :state=\"$v.newRequest.credentialingContactEmail.$dirty ? !$v.newRequest.credentialingContactEmail.$error : null\">\r\n                        </b-form-input>\r\n                    </b-form-group>\r\n                </b-col>\r\n\r\n                <b-col cols=\"4\">\r\n                    <b-form-group\r\n                        label=\"Credentialing Contact Phone #\"\r\n                        label-for=\"credentialingContactPhone\"\r\n                        invalid-feedback=\"* Required\">\r\n                        <b-form-input id=\"credentialingContactPhone\" type=\"tel\" trim lazy v-mask=\"{ mask: '(999) 999-9999', placeholder: '#', autoUnmask: false }\"\r\n                            v-model=\"$v.newRequest.credentialingContactPhone.$model\"\r\n                            :state=\"$v.newRequest.credentialingContactPhone.$dirty ? !$v.newRequest.credentialingContactPhone.$error : null\">\r\n                        </b-form-input>\r\n                    </b-form-group>\r\n                </b-col>\r\n            </b-row>\r\n        </b-container>\r\n\r\n\r\n        <b-container fluid>\r\n            <!-- Submit Button / Print Button -->\r\n            <b-row>\r\n                <b-col cols=\"6\" style=\"text-align: end;\">\r\n                    <br/>\r\n                    <b-button type=\"submit\" v-if=\"!requestSubmitted\" @click=\"submitForm\" variant=\"primary\">Submit</b-button>\r\n                    &nbsp;<b-button type=\"submit\" v-if=\"requestSubmitted\" @click=\"printForm\" variant=\"primary\">Print</b-button>\r\n                    <br/><br/>\r\n                </b-col>\r\n                <b-col cols=\"6\" style=\"text-align: start;\">\r\n                    <vue-recaptcha\r\n                        size=\"normal\"\r\n                        ref=\"recaptcha\"\r\n                        sitekey=\"6Le78xIUAAAAAB5HNSsND1LJLg_61mLDHF2vrRej\"\r\n                        :loadRecaptchaScript=true\r\n                        @verify=\"onVerify\"\r\n                        @expired=\"onExpired\"\r\n                        @error=\"onError\">\r\n                    </vue-recaptcha>\r\n                </b-col>\r\n            </b-row>\r\n        </b-container>\r\n\r\n    </div>\r\n</template>\r\n\r\n<script>\r\n\r\nimport {\r\n    required,\r\n    minLength,\r\n    maxLength,\r\n    requiredIf,\r\n    email,\r\n    helpers } from 'vuelidate/lib/validators'\r\n\r\nimport { mapState, mapGetters, mapActions } from 'vuex';\r\nimport VueRecaptcha from 'vue-recaptcha';\r\n\r\nconst EIN = helpers.regex('EIN', /\\d{2}[-]\\d{7}$/)  // with mask\r\n//const EIN = helpers.regex('EIN', /\\d{9}$/) // without mask\r\n\r\nconst NPI = helpers.regex('NPI', /^[0-9]{10}$/)  // with mask\r\n//const NPI = helpers.regex('NPI', /^\\d{10}$/) // without mask\r\n\r\nconst CAQH = helpers.regex('CAQH', /^[0-9]{8}$/)  // with mask\r\n//const CAQH = helpers.regex('CAQH', /^\\d{8}$/) // without mask\r\n\r\nconst PhoneNumber = helpers.regex('PhoneNumber', /^(\\+\\d{1,2}\\s)?\\(?\\d{3}\\)?[\\s.-]\\d{3}[\\s.-]\\d{4}$/) // with mask\r\n//const PhoneNumber = helpers.regex('PhoneNumber', /\\d{10}$/) // without mask\r\n\r\n//const ZipCode = helpers.regex('ZipCode', /^\\d{5}(-\\d{4})?$/) // with mask\r\nconst ZipCode = helpers.regex('ZipCode', /^\\d{5}(\\d{4})?$/) // without mask\r\n\r\n// eslint-disable-next-line no-unused-vars\r\nconst AgesServed = (value, vm) => vm.servesAges_0_2 || vm.servesAges_2_18 || vm.servesAges_18_Plus || vm.servesAges_Geriatric || vm.servesAges_Other;\r\n\r\n//https://stackoverflow.com/questions/16699007/regular-expression-to-match-standard-10-digit-phone-number\r\n//^(\\+\\d{1,2}\\s)?\\(?\\d{3}\\)?[\\s.-]\\d{3}[\\s.-]\\d{4}$\r\n//const EIN = (value) => !helpers.req(value) || helpers.regex(value, /\\d{2}[-]\\d{7}$/);\r\n\r\nexport default {\r\n    created() {\r\n        this.loadAll()\r\n        .then(() => {\r\n            if(this.$store.state.dataError) {\r\n                this.$store.dispatch('udpateStatus', 'error');\r\n                this.$store.commit('updateDataError', false, { root: true });\r\n                this.$router.push('/error');\r\n            }            \r\n        });\r\n    },\r\n    \r\n    data() {\r\n        return {\r\n        //modelIsDirty: false,\r\n\r\n        currentlyContractedQuestion: '',\r\n        otherPracticeTypeInputPlaceholder: 'If Other, enter a Practice Type',\r\n        disableOtherPracticeTypeInput: true,\r\n\r\n        otherFacilityTypeInputPlaceholder: 'If Other, enter a Facility Type',\r\n        disableOtherFacilityTypeInput: true,\r\n\r\n        showServiceAreasinput: false,\r\n\r\n        addressModalAction: '',\r\n        addAddressModalShowing: false,\r\n\r\n        otherPopulationTypeInputPlaceholder: 'If Other, Enter Age Range',\r\n        disableOtherPopulationTypeInput: true,\r\n\r\n        otherLanguageInputPlaceholder: 'If Other, Enter Languages',\r\n        disableOtherLanguageInput: true,\r\n\r\n        addressesFields: [\r\n            { key: 'addressLine1', label: 'Address' },\r\n            { key: 'suite', label: 'Suite' },\r\n            { key: 'city', label: 'City' },\r\n            { key: 'state', label: 'State' },\r\n            { key: 'zipcode', label: 'Zip', formatter: 'zipCodeFormatter'},\r\n            { key: 'actions', label: 'Actions' },\r\n            ],\r\n        showSelectedRecapSection: true,\r\n        captchaVerified: false,\r\n        }\r\n    },\r\n\r\n    validations: {\r\n        newRequest: {\r\n\r\n            contactName: {\r\n                required,\r\n                minLength: minLength(3),\r\n                maxLength: maxLength(100),\r\n            },\r\n            contactEmail: {\r\n                required,\r\n                email,\r\n            },\r\n            contactPhone: {\r\n                required,\r\n                PhoneNumber,\r\n            },\r\n            contactFax: {\r\n                PhoneNumber,\r\n            },\r\n\r\n            selectedProviderType: {\r\n                required,\r\n            },\r\n\r\n            associatedWithCurrentlyContractedEntity: {\r\n                required: requiredIf(function (){\r\n                    return this.showPracticeTypes || this.showFacilityTypes;\r\n                }),\r\n            },\r\n\r\n            selectedPracticeType: {\r\n                required: requiredIf(function (){\r\n                    return this.showPracticeTypes;\r\n                }),\r\n            },\r\n            otherPracticeTypeDescription: {\r\n                required: requiredIf(function () {\r\n                    return this.otherPracticeTypeChecked;\r\n                }),\r\n            },\r\n\r\n            selectedFacilityType: {\r\n                required: requiredIf(function (){\r\n                    return this.showFacilityTypes;\r\n                }),\r\n            },\r\n            otherFacilityTypeDescription: {\r\n                required: requiredIf(function () {\r\n                    return this.otherFacilityTypeChecked;\r\n                }),                \r\n            },\r\n            serviceAreas: {\r\n                required: requiredIf(function () {\r\n                    return this.showServiceAreasinput;\r\n                }),\r\n            },\r\n\r\n            practitionerName: {\r\n            },\r\n            businessName: {\r\n                required,\r\n                minLength: minLength(3),\r\n            },\r\n            taxId: {\r\n                required,\r\n                EIN,\r\n            },\r\n            npi: {\r\n                required,\r\n                NPI,\r\n            },\r\n            caqh: {\r\n                CAQH,\r\n            },\r\n\r\n            businessPhone: {\r\n                required,\r\n                PhoneNumber,\r\n            },\r\n            businessPhoneExtension: {\r\n            },\r\n            businessFax: {\r\n                PhoneNumber,\r\n            },\r\n            businessEmail: {\r\n                email,\r\n            },\r\n\r\n            primarySpecialty: {\r\n                required: requiredIf(function () {\r\n                    return this.showSpecialties;\r\n                }),\r\n            },\r\n            secondarySpecialty: {\r\n            },\r\n\r\n            servesAges_0_2: {\r\n                AgesServed,\r\n            },\r\n            servesAges_2_18: {\r\n                AgesServed,\r\n            },\r\n            servesAges_18_Plus: {\r\n                AgesServed,\r\n            },\r\n            servesAges_Geriatric: {\r\n                AgesServed,\r\n            },\r\n            servesAges_Other: {\r\n                AgesServed,\r\n            },            \r\n\r\n            primaryAddress: {\r\n              id: {},\r\n              addressLine1: {\r\n                  required,\r\n                  minLength: minLength(3),\r\n              },\r\n              suite: {},\r\n              city: {\r\n                  required,\r\n                  minLength: minLength(3),\r\n              },\r\n              state: {\r\n                  required,\r\n                  minLength: minLength(2),\r\n              },\r\n              zipcode: {\r\n                  required,\r\n                  ZipCode,\r\n              },\r\n              isPrimary: {},\r\n            },                \r\n\r\n            addresses: {\r\n            },\r\n\r\n            otherPopulationTypeDescription: {\r\n                required: requiredIf(function () {\r\n                    return this.otherPopulationTypeChecked;\r\n                }),\r\n            },\r\n\r\n            selectedLanguages: {\r\n            },\r\n            otherLanguageDescription: {\r\n                required: requiredIf(function () {\r\n                    return this.otherLanguageChecked;\r\n                }),                \r\n            },            \r\n\r\n            officeHoursMonday: {\r\n            },\r\n            officeHoursTuesday: {\r\n            },\r\n            officeHoursWednesday: {\r\n            },\r\n            officeHoursThursday: {\r\n            },\r\n            officeHoursFriday: {\r\n            },\r\n            officeHoursSaturday: {\r\n            },\r\n            officeHoursSunday: {\r\n            },\r\n\r\n            mhmdApplied: {\r\n                required,\r\n            },\r\n            mhmdApplicationStatus: {\r\n                required: requiredIf(function () {\r\n                    return this.mhmdAppliedYes;\r\n                    }),\r\n            },\r\n            mhmdTerminatedDate: {\r\n                required: requiredIf(function () {\r\n                    return this.mhmdApplicationStatusTermindated;\r\n                })\r\n            },\r\n            otherIPAPHOAffiliations: {\r\n            },\r\n\r\n            credentialingContactName: {\r\n                required,\r\n            },\r\n            credentialingContactEmail: {\r\n                required,\r\n                email,\r\n            },\r\n            credentialingContactPhone: {\r\n                required,\r\n                PhoneNumber,\r\n            },\r\n        },\r\n\r\n        \r\n        newAddress: {\r\n          id: {},\r\n          addressLine1: {\r\n            required: requiredIf(function () {\r\n                return this.addAddressModalShowing;\r\n            }),\r\n            minLength: minLength(3),\r\n          },\r\n          suite: {},\r\n          city: {\r\n            required: requiredIf(function () {\r\n                return this.addAddressModalShowing;\r\n            }),\r\n            minLength: minLength(3),\r\n          },\r\n          state: {\r\n            required: requiredIf(function () {\r\n                return this.addAddressModalShowing;\r\n            }),\r\n            minLength: minLength(2),\r\n          },\r\n          zipcode: {\r\n            required: requiredIf(function () {\r\n                return this.addAddressModalShowing;\r\n            }),\r\n            ZipCode,\r\n          },\r\n          isPrimary: {},\r\n        },\r\n        newAddressValidation: ['newAddress.addressLine1', 'newAddress.city', 'newAddress.state', 'newAddress.zipcode',]\r\n    },\r\n\r\n    computed: {\r\n        ...mapState(\r\n            'request', {\r\n                optionsProviderTypes: 'providerTypes',                \r\n                optionsPracticeTypes: 'practiceTypes',\r\n                otherPracticeType: 'otherPracticeType',\r\n                optionsFacilityTypes: 'facilityTypes',\r\n                otherFacilityType: 'otherFacilityType',\r\n                optionsSpecialties: 'specialties',\r\n                optionsLanguages: 'languages',\r\n                otherLanguage: 'otherLanguage',\r\n                optionsMHMDApplicationStatuses: 'MHMDApplicationStatuses',\r\n                newRequest: 'newRequest',\r\n                newAddress: 'newAddress',\r\n                }\r\n        ),\r\n        \r\n        ...mapGetters(\r\n            'request', {\r\n                getSecondaryAddresses: 'getSecondaryAddresses',\r\n            }\r\n        ),\r\n\r\n        getSelectedProviderType(){\r\n            return this.newRequest.selectedProviderType;\r\n        },\r\n\r\n        showCurrentlyContractedInput() {\r\n            return this.newRequest.selectedProviderType;\r\n        },\r\n\r\n        showPracticeTypes() {\r\n            return this.newRequest.selectedProviderType === 1;\r\n        },\r\n        otherPracticeTypeChecked() {\r\n            return this.newRequest.selectedPracticeType === 999;\r\n        },\r\n\r\n        showFacilityTypes() {\r\n            return this.newRequest.selectedProviderType === 2;\r\n        },\r\n        otherFacilityTypeChecked() {\r\n            return this.newRequest.selectedFacilityType === 999;\r\n        },\r\n        getSelectedFacilityTypes(){\r\n            return this.newRequest.selectedFacilityType;\r\n        },\r\n\r\n        showSpecialties(){\r\n            return this.newRequest.selectedProviderType === 1;\r\n        },\r\n\r\n        mhmdAppliedYes() {\r\n            return this.newRequest.mhmdApplied === 'Y';\r\n        },\r\n        mhmdApplicationStatusTermindated() {\r\n            return this.newRequest.mhmdApplicationStatus === 7;\r\n        },\r\n\r\n        otherPopulationTypeChecked() {\r\n            return this.newRequest.servesAges_Other === true;\r\n        },\r\n\r\n        otherLanguageChecked() {\r\n            return this.newRequest.selectedLanguages.includes(999);\r\n        },\r\n\r\n        requestSubmitted() {\r\n            return this.$store.state.requestSubmitted;\r\n        }\r\n    },\r\n\r\n    mounted () {\r\n        this.$nextTick(function (){\r\n            // Used to load mock data.\r\n            //this.$store.commit('request/initializeStateWithData');\r\n        })\r\n    },\r\n\r\n    methods: {\r\n        ...mapActions(\r\n            'request', {\r\n                loadAll: 'loadAll',\r\n                loadProviderTypes: 'loadProviderTypes',                \r\n                loadPracticeTypes: 'loadPracticeTypes',\r\n                loadFacilityTypes: 'loadFacilityTypes',\r\n                loadSpecialties: 'loadSpecialties',\r\n                loadLanguages: 'loadLanguages',\r\n                loadMHMDApplicationStatuses: 'loadMHMDApplicationStatuses',\r\n                addRequest: 'addRequest',\r\n                }\r\n        ),\r\n\r\n        providerTypeChange (checked) {\r\n            this.newRequest.associatedWithCurrentlyContractedEntity = null;\r\n\r\n            if(checked === 1) {\r\n                this.currentlyContractedQuestion = 'Is the practitioner joining a group that is currently contracted with Memorial Hermann Health Plan?';\r\n                this.newRequest.selectedFacilityType = '';\r\n                this.newRequest.otherFacilityTypeDescription = '';\r\n                this.disableOtherFacilityTypeInput = true;\r\n            }\r\n            if(checked === 2) {\r\n                this.currentlyContractedQuestion = 'Is this a new location for a company that is currently contracted with Memorial Hermann Health Plan?';\r\n                this.newRequest.selectedPracticeType = '';\r\n                this.newRequest.otherPracticeTypeDescription = '';\r\n                this.disableOtherPracticeTypeInput = true;\r\n                this.newRequest.practitionerName = '';\r\n            }\r\n        },\r\n                \r\n        otherPracticeTypeChange (checked) {\r\n            if(!this.$v.newRequest.otherPracticeTypeDescription.$dirty) {\r\n                this.$v.newRequest.otherPracticeTypeDescription.$touch();\r\n            }\r\n\r\n            switch(checked) {\r\n                case 999:\r\n                    this.disableOtherPracticeTypeInput = false;\r\n                    break;\r\n\r\n                default:\r\n                    this.newRequest.otherPracticeTypeDescription = '';\r\n                    this.disableOtherPracticeTypeInput = true;\r\n                    break;\r\n            }\r\n        },\r\n\r\n        otherFacilityTypeChange (checked) {\r\n            if(!this.$v.newRequest.otherFacilityTypeDescription.$dirty) {\r\n                this.$v.newRequest.otherFacilityTypeDescription.$touch();\r\n            }\r\n\r\n            switch(checked) {\r\n                case 999:\r\n                    this.disableOtherFacilityTypeInput = false;\r\n                    break;\r\n\r\n                default:\r\n                    this.newRequest.otherFacilityTypeDescription = '';\r\n                    this.disableOtherFacilityTypeInput = true;\r\n                    break;\r\n            }\r\n        },\r\n        \r\n        handleOkNewAddress(bvModalEvt) {\r\n            if(this.$v.newAddressValidation.$invalid){\r\n                this.$v.newAddressValidation.$touch();\r\n                bvModalEvt.preventDefault();\r\n                return;\r\n            }\r\n\r\n            if(this.addressModalAction === 'add') {\r\n\r\n                var maxId = 0;\r\n                maxId = Math.max(...this.newRequest.addresses.map(o => o.id), 0) + 1;\r\n\r\n                var newAddress = \r\n                {\r\n                    id: maxId,\r\n                    addressLine1: this.newAddress.addressLine1,\r\n                    suite: this.newAddress.suite,\r\n                    city: this.newAddress.city,\r\n                    state: this.newAddress.state,\r\n                    zipcode: this.newAddress.zipcode,\r\n                    isPrimary: this.newAddress.isPrimary,\r\n                };\r\n\r\n                this.$store.commit('request/addAddress', newAddress);\r\n                this.$bvModal.hide('add-address');\r\n\r\n            } else if (this.addressModalAction === 'edit') {\r\n                var updateAddress = \r\n                {\r\n                    id: this.newAddress.id,\r\n                    addressLine1: this.newAddress.addressLine1,\r\n                    suite: this.newAddress.suite,\r\n                    city: this.newAddress.city,\r\n                    state: this.newAddress.state,\r\n                    zipcode: this.newAddress.zipcode,\r\n                    isPrimary: this.newAddress.isPrimary,\r\n                };\r\n\r\n                this.$store.commit('request/updateAddress', updateAddress);\r\n                this.$bvModal.hide('add-address');                \r\n            }\r\n        },\r\n        handleCancelNewAddress() {\r\n            this.resetNewAddressState();\r\n            this.$bvModal.hide('add-address');\r\n        },\r\n\r\n        showAddressDialog (/*bvModalEvt*/){\r\n            if(this.addressModalAction === 'add') {\r\n                this.$store.commit('request/resetNewAddress');\r\n                this.resetNewAddressState();\r\n            } else if (this.addressModalAction === 'edit') {\r\n                this.resetNewAddressState();\r\n            }\r\n        },\r\n        hideAddressDialog (/*bvModalEvt*/) {\r\n            this.$store.commit('request/resetNewAddress');\r\n            this.resetNewAddressState();\r\n        },\r\n\r\n        resetNewAddress() {\r\n            if(this.addressModalAction === 'add')\r\n            {\r\n             this.$store.commit('request/resetNewAddress');\r\n             this.resetNewAddressState();\r\n            }\r\n        },\r\n        resetNewAddressState(){\r\n            this.$v.newAddressValidation.$reset();\r\n        },\r\n        addAddress() {\r\n            this.addressModalAction = 'add';\r\n            this.$bvModal.show('add-address');\r\n        },\r\n        editAddress(item /*, index, button */) {\r\n            //alert(`Button: ${button.innerHTML}\\n` + `Row index: ${index}\\n` + `Item:\\n ${JSON.stringify(item, null, 2)}`);\r\n            \r\n            this.addressModalAction = 'edit';\r\n            this.$store.commit('request/loadAddress', item.id);\r\n            this.$bvModal.show('add-address');\r\n\r\n        },\r\n        deleteAddress(item) {\r\n            this.$store.commit('request/deleteAddress', item.id)\r\n        },\r\n        zipCodeFormatter(value) {\r\n            var result = \"\";\r\n            if(value.length == 5)\r\n            {\r\n                result = value.substring(0, 5);\r\n            } else if (value.length == 9) { \r\n                result = value.substring(0, 5) + '-' + value.substring(5, 9);\r\n            }\r\n             \r\n            return `${result}`;\r\n        },\r\n        booleanToYNFormatter(value) {\r\n            return `${(value == null ? \"\" : value == \"true\" ? \"Yes\" : \"No\")}`;\r\n        },\r\n\r\n        onVerify: function (response) {\r\n            this.captchaVerified = true;\r\n            this.newRequest.captchaResponse = response;\r\n            \r\n            //eslint-disable-next-line no-console\r\n            //console.log('captchaResponse: [' + this.newRequest.captchaResponse + ']');\r\n        },\r\n        onExpired: function (){\r\n            this.captchaVerified = false;\r\n            this.newRequest.captchaResponse = '';\r\n\r\n            //eslint-disable-next-line no-console\r\n            //console.log('captchaResponse: [' + this.newRequest.captchaResponse + ']');            \r\n        },\r\n        onError: function (){\r\n            alert('Captcha Error');\r\n        },\r\n\r\n        submitForm(evt) {\r\n            evt.preventDefault();\r\n\r\n            this.$v.$touch();\r\n\r\n            // eslint-disable-next-line no-console\r\n            // console.log(JSON.stringify(this.newRequest));\r\n\r\n            // alert(this.$v.$error)            \r\n            // alert(JSON.stringify(this.$v.newRequest.contactName));\r\n            // alert(JSON.stringify(this.$v.newRequest.contactName.$error));\r\n            \r\n            if(this.$v.$invalid) {\r\n                alert('Some fields are either missing or incorrect. Please complete/correct them and try again.');\r\n            }\r\n            else if (!this.captchaVerified) {\r\n                alert(\"Please check the 'Im not a robot' checkbox on the right.\");\r\n            } else {\r\n                this.addRequest()\r\n                .then(() => {\r\n                    if(this.$store.state.requestSubmitted)\r\n                    {\r\n                        this.$store.dispatch('udpateStatus', 'print');\r\n                        this.$router.push('/printRequest');\r\n                    } else {\r\n                        if(this.$store.state.requestSubmitCount < 3) {\r\n                            var tryAgainMessage = 'Sorry but we seem to be experiencing difficulties submitting your request form.' + '\\n\\n';\r\n                            if(this.$store.state.requestSubmitCount === 1) {\r\n                                tryAgainMessage += 'Please check you have an internet connection and try submitting your request again.'\r\n                            } else if(this.$store.state.requestSubmitCount === 2) {\r\n                                tryAgainMessage += 'Please wait a few more seconds and try submitting your request once more.'\r\n                            }\r\n                            alert(tryAgainMessage);\r\n                        } else {\r\n                            var errorMessage = 'Sorry but we seem to be experiencing difficulties submitting your request form.' + '\\n\\n';\r\n                            errorMessage += 'You will be routed to a Print page so you can print your request form as a pdf and email it to MHHPContractingRFP@memorialhermann.org.';\r\n                            alert(errorMessage);\r\n\r\n                            this.$store.dispatch('udpateStatus', 'print');\r\n                            this.$router.push('/printRequest');                            \r\n                        }\r\n                    }\r\n\r\n                });\r\n            }\r\n        },\r\n        \r\n        //*** Determine if this is needed ***\r\n        printForm(evt) {\r\n            evt.preventDefault();\r\n\r\n            this.$store.dispatch('udpateStatus', 'print')\r\n            .then(this.$router.push('/printRequest'));\r\n        },\r\n\r\n        // *** Determine if this is needed ***\r\n        status(validation) {\r\n            return {\r\n                error: validation.$error,\r\n                dirty: validation.$dirty\r\n            }\r\n        },\r\n\r\n\r\n        otherPopulationTypeChange (checked) {\r\n            if(!this.$v.newRequest.otherPopulationTypeDescription.$dirty) {\r\n                this.$v.newRequest.otherPopulationTypeDescription.$touch();\r\n            }\r\n\r\n            if(!checked) {\r\n                this.newRequest.otherPopulationTypeDescription = '';\r\n                this.disableOtherPopulationTypeInput = true;\r\n            } else {\r\n                this.disableOtherPopulationTypeInput = false;\r\n            }\r\n        },\r\n\r\n        otherLanguageChange (checked) {\r\n            if(!this.$v.newRequest.otherLanguageDescription.$dirty) {\r\n                this.$v.newRequest.otherLanguageDescription.$touch();\r\n            }\r\n\r\n            if(checked == null) {\r\n                this.newRequest.otherLanguageDescription = '';\r\n                this.disableOtherLanguageInput = true;\r\n            } else {\r\n                this.disableOtherLanguageInput = false;\r\n            }\r\n        },\r\n\r\n        mhmdAppliedChange (checked) {\r\n            if(this.$v.newRequest.mhmdApplicationStatus.$dirty) {\r\n                this.$v.newRequest.mhmdApplicationStatus.$reset();\r\n            }\r\n\r\n            if(checked == null || checked === 'N') {\r\n                this.newRequest.mhmdApplicationStatus = '';\r\n                this.newRequest.mhmdTerminatedDate = '';\r\n            }\r\n        },\r\n        mhmdApplicationStatusChange (value) {\r\n            if(value != 7) {\r\n                this.newRequest.mhmdTerminatedDate = '';\r\n            }\r\n        },\r\n    },\r\n\r\n    watch: {\r\n        getSelectedProviderType() {\r\n            if(this.newRequest.selectedProviderType !== 1)\r\n            {\r\n                if(this.$v.newRequest.primarySpecialty.$dirty) {\r\n                    this.$v.newRequest.primarySpecialty.$reset();\r\n                }\r\n\r\n                this.newRequest.primarySpecialty = null;\r\n                this.newRequest.secondarySpecialty = null;\r\n            }\r\n\r\n            if(this.$v.newRequest.associatedWithCurrentlyContractedEntity.$dirty) {\r\n                this.$v.newRequest.associatedWithCurrentlyContractedEntity.$reset();\r\n            }\r\n        },\r\n\r\n        getSelectedFacilityTypes() {\r\n            if(this.showFacilityTypes\r\n                && this.optionsFacilityTypes.filter(ft => ft.EnableAdditionalDetails === true).map(function(a) {return a.Id}).includes(this.newRequest.selectedFacilityType))\r\n            {\r\n                this.showServiceAreasinput = true;\r\n            } else {\r\n                this.newRequest.serviceAreas = '';\r\n                this.showServiceAreasinput = false;\r\n            }\r\n        },\r\n        // newRequest: {\r\n        //     // eslint-disable-next-line no-unused-vars\r\n        //     handler(val, oldVal) {\r\n        //         this.modelIsDirty = true;\r\n        //         // eslint-disable-next-line no-console                \r\n        //         console.log('modelIsDirty: ' + this.modelIsDirty);\r\n        //     },\r\n        //     deep: true\r\n        // },\r\n    },\r\n    components: {\r\n        'vue-recaptcha': VueRecaptcha\r\n    },    \r\n}\r\n</script>\r\n\r\n<style scoped>\r\n/* @media print {\r\n  body {-webkit-print-color-adjust: exact;}\r\n}\r\n@page {\r\n    size:A4 landscape;\r\n    margin-left: 0px;\r\n    margin-right: 0px;\r\n    margin-top: 0px;\r\n    margin-bottom: 0px;\r\n    margin: 0;\r\n    -webkit-print-color-adjust: exact;\r\n} */\r\n.formDisclaimer {\r\n    color:green;\r\n    font-size: small;\r\n    font-weight: bolder;\r\n    padding-bottom: 5px;\r\n}\r\n.grp-caption {\r\n    font-size: large;\r\n    font-weight: bolder;\r\n    padding-bottom: 5px;\r\n    display:flexbox;\r\n}\r\nhr.sectionBorder {\r\n  border: 1px dashed black;\r\n}\r\nh6.sectionCaption {\r\n  font-weight: bold;\r\n  text-align: center\r\n}\r\n\r\n/* input {\r\n  border: 1px solid silver;\r\n  border-radius: 4px;\r\n  background: white;\r\n  padding: 5px 10px;\r\n}\r\n.dirty {\r\n  border-color: #5A5;\r\n  background: #EFE;\r\n}\r\n.dirty:focus {\r\n  outline-color: #8E8;\r\n}\r\n.error {\r\n  border-color: red;\r\n  background: #FDD;\r\n}\r\n.error:focus {\r\n  outline-color: #F99;\r\n}\r\n */\r\n.form-control.is-invalid{\r\n    background-image: none;\r\n}\r\n.form-control.is-valid{\r\n    background-image: none;\r\n}\r\n/* .custom-select.is-invalid {\r\n    background-image: none;    \r\n} */\r\n/* .custom-select.is-valid {\r\n    background-image: none;\r\n} */\r\n.d-block {\r\n    display: inline !important;\r\n}\r\n.facility-additional-details-indicator {\r\n    color: red;\r\n}\r\n/* .checkbox.checked:after {\r\n  content: '';\r\n  display: block;\r\n  width: 4px;\r\n  height: 7px;\r\n  \r\n   position:relative;\r\n  top:4px;\r\n  left:7px;\r\n  \r\n  border: solid #000;\r\n  border-width: 0 2px 2px 0;\r\n  transform: rotate(45deg);\r\n} */\r\n</style>","import mod from \"-!../../node_modules/cache-loader/dist/cjs.js??ref--12-0!../../node_modules/thread-loader/dist/cjs.js!../../node_modules/babel-loader/lib/index.js!../../node_modules/cache-loader/dist/cjs.js??ref--0-0!../../node_modules/vue-loader/lib/index.js??vue-loader-options!./SubmitRequest.vue?vue&type=script&lang=js&\"; export default mod; export * from \"-!../../node_modules/cache-loader/dist/cjs.js??ref--12-0!../../node_modules/thread-loader/dist/cjs.js!../../node_modules/babel-loader/lib/index.js!../../node_modules/cache-loader/dist/cjs.js??ref--0-0!../../node_modules/vue-loader/lib/index.js??vue-loader-options!./SubmitRequest.vue?vue&type=script&lang=js&\"","import { render, staticRenderFns } from \"./SubmitRequest.vue?vue&type=template&id=03816b10&scoped=true&\"\nimport script from \"./SubmitRequest.vue?vue&type=script&lang=js&\"\nexport * from \"./SubmitRequest.vue?vue&type=script&lang=js&\"\nimport style0 from \"./SubmitRequest.vue?vue&type=style&index=0&id=03816b10&scoped=true&lang=css&\"\n\n\n/* normalize component */\nimport normalizer from \"!../../node_modules/vue-loader/lib/runtime/componentNormalizer.js\"\nvar component = normalizer(\n  script,\n  render,\n  staticRenderFns,\n  false,\n  null,\n  \"03816b10\",\n  null\n  \n)\n\nexport default component.exports","var render = function () {var _vm=this;var _h=_vm.$createElement;var _c=_vm._self._c||_h;return _c('div',[(this.$store.state.requestSubmitted)?_c('b-container',{staticClass:\"confirmation-print\",staticStyle:{\"border-color\":\"green\"},attrs:{\"fluid\":\"\"}},[_c('b-row',{staticClass:\"text-left\"},[_c('b-col',{attrs:{\"cols\":\"auto\"}},[_c('span',{staticStyle:{\"font-size\":\"20px\",\"font-weight\":\"bold\",\"color\":\"green\"}},[_vm._v(\"Thank you, your request has been submitted.\")]),_c('br'),_c('span',{staticStyle:{\"font-size\":\"14px\"}},[_vm._v(\"Please check your email for a submission confirmation.\")]),_c('br'),_c('br'),_c('span',{staticStyle:{\"font-size\":\"16px\"}},[_vm._v(\"Your Reference Number: \"+_vm._s(this.newRequest.id))]),_c('br')]),_c('b-col',{attrs:{\"cols\":\"auto\"}},[_c('b-button',{attrs:{\"type\":\"submit\",\"variant\":\"primary\"},on:{\"click\":_vm.printForm}},[_vm._v(\"Print\")])],1)],1)],1):_c('b-container',{staticClass:\"confirmation-print\",staticStyle:{\"border-color\":\"red\"},attrs:{\"fluid\":\"\"}},[_c('b-row',{staticClass:\"text-left\"},[_c('b-col',{attrs:{\"cols\":\"auto\"}},[_c('span',{staticStyle:{\"font-size\":\"20px\",\"font-weight\":\"bold\",\"color\":\"red\"}},[_vm._v(\"Your request was NOT submitted.\")]),_c('br'),_c('span',{staticStyle:{\"font-size\":\"14px\"}},[_vm._v(\"There was a problem submitting your request.\")]),_c('br'),_c('span',{staticStyle:{\"font-size\":\"14px\"}},[_vm._v(\"You can try again later or print your request and email it to MHHPContractingRFP@memorialhermann.org.\")]),_c('br')]),_c('b-col',{attrs:{\"cols\":\"auto\"}},[_c('b-button',{attrs:{\"type\":\"submit\",\"variant\":\"primary\"},on:{\"click\":_vm.printForm}},[_vm._v(\"Print\")])],1)],1)],1),_c('br'),_c('hr',{staticClass:\"sectionBorder\"}),_c('h6',{staticClass:\"sectionCaption\"},[_vm._v(\"CONTACT INFORMATION\")]),_c('b-container',{attrs:{\"fluid\":\"\"}},[_c('b-row',[_c('b-col',{attrs:{\"cols\":\"5\"}},[_c('span',{staticClass:\"normal-caption\"},[_vm._v(\"Name\")]),_c('br'),_c('div',{staticClass:\"textbox-print\"},[_vm._v(\" \"+_vm._s(this.newRequest.contactName != \"\" ? this.newRequest.contactName : \"‌\")+\" \")])]),_c('b-col',{attrs:{\"cols\":\"7\"}},[_c('span',{staticClass:\"normal-caption\"},[_vm._v(\"Email\")]),_c('br'),_c('div',{staticClass:\"textbox-print\"},[_vm._v(\" \"+_vm._s(this.newRequest.contactEmail != \"\" ? this.newRequest.contactEmail : \"‌\")+\" \")])])],1),_c('b-row',[_c('b-col',{attrs:{\"cols\":\"12\"}},[_c('br')])],1),_c('b-row',[_c('b-col',{attrs:{\"cols\":\"3\"}},[_c('span',{staticClass:\"normal-caption\"},[_vm._v(\"Phone\")]),_c('br'),_c('div',{staticClass:\"textbox-print\"},[_vm._v(\" \"+_vm._s(this.newRequest.contactPhone != \"\" ? this.newRequest.contactPhone : \"‌\")+\" \")])]),_c('b-col',{attrs:{\"cols\":\"3\"}},[_c('span',{staticClass:\"normal-caption\"},[_vm._v(\"Fax\")]),_c('br'),_c('div',{staticClass:\"textbox-print\"},[_vm._v(\" \"+_vm._s(this.newRequest.contactFax != \"\" ? this.newRequest.contactFax : \"‌\")+\" \")])])],1),_c('b-row',[_c('b-col',{attrs:{\"cols\":\"12\"}},[_c('br')])],1)],1),_c('hr',{staticClass:\"sectionBorder\"}),_c('h6',{staticClass:\"sectionCaption\"},[_vm._v(\"PRACTICE INFORMATION\")]),_c('b-container',{attrs:{\"fluid\":\"\"}},[_c('b-row',[_c('b-col',{attrs:{\"cols\":\"12\"}},[_c('div',[_c('div',{staticClass:\"grp-caption\"},[_vm._v(\"Provider Type: \"),_c('span',{staticClass:\"normal-text\"},[_vm._v(_vm._s(_vm.getSelectedProviderType().Description))])])])])],1),_c('b-row',[_c('b-col',{attrs:{\"cols\":\"12\"}},[_c('br')])],1),(_vm.showPracticeTypes)?_c('div',[_c('b-row',[_c('b-col',{attrs:{\"cols\":\"12\"}},[_c('div',[_c('div',{staticClass:\"grp-caption\"},[_vm._v(\"Practice Type: \"),_c('span',{staticClass:\"normal-text\"},[_vm._v(_vm._s(_vm.getSelectedPracticeType().Description))])])])])],1),(_vm.otherPracticeTypeChecked)?_c('b-row',[_c('b-col',{attrs:{\"cols\":\"12\"}},[_c('div',{staticClass:\"textbox-print\"},[_vm._v(\" \"+_vm._s(this.newRequest.otherPracticeTypeDescription)+\" \")])])],1):_vm._e(),_c('b-row',[_c('b-col',{attrs:{\"cols\":\"12\"}},[_c('br')])],1),_c('b-row',[_c('b-col',{attrs:{\"cols\":\"12\"}},[_c('span',{staticClass:\"normal-caption\"},[_vm._v(\"Is the practitioner joining a group that is currently contracted with Memorial Hermann Health Plan?\")]),_c('span',{staticStyle:{\"padding-left\":\"5px\",\"padding-right\":\"20px\"}},[_vm._v(_vm._s(this.newRequest.associatedWithCurrentlyContractedEntity != null ? this.newRequest.associatedWithCurrentlyContractedEntity === 'Y' ? 'Yes' : 'No' : ''))])])],1),_c('b-row',[_c('b-col',{attrs:{\"cols\":\"12\"}},[_c('br')])],1)],1):_vm._e(),(_vm.showFacilityTypes)?_c('div',[_c('b-row',[_c('b-col',{attrs:{\"cols\":\"12\"}},[_c('div',[_c('div',{staticClass:\"grp-caption\"},[_vm._v(\"Facility Type: \"),_c('span',{staticClass:\"normal-text\"},[_vm._v(_vm._s(_vm.getSelectedFacilityType().Description))])])])])],1),(_vm.otherFacilityTypeChecked)?_c('b-row',[_c('b-col',{attrs:{\"cols\":\"12\"}},[_c('div',{staticClass:\"textbox-print\"},[_vm._v(\" \"+_vm._s(this.newRequest.otherFacilityTypeDescription)+\" \")])])],1):_vm._e(),_c('b-row',[_c('b-col',{attrs:{\"cols\":\"12\"}},[_c('br')])],1),_c('b-row',[_c('b-col',{attrs:{\"cols\":\"12\"}},[_c('span',{staticClass:\"normal-caption\"},[_vm._v(\"Is this a new location for a company that is currently contracted with Memorial Hermann Health Plan?\")]),_c('span',{staticStyle:{\"padding-left\":\"5px\",\"padding-right\":\"20px\"}},[_vm._v(_vm._s(this.newRequest.associatedWithCurrentlyContractedEntity != null ? this.newRequest.associatedWithCurrentlyContractedEntity === 'Y' ? 'Yes' : 'No' : ''))])])],1),_c('b-row',[_c('b-col',{attrs:{\"cols\":\"12\"}},[_c('br')])],1)],1):_vm._e(),(_vm.showServiceAreasinput)?_c('b-row',[_c('b-col',{attrs:{\"cols\":\"12\"}},[_c('span',{staticClass:\"normal-caption\"},[_vm._v(\"Service Areas (For Home Health; mobile providers and mail-order DME providers ONLY):\")]),_c('br'),_c('div',{staticClass:\"textbox-print\"},[_vm._v(\" \"+_vm._s(this.newRequest.serviceAreas != \"\" ? this.newRequest.serviceAreas : \"‌\")+\" \")])])],1):_vm._e()],1),_c('hr',{staticClass:\"sectionBorder\"}),_c('h6',{staticClass:\"sectionCaption\"},[_vm._v(\"DEMOGRAPHIC INFORMATION\")]),_c('b-container',{attrs:{\"fluid\":\"\"}},[_c('b-row',[(_vm.showPracticeTypes)?_c('b-col',{attrs:{\"cols\":\"6\"}},[_c('span',{staticClass:\"normal-caption\"},[_vm._v(\"Practitioner Name\")]),_c('br'),_c('div',{staticClass:\"textbox-print\"},[_vm._v(\" \"+_vm._s(this.newRequest.practitionerName != \"\" ? this.newRequest.practitionerName : \"‌\")+\" \")])]):_vm._e(),_c('b-col',{attrs:{\"cols\":\"2\"}},[_c('span',{staticClass:\"normal-caption\"},[_vm._v(\"Tax ID #\")]),_c('br'),_c('div',{staticClass:\"textbox-print\"},[_vm._v(\" \"+_vm._s(this.newRequest.taxId != \"\" ? this.newRequest.taxId : \"‌\")+\" \")])]),_c('b-col',{attrs:{\"cols\":\"2\"}},[_c('span',{staticClass:\"normal-caption\"},[_vm._v(\"NPI\")]),_c('br'),_c('div',{staticClass:\"textbox-print\"},[_vm._v(\" \"+_vm._s(this.newRequest.npi != \"\" ? this.newRequest.npi : \"‌\")+\" \")])]),_c('b-col',{attrs:{\"cols\":\"2\"}},[_c('span',{staticClass:\"normal-caption\"},[_vm._v(\"CAQH\")]),_c('br'),_c('div',{staticClass:\"textbox-print\"},[_vm._v(\" \"+_vm._s(this.newRequest.caqh != \"\" ? this.newRequest.caqh : \"‌\")+\" \")])])],1),_c('b-row',[_c('b-col',{attrs:{\"cols\":\"12\"}},[_c('br')])],1),_c('b-row',[_c('b-col',{attrs:{\"cols\":\"3\"}},[_c('span',{staticClass:\"normal-caption\"},[_vm._v(\"Business Phone\")]),_c('br'),_c('div',{staticClass:\"textbox-print\"},[_vm._v(\" \"+_vm._s(this.newRequest.businessPhone != \"\" ? this.newRequest.businessPhone : \"‌\")+\" \")])]),_c('b-col',{attrs:{\"cols\":\"2\"}},[_c('span',{staticClass:\"normal-caption\"},[_vm._v(\"Extension\")]),_c('br'),_c('div',{staticClass:\"textbox-print\"},[_vm._v(\" \"+_vm._s(this.newRequest.businessPhoneExtension != \"\" ? this.newRequest.businessPhoneExtension : \"‌\")+\" \")])]),_c('b-col',{attrs:{\"cols\":\"3\"}},[_c('span',{staticClass:\"normal-caption\"},[_vm._v(\"Business Fax\")]),_c('br'),_c('div',{staticClass:\"textbox-print\"},[_vm._v(\" \"+_vm._s(this.newRequest.businessFax != \"\" ? this.newRequest.businessFax : \"‌\")+\" \")])]),_c('b-col',{attrs:{\"cols\":\"4\"}},[_c('span',{staticClass:\"normal-caption\"},[_vm._v(\"Business Email\")]),_c('br'),_c('div',{staticClass:\"textbox-print\"},[_vm._v(\" \"+_vm._s(this.newRequest.businessEmail != \"\" ? this.newRequest.businessEmail : \"‌\")+\" \")])])],1),_c('b-row',[_c('b-col',{attrs:{\"cols\":\"12\"}},[_c('br')])],1),_c('b-row',{directives:[{name:\"show\",rawName:\"v-show\",value:(_vm.showSpecialties),expression:\"showSpecialties\"}]},[_c('b-col',{attrs:{\"cols\":\"6\"}},[_c('span',{staticClass:\"normal-caption\"},[_vm._v(\"Primary Specialty\")]),_c('br'),_c('div',{staticClass:\"textbox-print\"},[_vm._v(\" \"+_vm._s(this.getPrimarySpecialty() != undefined ? this.getPrimarySpecialty().Description : \"‌\")+\" \")])]),_c('b-col',{attrs:{\"cols\":\"6\"}},[_c('span',{staticClass:\"normal-caption\"},[_vm._v(\"Secondary Specialty\")]),_c('br'),_c('div',{staticClass:\"textbox-print\"},[_vm._v(\" \"+_vm._s(this.getSecondarySpecialty() != undefined ? this.getSecondarySpecialty().Description : \"‌\")+\" \")])])],1),_c('b-row',{directives:[{name:\"show\",rawName:\"v-show\",value:(_vm.showSpecialties),expression:\"showSpecialties\"}]},[_c('b-col',{attrs:{\"cols\":\"12\"}},[_c('br')])],1),_c('b-row',[_c('b-col',{attrs:{\"cols\":\"6\"}},[_c('span',{staticClass:\"normal-caption\"},[_vm._v(\"Business Name\")]),_c('br'),_c('div',{staticClass:\"textbox-print\"},[_vm._v(\" \"+_vm._s(this.newRequest.businessName != \"\" ? this.newRequest.businessName : \"‌\")+\" \")])])],1),_c('b-row',[_c('b-col',{attrs:{\"cols\":\"12\"}},[_c('br')])],1),_c('b-row',[_c('b-col',{attrs:{\"cols\":\"9\"}},[_c('span',{staticClass:\"normal-caption\"},[_vm._v(\"Address\")]),_c('br'),_c('div',{staticClass:\"textbox-print\"},[_vm._v(\" \"+_vm._s(this.newRequest.primaryAddress.addressLine1 != \"\" ? this.newRequest.primaryAddress.addressLine1 : \"‌\")+\" \")])]),_c('b-col',{attrs:{\"cols\":\"3\"}},[_c('span',{staticClass:\"normal-caption\"},[_vm._v(\"Suite\")]),_c('br'),_c('div',{staticClass:\"textbox-print\"},[_vm._v(\" \"+_vm._s(this.newRequest.primaryAddress.suite != \"\" ? this.newRequest.primaryAddress.suite : \"‌\")+\" \")])])],1),_c('b-row',[_c('b-col',{attrs:{\"cols\":\"12\"}},[_c('br')])],1),_c('b-row',[_c('b-col',{attrs:{\"cols\":\"5\"}},[_c('span',{staticClass:\"normal-caption\"},[_vm._v(\"City\")]),_c('br'),_c('div',{staticClass:\"textbox-print\"},[_vm._v(\" \"+_vm._s(this.newRequest.primaryAddress.city != \"\" ? this.newRequest.primaryAddress.city : \"‌\")+\" \")])]),_c('b-col',{attrs:{\"cols\":\"2\"}},[_c('span',{staticClass:\"normal-caption\"},[_vm._v(\"State\")]),_c('br'),_c('div',{staticClass:\"textbox-print\"},[_vm._v(\" \"+_vm._s(this.newRequest.primaryAddress.state != \"\" ? this.newRequest.primaryAddress.state : \"‌\")+\" \")])]),_c('b-col',{attrs:{\"cols\":\"4\"}},[_c('span',{staticClass:\"normal-caption\"},[_vm._v(\"Zip Code\")]),_c('br'),_c('div',{staticClass:\"textbox-print\"},[_vm._v(\" \"+_vm._s(this.newRequest.primaryAddress.zipcode != \"\" ? this.newRequest.primaryAddress.zipcode : \"‌\")+\" \")])])],1),_c('b-row',[_c('b-col',{attrs:{\"cols\":\"12\"}},[_c('br')])],1),_c('b-row',[_c('b-col',{attrs:{\"cols\":\"12\"}},[_c('br'),_c('span',{staticClass:\"normal-caption\"},[_vm._v(\"Additional Addresses:\")]),_c('br')])],1),_c('b-row',[_c('b-col',{attrs:{\"cols\":\"12\"}},[_c('b-table',{attrs:{\"responsive\":\"\",\"outlined\":\"\",\"id\":\"addresses\",\"items\":this.newRequest.addresses,\"fields\":this.addressesFields}})],1)],1)],1),_c('hr',{staticClass:\"sectionBorder\"}),_c('h6',{staticClass:\"sectionCaption\"},[_vm._v(\"SERVICE INFORMATION\")]),_c('b-container',{attrs:{\"fluid\":\"\"}},[_c('b-row',[_c('b-col',{attrs:{\"cols\":\"12\"}},[_c('div',[_c('div',{staticClass:\"grp-caption\"},[_vm._v(\"Ages Served\")])])])],1),_c('b-row',[(this.newRequest.servesAges_0_2)?_c('b-col',{attrs:{\"cols\":\"2\"}},[_vm._v(\"0-2 Years\")]):_vm._e(),(this.newRequest.servesAges_2_18)?_c('b-col',{attrs:{\"cols\":\"2\"}},[_vm._v(\"2-18 Years\")]):_vm._e(),(this.newRequest.servesAges_18_Plus)?_c('b-col',{attrs:{\"cols\":\"2\"}},[_vm._v(\"18+ Years\")]):_vm._e(),(this.newRequest.servesAges_Geriatric)?_c('b-col',{attrs:{\"cols\":\"2\"}},[_vm._v(\"Geriatrics\")]):_vm._e()],1),(_vm.otherPopulationTypeChecked)?_c('b-row',[_c('b-col',{attrs:{\"cols\":\"12\"}},[_c('br'),_vm._v(\" Other Ages Served: \"),_c('br'),_c('div',{staticClass:\"textbox-print\"},[_vm._v(\" \"+_vm._s(this.newRequest.otherPopulationTypeDescription)+\" \")])])],1):_vm._e(),_c('b-row',[_c('b-col',{staticStyle:{\"padding-left\":\"0px\",\"padding-right\":\"0px\"},attrs:{\"cols\":\"6\"}},[_c('b-container',{attrs:{\"fluid\":\"\"}},[_c('b-row',[_c('b-col',[_c('br'),_c('span',{staticClass:\"normal-caption\"},[_vm._v(\"Languages Spoken (other than English)\")]),_c('br')])],1),_c('b-row',[_c('b-col',[_c('div',{staticStyle:{\"margin-top\":\"5px\",\"border\":\"1px solid rgb(206, 212, 218)\",\"border-radius\":\"0.25rem\",\"padding\":\"3px\"}},_vm._l((_vm.getSelectedLanguages()),function(language){return _c('span',{key:language.Id},[_vm._v(_vm._s(language.Description)+\" \"),_c('br')])}),0)])],1),(_vm.otherLanguageChecked)?_c('b-row',[_c('b-col',[_c('br'),_vm._v(\" Other Languages Spoken \"),_c('br'),_c('div',{staticClass:\"textbox-print\"},[_vm._v(\" \"+_vm._s(this.newRequest.otherLanguageDescription)+\" \")])])],1):_vm._e()],1)],1),_c('b-col',{staticStyle:{\"padding-left\":\"0px\",\"padding-right\":\"0px\"},attrs:{\"cols\":\"6\"}},[_c('b-container',{attrs:{\"fluid\":\"\"}},[_c('b-row',[_c('b-col',[_c('br'),_c('span',{staticClass:\"normal-caption\"},[_vm._v(\"Office Hours\")]),_c('br')])],1),_c('b-row',[_c('b-col',[_c('b-container',{staticStyle:{\"margin-top\":\"5px\",\"border\":\"1px solid rgb(206, 212, 218)\",\"border-radius\":\"0.25rem\",\"padding\":\"5px\",\"overflow-x\":\"hidden !important\",\"overflow-y\":\"hidden\"},attrs:{\"fluid\":\"\"}},[_c('b-row',[_c('b-col',{staticClass:\"weekdayCaption\",attrs:{\"cols\":\"2\"}},[_vm._v(\" Monday: \")]),_c('b-col',{staticClass:\"weekdayTextContainer\",attrs:{\"cols\":\"10\"}},[_c('div',{staticClass:\"textbox-print\"},[_vm._v(\" \"+_vm._s(this.newRequest.officeHoursMonday != \"\" ? this.newRequest.officeHoursMonday : \"‌\")+\" \")])])],1),_c('b-row',[_c('b-col',{staticClass:\"weekdayCaption\",attrs:{\"cols\":\"2\"}},[_c('span',{staticClass:\"normal-text\",staticStyle:{\"text-align\":\"right !important\"}},[_vm._v(\"Tuesday:\")])]),_c('b-col',{staticClass:\"weekdayTextContainer\",attrs:{\"cols\":\"10\"}},[_c('div',{staticClass:\"textbox-print\"},[_vm._v(\" \"+_vm._s(this.newRequest.officeHoursTuesday != \"\" ? this.newRequest.officeHoursTuesday : \"‌\")+\" \")])])],1),_c('b-row',[_c('b-col',{staticClass:\"weekdayCaption\",attrs:{\"cols\":\"2\"}},[_c('span',{staticClass:\"normal-text\",staticStyle:{\"text-align\":\"right !important\"}},[_vm._v(\"Wednesday:\")])]),_c('b-col',{staticClass:\"weekdayTextContainer\",attrs:{\"cols\":\"10\"}},[_c('div',{staticClass:\"textbox-print\"},[_vm._v(\" \"+_vm._s(this.newRequest.officeHoursWednesday != \"\" ? this.newRequest.officeHoursWednesday : \"‌\")+\" \")])])],1),_c('b-row',[_c('b-col',{staticClass:\"weekdayCaption\",attrs:{\"cols\":\"2\"}},[_c('span',{staticClass:\"normal-text\",staticStyle:{\"text-align\":\"right !important\"}},[_vm._v(\"Thursday:\")])]),_c('b-col',{staticClass:\"weekdayTextContainer\",attrs:{\"cols\":\"10\"}},[_c('div',{staticClass:\"textbox-print\"},[_vm._v(\" \"+_vm._s(this.newRequest.officeHoursThursday != \"\" ? this.newRequest.officeHoursThursday : \"‌\")+\" \")])])],1),_c('b-row',[_c('b-col',{staticClass:\"weekdayCaption\",attrs:{\"cols\":\"2\"}},[_c('span',{staticClass:\"normal-text\",staticStyle:{\"text-align\":\"right !important\"}},[_vm._v(\"Friday:\")])]),_c('b-col',{staticClass:\"weekdayTextContainer\",attrs:{\"cols\":\"10\"}},[_c('div',{staticClass:\"textbox-print\"},[_vm._v(\" \"+_vm._s(this.newRequest.officeHoursFriday != \"\" ? this.newRequest.officeHoursFriday : \"‌\")+\" \")])])],1),_c('b-row',[_c('b-col',{staticClass:\"weekdayCaption\",attrs:{\"cols\":\"2\"}},[_c('span',{staticClass:\"normal-text\",staticStyle:{\"text-align\":\"right !important\"}},[_vm._v(\"Saturday:\")])]),_c('b-col',{staticClass:\"weekdayTextContainer\",attrs:{\"cols\":\"10\"}},[_c('div',{staticClass:\"textbox-print\"},[_vm._v(\" \"+_vm._s(this.newRequest.officeHoursSaturday != \"\" ? this.newRequest.officeHoursSaturday : \"‌\")+\" \")])])],1),_c('b-row',[_c('b-col',{staticClass:\"weekdayCaption\",attrs:{\"cols\":\"2\"}},[_c('span',{staticClass:\"normal-text\",staticStyle:{\"text-align\":\"right !important\"}},[_vm._v(\"Sunday:\")])]),_c('b-col',{staticClass:\"weekdayTextContainer\",attrs:{\"cols\":\"10\"}},[_c('div',{staticClass:\"textbox-print\"},[_vm._v(\" \"+_vm._s(this.newRequest.officeHoursSunday != \"\" ? this.newRequest.officeHoursSunday : \"‌\")+\" \")])])],1)],1)],1)],1)],1)],1)],1)],1),_c('hr',{staticClass:\"sectionBorder\"}),_c('h6',{staticClass:\"sectionCaption\"},[_vm._v(\"NETWORK AFFILIATIONS\")]),_c('b-container',{attrs:{\"fluid\":\"\"}},[_c('b-row',[_c('b-col',{attrs:{\"cols\":\"12\"}},[_c('span',{staticClass:\"normal-caption\"},[_vm._v(\"Have you ever applied to MHMD?\")]),_c('span',{staticStyle:{\"padding-left\":\"5px\",\"padding-right\":\"20px\"}},[_vm._v(_vm._s(this.newRequest.mhmdApplied != null ? this.newRequest.mhmdApplied === 'Y' ? 'Yes' : 'No' : ''))]),(_vm.mhmdAppliedYes)?_c('span',{staticClass:\"normal-caption\"},[_vm._v(\"Application Status:\")]):_vm._e(),(_vm.mhmdAppliedYes)?_c('span',{staticStyle:{\"padding-left\":\"5px\",\"padding-right\":\"20px\"}},[_vm._v(_vm._s(this.getMHMDApplicationStatus() != undefined ? this.getMHMDApplicationStatus().Description : \"‌\"))]):_vm._e(),(_vm.mhmdAppliedYes && this.newRequest.mhmdApplicationStatus === 7)?_c('span',{staticClass:\"normal-caption\"},[_vm._v(\"Terminated Date:\")]):_vm._e(),(_vm.mhmdAppliedYes && this.newRequest.mhmdApplicationStatus === 7)?_c('span',{staticStyle:{\"padding-left\":\"5px\"}},[_vm._v(_vm._s(this.newRequest.mhmdTerminatedDate))]):_vm._e()])],1),_c('b-row',[_c('b-col',{attrs:{\"cols\":\"12\"}},[_c('br')])],1),_c('b-row',[_c('b-col',{attrs:{\"cols\":\"12\"}},[_c('span',{staticClass:\"normal-caption\"},[_vm._v(\"Other Network/IPA/PHO Affliations\")]),_c('br'),_c('div',{staticClass:\"textbox-print\"},[_vm._v(\" \"+_vm._s(this.newRequest.otherIPAPHOAffiliations != \"\" ? this.newRequest.otherIPAPHOAffiliations : \"‌\")+\" \")])])],1),_c('b-row',[_c('b-col',{attrs:{\"cols\":\"12\"}},[_c('br')])],1)],1),_c('hr',{staticClass:\"sectionBorder\"}),_c('h6',{staticClass:\"sectionCaption\"},[_vm._v(\"CREDENTIALING CONTACT INFORMATION\")]),_c('b-container',{attrs:{\"fluid\":\"\"}},[_c('b-row',[_c('b-col',{attrs:{\"cols\":\"4\"}},[_c('span',{staticClass:\"normal-caption\"},[_vm._v(\"Credentialing Contact:\")]),_c('br'),_c('div',{staticClass:\"textbox-print\"},[_vm._v(\" \"+_vm._s(this.newRequest.credentialingContactName != \"\" ? this.newRequest.credentialingContactName : \"‌\")+\" \")])]),_c('b-col',{attrs:{\"cols\":\"4\"}},[_c('span',{staticClass:\"normal-caption\"},[_vm._v(\"Credentialing Contact E-mail Address:\")]),_c('br'),_c('div',{staticClass:\"textbox-print\"},[_vm._v(\" \"+_vm._s(this.newRequest.credentialingContactEmail != \"\" ? this.newRequest.credentialingContactEmail : \"‌\")+\" \")])]),_c('b-col',{attrs:{\"cols\":\"4\"}},[_c('span',{staticClass:\"normal-caption\"},[_vm._v(\"Credentialing Contact Phone #:\")]),_c('br'),_c('div',{staticClass:\"textbox-print\"},[_vm._v(\" \"+_vm._s(this.newRequest.credentialingContactPhone != \"\" ? this.newRequest.credentialingContactPhone : \"‌\")+\" \")])])],1)],1)],1)}\nvar staticRenderFns = []\n\nexport { render, staticRenderFns }","<template>\r\n    <div>\r\n        <!-- Confirmation / Print Button -->\r\n        <b-container v-if=\"this.$store.state.requestSubmitted\" fluid class=\"confirmation-print\" style=\"border-color: green;\">\r\n            <b-row class=\"text-left\">\r\n                <b-col cols=\"auto\">\r\n                    <span style=\"font-size: 20px; font-weight: bold; color: green;\">Thank you, your request has been submitted.</span>\r\n                    <br/>\r\n                    <span style=\"font-size: 14px;\">Please check your email for a submission confirmation.</span>\r\n                    <br/><br/>\r\n                    <span style=\"font-size: 16px;\">Your Reference Number: {{ this.newRequest.id }}</span>\r\n                    <br/>\r\n                </b-col>\r\n                <b-col cols=\"auto\">\r\n                    <b-button type=\"submit\" @click=\"printForm\" variant=\"primary\">Print</b-button>    \r\n                </b-col>\r\n            </b-row>\r\n        </b-container>\r\n        <b-container v-else fluid class=\"confirmation-print\"  style=\"border-color: red;\">\r\n            <b-row class=\"text-left\">\r\n                <b-col cols=\"auto\">\r\n                        <span style=\"font-size: 20px; font-weight: bold; color: red;\">Your request was NOT submitted.</span>\r\n                        <br/>\r\n                        <span style=\"font-size: 14px;\">There was a problem submitting your request.</span>\r\n                        <br/>\r\n                        <span style=\"font-size: 14px;\">You can try again later or print your request and email it to MHHPContractingRFP@memorialhermann.org.</span>\r\n                        <br/>\r\n                </b-col>\r\n                <b-col cols=\"auto\">\r\n                    <b-button type=\"submit\" @click=\"printForm\" variant=\"primary\">Print</b-button>    \r\n                </b-col>\r\n            </b-row>            \r\n        </b-container>\r\n\r\n        <br/>\r\n        <hr class=\"sectionBorder\">\r\n        <h6 class=\"sectionCaption\">CONTACT INFORMATION</h6>\r\n        <b-container fluid>\r\n            <!-- Contact Information -->\r\n            <b-row>\r\n                <b-col cols=\"5\">\r\n                    <span class=\"normal-caption\">Name</span>\r\n                    <br/>\r\n                    <div class=\"textbox-print\">\r\n                        {{ this.newRequest.contactName != \"\" ? this.newRequest.contactName : \"&zwnj;\" }}\r\n                    </div>\r\n                </b-col>                \r\n                <b-col cols=\"7\">\r\n                    <span class=\"normal-caption\">Email</span>\r\n                    <br/>\r\n                    <div class=\"textbox-print\">\r\n                        {{ this.newRequest.contactEmail != \"\" ? this.newRequest.contactEmail : \"&zwnj;\" }}\r\n                    </div>\r\n                </b-col>\r\n            </b-row>\r\n            <b-row>\r\n                <b-col cols=\"12\"><br/></b-col>\r\n            </b-row>\r\n\r\n            <b-row>\r\n                <b-col cols=\"3\">\r\n                    <span class=\"normal-caption\">Phone</span>\r\n                    <br/>\r\n                    <div class=\"textbox-print\">\r\n                        {{ this.newRequest.contactPhone != \"\" ? this.newRequest.contactPhone : \"&zwnj;\" }}\r\n                    </div>\r\n                </b-col>\r\n\r\n                <b-col cols=\"3\">\r\n                    <span class=\"normal-caption\">Fax</span>\r\n                    <br/>\r\n                    <div class=\"textbox-print\">\r\n                        {{ this.newRequest.contactFax != \"\" ? this.newRequest.contactFax : \"&zwnj;\" }}\r\n                    </div>\r\n                </b-col>\r\n            </b-row>\r\n            <b-row>\r\n                <b-col cols=\"12\"><br/></b-col>\r\n            </b-row>\r\n        </b-container>\r\n\r\n        <hr class=\"sectionBorder\">\r\n        <h6 class=\"sectionCaption\">PRACTICE INFORMATION</h6>\r\n        <b-container fluid>\r\n            <!-- Provider Types -->\r\n            <b-row>\r\n                <b-col cols=\"12\">\r\n                    <div>\r\n                        <div class=\"grp-caption\">Provider Type:&nbsp;<span class=\"normal-text\">{{ getSelectedProviderType().Description }}</span></div>\r\n                    </div>\r\n                </b-col>\r\n            </b-row>\r\n            <b-row>\r\n                <b-col cols=\"12\"><br/></b-col>\r\n            </b-row>\r\n\r\n            <!-- Practice Types -->\r\n            <div v-if=\"showPracticeTypes\">\r\n                <b-row>\r\n                    <b-col cols=\"12\">\r\n                        <div>\r\n                            <div class=\"grp-caption\">Practice Type:&nbsp;<span class=\"normal-text\">{{ getSelectedPracticeType().Description }}</span></div>\r\n                        </div>\r\n                    </b-col>\r\n                </b-row>\r\n                <b-row v-if=\"otherPracticeTypeChecked\">\r\n                    <b-col cols=\"12\">\r\n                        <div class=\"textbox-print\">\r\n                            {{ this.newRequest.otherPracticeTypeDescription }}\r\n                        </div>\r\n                    </b-col>\r\n                </b-row>\r\n                <b-row>\r\n                    <b-col cols=\"12\"><br/></b-col>\r\n                </b-row>                \r\n                <b-row>\r\n                    <b-col cols=\"12\">\r\n                        <span class=\"normal-caption\">Is the practitioner joining a group that is currently contracted with Memorial Hermann Health Plan?</span>\r\n                        <span style=\"padding-left: 5px; padding-right: 20px;\">{{ this.newRequest.associatedWithCurrentlyContractedEntity != null ? this.newRequest.associatedWithCurrentlyContractedEntity === 'Y' ? 'Yes' : 'No' : '' }}</span>\r\n                    </b-col>\r\n                </b-row>\r\n                <b-row>\r\n                    <b-col cols=\"12\"><br/></b-col>\r\n                </b-row>\r\n            </div>\r\n\r\n            <!-- Facility Types -->\r\n            <div v-if=\"showFacilityTypes\">\r\n                <b-row>\r\n                    <b-col cols=\"12\">\r\n                        <div>\r\n                            <div class=\"grp-caption\">Facility Type:&nbsp;<span class=\"normal-text\">{{ getSelectedFacilityType().Description }}</span></div>\r\n                        </div>\r\n                    </b-col>\r\n                </b-row>\r\n                <b-row v-if=\"otherFacilityTypeChecked\">\r\n                    <b-col cols=\"12\">\r\n                        <div class=\"textbox-print\">\r\n                            {{ this.newRequest.otherFacilityTypeDescription }}\r\n                        </div>\r\n                    </b-col>\r\n                </b-row>\r\n                <b-row>\r\n                    <b-col cols=\"12\"><br/></b-col>\r\n                </b-row>                \r\n                <b-row>\r\n                    <b-col cols=\"12\">\r\n                        <span class=\"normal-caption\">Is this a new location for a company that is currently contracted with Memorial Hermann Health Plan?</span>\r\n                        <span style=\"padding-left: 5px; padding-right: 20px;\">{{ this.newRequest.associatedWithCurrentlyContractedEntity != null ? this.newRequest.associatedWithCurrentlyContractedEntity === 'Y' ? 'Yes' : 'No' : '' }}</span>\r\n                    </b-col>\r\n                </b-row>\r\n                <b-row>\r\n                    <b-col cols=\"12\"><br/></b-col>\r\n                </b-row>\r\n            </div>\r\n\r\n            <!-- Service Areas -->\r\n            <b-row v-if=\"showServiceAreasinput\">\r\n                <b-col cols=\"12\">\r\n                    <span class=\"normal-caption\">Service Areas (For Home Health; mobile providers and mail-order DME providers ONLY):</span>\r\n                    <br/>\r\n                    <div class=\"textbox-print\">\r\n                        {{ this.newRequest.serviceAreas  != \"\" ? this.newRequest.serviceAreas : \"&zwnj;\" }}\r\n                    </div>\r\n                </b-col>\r\n            </b-row>\r\n\r\n        </b-container>\r\n\r\n        <hr class=\"sectionBorder\">\r\n        <h6 class=\"sectionCaption\">DEMOGRAPHIC INFORMATION</h6>\r\n        <b-container fluid>\r\n            <!-- Practitioner Name / Tax ID / NPI  / CAQH-->\r\n            <b-row>\r\n                <b-col v-if=\"showPracticeTypes\" cols=\"6\">\r\n                    <span class=\"normal-caption\">Practitioner Name</span>\r\n                    <br/>\r\n                    <div class=\"textbox-print\">\r\n                        {{ this.newRequest.practitionerName != \"\" ? this.newRequest.practitionerName : \"&zwnj;\" }}\r\n                    </div>\r\n                </b-col>\r\n\r\n                <b-col cols=\"2\">\r\n                    <span class=\"normal-caption\">Tax ID #</span>\r\n                    <br/>\r\n                    <div class=\"textbox-print\">\r\n                        {{ this.newRequest.taxId != \"\" ? this.newRequest.taxId : \"&zwnj;\" }}\r\n                    </div>\r\n                </b-col>\r\n\r\n                <b-col cols=\"2\">\r\n                    <span class=\"normal-caption\">NPI</span>\r\n                    <br/>\r\n                    <div class=\"textbox-print\">\r\n                        {{ this.newRequest.npi != \"\" ? this.newRequest.npi : \"&zwnj;\" }}\r\n                    </div>                    \r\n                </b-col>\r\n\r\n                <b-col cols=\"2\">\r\n                    <span class=\"normal-caption\">CAQH</span>\r\n                    <br/>\r\n                    <div class=\"textbox-print\">\r\n                        {{ this.newRequest.caqh != \"\" ? this.newRequest.caqh : \"&zwnj;\" }}\r\n                    </div>                    \r\n                </b-col>\r\n            </b-row>\r\n            <b-row>\r\n                <b-col cols=\"12\"><br/></b-col>\r\n            </b-row>\r\n\r\n            <!-- Business Phone / Extension / Business Fax / Business Email -->\r\n            <b-row>\r\n\t\t\t\t<b-col cols=\"3\">\r\n                    <span class=\"normal-caption\">Business Phone</span>\r\n                    <br/>\r\n                    <div class=\"textbox-print\">\r\n                        {{ this.newRequest.businessPhone != \"\" ? this.newRequest.businessPhone : \"&zwnj;\" }}\r\n                    </div>\r\n                </b-col>\r\n\r\n\t\t\t\t<b-col cols=\"2\">\r\n                    <span class=\"normal-caption\">Extension</span>\r\n                    <br/>\r\n                    <div class=\"textbox-print\">\r\n                        {{ this.newRequest.businessPhoneExtension != \"\" ? this.newRequest.businessPhoneExtension : \"&zwnj;\" }}\r\n                    </div>\r\n                </b-col>\r\n\r\n\t\t\t\t<b-col cols=\"3\">\r\n                    <span class=\"normal-caption\">Business Fax</span>\r\n                    <br/>\r\n                    <div class=\"textbox-print\">\r\n                        {{ this.newRequest.businessFax != \"\" ? this.newRequest.businessFax : \"&zwnj;\" }}\r\n                    </div>\r\n                </b-col>\r\n\r\n\t\t\t\t<b-col cols=\"4\">\r\n                    <span class=\"normal-caption\">Business Email</span>\r\n                    <br/>\r\n                    <div class=\"textbox-print\">\r\n                        {{ this.newRequest.businessEmail != \"\" ? this.newRequest.businessEmail : \"&zwnj;\" }}\r\n                    </div>\r\n                </b-col>\r\n            </b-row>\r\n            <b-row>\r\n                <b-col cols=\"12\"><br/></b-col>\r\n            </b-row>\r\n\r\n            <!-- Specialties -->\r\n            <b-row v-show=\"showSpecialties\">\r\n                <b-col cols=\"6\">\r\n                    <span class=\"normal-caption\">Primary Specialty</span>\r\n                    <br/>\r\n                    <div class=\"textbox-print\">\r\n                        {{ this.getPrimarySpecialty() != undefined ? this.getPrimarySpecialty().Description : \"&zwnj;\" }}\r\n                    </div>\r\n                </b-col>\r\n                <b-col cols=\"6\">\r\n                    <span class=\"normal-caption\">Secondary Specialty</span>\r\n                    <br/>\r\n                    <div class=\"textbox-print\">\r\n                        {{ this.getSecondarySpecialty() != undefined ? this.getSecondarySpecialty().Description : \"&zwnj;\" }}                        \r\n                    </div>\r\n                </b-col>\r\n            </b-row>\r\n            <b-row v-show=\"showSpecialties\">\r\n                <b-col cols=\"12\">\r\n                    <br/>\r\n                </b-col>\r\n            </b-row>\r\n\r\n            <!-- Business Name -->\r\n            <b-row>\r\n                <b-col cols=\"6\">\r\n                    <span class=\"normal-caption\">Business Name</span>\r\n                    <br/>\r\n                    <div class=\"textbox-print\">\r\n                        {{ this.newRequest.businessName != \"\" ? this.newRequest.businessName : \"&zwnj;\" }}\r\n                    </div>\r\n                </b-col>\r\n            </b-row>\r\n            <b-row>\r\n                <b-col cols=\"12\"><br/></b-col>\r\n            </b-row>            \r\n\r\n            <!-- Primary Address -->\r\n            <b-row>\r\n                <b-col cols=\"9\">\r\n                    <span class=\"normal-caption\">Address</span>\r\n                    <br/>\r\n                    <div class=\"textbox-print\">\r\n                        {{ this.newRequest.primaryAddress.addressLine1 != \"\" ? this.newRequest.primaryAddress.addressLine1 : \"&zwnj;\" }}\r\n                    </div>\r\n                </b-col>\r\n\r\n                <b-col cols=\"3\">\r\n                    <span class=\"normal-caption\">Suite</span>\r\n                    <br/>\r\n                    <div class=\"textbox-print\">\r\n                        {{ this.newRequest.primaryAddress.suite != \"\" ? this.newRequest.primaryAddress.suite : \"&zwnj;\" }}\r\n                    </div>\r\n                </b-col>\r\n            </b-row>\r\n            <b-row>\r\n                <b-col cols=\"12\"><br/></b-col>\r\n            </b-row>            \r\n\r\n            <b-row>\r\n                <b-col cols=\"5\">\r\n                    <span class=\"normal-caption\">City</span>\r\n                    <br/>\r\n                    <div class=\"textbox-print\">\r\n                        {{ this.newRequest.primaryAddress.city != \"\" ? this.newRequest.primaryAddress.city : \"&zwnj;\" }}\r\n                    </div>                    \r\n                </b-col>\r\n\r\n                <b-col cols=\"2\">\r\n                    <span class=\"normal-caption\">State</span>\r\n                    <br/>\r\n                    <div class=\"textbox-print\">\r\n                        {{ this.newRequest.primaryAddress.state != \"\" ? this.newRequest.primaryAddress.state : \"&zwnj;\" }}\r\n                    </div>                    \r\n                </b-col>\r\n\r\n                <b-col cols=\"4\">\r\n                    <span class=\"normal-caption\">Zip Code</span>\r\n                    <br/>\r\n                    <div class=\"textbox-print\">\r\n                        {{ this.newRequest.primaryAddress.zipcode != \"\" ? this.newRequest.primaryAddress.zipcode : \"&zwnj;\" }}\r\n                    </div>                    \r\n                </b-col>                \r\n            </b-row>\r\n            <b-row>\r\n                <b-col cols=\"12\">\r\n                    <br/>\r\n                </b-col>\r\n            </b-row>                        \r\n\r\n            <!-- Address Grid -->\r\n            <b-row>\r\n                <b-col cols=\"12\">\r\n                    <br/>\r\n                    <span class=\"normal-caption\">Additional Addresses:</span>\r\n                    <br/>\r\n                </b-col>\r\n            </b-row>\r\n            \r\n            <b-row>\r\n                <b-col cols=\"12\">\r\n                    <b-table\r\n                    responsive\r\n                    outlined\r\n                    id=\"addresses\"\r\n                    :items=\"this.newRequest.addresses\"\r\n                    :fields=\"this.addressesFields\">\r\n                    </b-table>\r\n                </b-col>\r\n            </b-row>            \r\n        </b-container>\r\n\r\n\r\n        <hr class=\"sectionBorder\">\r\n        <h6 class=\"sectionCaption\">SERVICE INFORMATION</h6>\r\n        <b-container fluid>\r\n\r\n            <!-- Population Types -->\r\n            <b-row>\r\n                <b-col cols=\"12\">\r\n                    <div>\r\n                        <div class=\"grp-caption\">Ages Served</div>\r\n                    </div>\r\n                </b-col>\r\n            </b-row>\r\n            <b-row>\r\n                <b-col v-if=\"this.newRequest.servesAges_0_2\" cols=\"2\">0-2 Years</b-col>\r\n                <b-col v-if=\"this.newRequest.servesAges_2_18\" cols=\"2\">2-18 Years</b-col>\r\n                <b-col v-if=\"this.newRequest.servesAges_18_Plus\" cols=\"2\">18+ Years</b-col>\r\n                <b-col v-if=\"this.newRequest.servesAges_Geriatric\" cols=\"2\">Geriatrics</b-col>\r\n            </b-row>\r\n            <b-row v-if=\"otherPopulationTypeChecked\">\r\n                <b-col cols=\"12\">\r\n                    <br/>\r\n                    Other Ages Served:\r\n                    <br/>\r\n                    <div class=\"textbox-print\">\r\n                        {{ this.newRequest.otherPopulationTypeDescription }}\r\n                    </div>\r\n                </b-col>\r\n            </b-row>\r\n\r\n            <b-row>\r\n                <!-- Languages -->\r\n                <b-col cols=\"6\" style=\"padding-left: 0px; padding-right: 0px;\">\r\n                    <b-container fluid>\r\n                        <b-row>\r\n                            <b-col>\r\n                                <br/>\r\n                                <span class=\"normal-caption\">Languages Spoken (other than English)</span>\r\n                                <br/>\r\n                            </b-col>\r\n                        </b-row>\r\n                        <b-row>\r\n                            <b-col>\r\n                                <div class=\"\" style=\"margin-top: 5px; border: 1px solid rgb(206, 212, 218); border-radius: 0.25rem; padding: 3px;\">\r\n                                    <span v-for=\"language in getSelectedLanguages()\" :key=\"language.Id\">{{ language.Description }} <br/></span>\r\n                                </div>\r\n                            </b-col>\r\n                        </b-row>\r\n                        <b-row v-if=\"otherLanguageChecked\">\r\n                            <b-col>\r\n                                <br/>\r\n                                Other Languages Spoken\r\n                                <br/>\r\n                                <div class=\"textbox-print\">\r\n                                    {{ this.newRequest.otherLanguageDescription }}\r\n                                </div>\r\n                            </b-col>\r\n                        </b-row>\r\n                    </b-container>\r\n                </b-col>\r\n\r\n                <!-- Office Hours -->\r\n                <b-col cols=\"6\" style=\"padding-left: 0px; padding-right: 0px;\">\r\n                    <b-container fluid>\r\n                        <b-row>\r\n                            <b-col>\r\n                                <br/>\r\n                                <span class=\"normal-caption\">Office Hours</span>\r\n                                <br/>\r\n                            </b-col>\r\n                        </b-row>\r\n                        <b-row>\r\n                            <b-col>\r\n                                <b-container fluid style=\"margin-top: 5px; border: 1px solid rgb(206, 212, 218); border-radius: 0.25rem; padding: 5px; overflow-x: hidden !important; overflow-y: hidden;\">\r\n                                    <b-row>\r\n                                        <b-col cols=\"2\" class=\"weekdayCaption\">\r\n                                            Monday:\r\n                                        </b-col>\r\n                                        <b-col cols=\"10\" class=\"weekdayTextContainer\">\r\n                                            <div class=\"textbox-print\">\r\n                                                {{ this.newRequest.officeHoursMonday != \"\" ? this.newRequest.officeHoursMonday : \"&zwnj;\" }}\r\n                                            </div>\r\n                                        </b-col>\r\n                                    </b-row>\r\n                                    <b-row>\r\n                                        <b-col cols=\"2\" class=\"weekdayCaption\">\r\n                                            <span class=\"normal-text\" style=\"text-align: right !important;\">Tuesday:</span>\r\n                                        </b-col>\r\n                                        <b-col cols=\"10\" class=\"weekdayTextContainer\">\r\n                                            <div class=\"textbox-print\">\r\n                                                {{ this.newRequest.officeHoursTuesday != \"\" ? this.newRequest.officeHoursTuesday : \"&zwnj;\" }}\r\n                                            </div>\r\n                                        </b-col>\r\n                                    </b-row>\r\n                                    <b-row>\r\n                                        <b-col cols=\"2\" class=\"weekdayCaption\">\r\n                                            <span class=\"normal-text\" style=\"text-align: right !important;\">Wednesday:</span>\r\n                                        </b-col>\r\n                                        <b-col cols=\"10\" class=\"weekdayTextContainer\">\r\n                                            <div class=\"textbox-print\">\r\n                                                {{ this.newRequest.officeHoursWednesday != \"\" ? this.newRequest.officeHoursWednesday : \"&zwnj;\" }}\r\n                                            </div>\r\n                                        </b-col>\r\n                                    </b-row>\r\n                                    <b-row>\r\n                                        <b-col cols=\"2\" class=\"weekdayCaption\">\r\n                                            <span class=\"normal-text\" style=\"text-align: right !important;\">Thursday:</span>\r\n                                        </b-col>\r\n                                        <b-col cols=\"10\" class=\"weekdayTextContainer\">\r\n                                            <div class=\"textbox-print\">\r\n                                                {{ this.newRequest.officeHoursThursday != \"\" ? this.newRequest.officeHoursThursday : \"&zwnj;\" }}\r\n                                            </div>\r\n                                        </b-col>\r\n                                    </b-row>\r\n                                    <b-row>\r\n                                        <b-col cols=\"2\" class=\"weekdayCaption\">\r\n                                            <span class=\"normal-text\" style=\"text-align: right !important;\">Friday:</span>\r\n                                        </b-col>\r\n                                        <b-col cols=\"10\" class=\"weekdayTextContainer\">\r\n                                            <div class=\"textbox-print\">\r\n                                                {{ this.newRequest.officeHoursFriday != \"\" ? this.newRequest.officeHoursFriday : \"&zwnj;\" }}\r\n                                            </div>\r\n                                        </b-col>\r\n                                    </b-row>\r\n                                    <b-row>\r\n                                        <b-col cols=\"2\" class=\"weekdayCaption\">\r\n                                            <span class=\"normal-text\" style=\"text-align: right !important;\">Saturday:</span>\r\n                                        </b-col>\r\n                                        <b-col cols=\"10\" class=\"weekdayTextContainer\">\r\n                                            <div class=\"textbox-print\">\r\n                                                {{ this.newRequest.officeHoursSaturday != \"\" ? this.newRequest.officeHoursSaturday : \"&zwnj;\" }}\r\n                                            </div>\r\n                                        </b-col>\r\n                                    </b-row>\r\n                                    <b-row>\r\n                                        <b-col cols=\"2\" class=\"weekdayCaption\">\r\n                                            <span class=\"normal-text\" style=\"text-align: right !important;\">Sunday:</span>\r\n                                        </b-col>\r\n                                        <b-col cols=\"10\" class=\"weekdayTextContainer\">\r\n                                            <div class=\"textbox-print\">\r\n                                                {{ this.newRequest.officeHoursSunday != \"\" ? this.newRequest.officeHoursSunday : \"&zwnj;\" }}\r\n                                            </div>\r\n                                        </b-col>\r\n                                    </b-row>\r\n                                </b-container>                                \r\n                            </b-col>\r\n                        </b-row>\r\n                    </b-container>                    \r\n                </b-col>\r\n            </b-row>           \r\n        </b-container>\r\n\r\n\r\n        <hr class=\"sectionBorder\">\r\n        <h6 class=\"sectionCaption\">NETWORK AFFILIATIONS</h6>\r\n        <b-container fluid>\r\n            <!-- MHMD Affiliation / Ohter IPA/PHO Affiliations -->            \r\n            <!-- MHMD Applied -->\r\n            <b-row>\r\n                <b-col cols=\"12\">\r\n                    <span class=\"normal-caption\">Have you ever applied to MHMD?</span>\r\n                    <span style=\"padding-left: 5px; padding-right: 20px;\">{{ this.newRequest.mhmdApplied != null ? this.newRequest.mhmdApplied === 'Y' ? 'Yes' : 'No' : '' }}</span>\r\n                    <span v-if=\"mhmdAppliedYes\" class=\"normal-caption\">Application Status:</span>\r\n                    <span v-if=\"mhmdAppliedYes\" style=\"padding-left: 5px; padding-right: 20px;\">{{ this.getMHMDApplicationStatus() != undefined ? this.getMHMDApplicationStatus().Description : \"&zwnj;\" }}</span>\r\n                    <span v-if=\"mhmdAppliedYes && this.newRequest.mhmdApplicationStatus === 7\" class=\"normal-caption\">Terminated Date:</span>\r\n                    <span v-if=\"mhmdAppliedYes && this.newRequest.mhmdApplicationStatus === 7\" style=\"padding-left: 5px;\">{{ this.newRequest.mhmdTerminatedDate }}</span>\r\n                </b-col>\r\n            </b-row>\r\n            <b-row>\r\n                <b-col cols=\"12\"><br/></b-col>\r\n            </b-row>\r\n            <b-row>\r\n                <b-col cols=\"12\">\r\n                    <span class=\"normal-caption\">Other Network/IPA/PHO Affliations</span>\r\n                    <br/>\r\n                    <div class=\"textbox-print\">\r\n                        {{ this.newRequest.otherIPAPHOAffiliations != \"\" ? this.newRequest.otherIPAPHOAffiliations : \"&zwnj;\" }}\r\n                    </div>\r\n                </b-col>            \r\n            </b-row>\r\n            <b-row>\r\n                <b-col cols=\"12\"><br/></b-col>\r\n            </b-row>\r\n        </b-container>\r\n\r\n\r\n        <hr class=\"sectionBorder\">\r\n        <h6 class=\"sectionCaption\">CREDENTIALING CONTACT INFORMATION</h6>\r\n        <b-container fluid>\r\n            <!-- Credintialing Contact / Email / Phone -->\r\n            <b-row>\r\n                <b-col cols=\"4\">\r\n                    <span class=\"normal-caption\">Credentialing Contact:</span>\r\n                    <br/>\r\n                    <div class=\"textbox-print\">\r\n                        {{ this.newRequest.credentialingContactName != \"\" ? this.newRequest.credentialingContactName : \"&zwnj;\" }}\r\n                    </div>\r\n                </b-col>\r\n\r\n                <b-col cols=\"4\">\r\n                    <span class=\"normal-caption\">Credentialing Contact E-mail Address:</span>\r\n                    <br/>\r\n                    <div class=\"textbox-print\">\r\n                        {{ this.newRequest.credentialingContactEmail != \"\" ? this.newRequest.credentialingContactEmail : \"&zwnj;\" }}\r\n                    </div>\r\n                </b-col>\r\n\r\n                <b-col cols=\"4\">\r\n                    <span class=\"normal-caption\">Credentialing Contact Phone #:</span>\r\n                    <br/>\r\n                    <div class=\"textbox-print\">\r\n                        {{ this.newRequest.credentialingContactPhone != \"\" ? this.newRequest.credentialingContactPhone : \"&zwnj;\" }}\r\n                    </div>                    \r\n                </b-col>\r\n            </b-row>            \r\n        </b-container>\r\n\r\n    </div>\r\n\r\n</template>\r\n\r\n<script>\r\nimport { mapState, mapActions } from 'vuex';\r\n\r\nexport default {\r\ncreated() {\r\n    },    \r\n    data() {\r\n        return {\r\n        addressesFields: [\r\n            { key: 'addressLine1', label: 'Address' },\r\n            { key: 'suite', label: 'Suite' },\r\n            { key: 'city', label: 'City' },\r\n            { key: 'state', label: 'State' },\r\n            { key: 'zipcode', label: 'Zip', formatter: 'zipCodeFormatter'},\r\n            ],           \r\n        } \r\n    },\r\n\r\n    computed: {\r\n        ...mapState(\r\n            'request', {\r\n                optionsProviderTypes: 'providerTypes',                \r\n                optionsPracticeTypes: 'practiceTypes',\r\n                otherPracticeType: 'otherPracticeType',\r\n                optionsFacilityTypes: 'facilityTypes',\r\n                otherFacilityType: 'otherFacilityType',\r\n                optionsSpecialties: 'specialties',\r\n                optionsLanguages: 'languages',\r\n                otherLanguage: 'otherLanguage',\r\n                optionsMHMDApplicationStatuses: 'MHMDApplicationStatuses',\r\n                newRequest: 'newRequest',\r\n                newAddress: 'newAddress'\r\n                }\r\n        ),\r\n\r\n        showPracticeTypes() {\r\n            return this.newRequest.selectedProviderType === 1;\r\n        },        \r\n        otherPracticeTypeChecked() {\r\n            return this.newRequest.selectedPracticeType === 999;\r\n        },\r\n\r\n        showFacilityTypes() {\r\n            return this.newRequest.selectedProviderType === 2;\r\n        },\r\n        otherFacilityTypeChecked() {\r\n            return this.newRequest.selectedFacilityType === 999;\r\n        },\r\n        showServiceAreasinput() {\r\n            return this.showFacilityTypes\r\n                && this.optionsFacilityTypes\r\n                    .filter(ft => ft.EnableAdditionalDetails === true)\r\n                        .map(function(a) {return a.Id})\r\n                            .includes(this.newRequest.selectedFacilityType);\r\n        },\r\n\r\n        showSpecialties() {\r\n            return this.newRequest.selectedProviderType === 1;\r\n        },\r\n\r\n        mhmdAppliedYes() {\r\n            return this.newRequest.mhmdApplied === 'Y';\r\n        },\r\n\r\n        otherPopulationTypeChecked() {\r\n            return this.newRequest.servesAges_Other === true;\r\n        },\r\n\r\n        otherLanguageChecked() {\r\n            return this.newRequest.selectedLanguages.includes(999);\r\n        },        \r\n    },\r\n\r\n    mounted () {\r\n        this.$nextTick(function (){\r\n            // setTimeout(function() {\r\n            //     window.print();\r\n            //     }, 1500);\r\n        })\r\n    },\r\n\r\n    methods: {\r\n        ...mapActions(\r\n            'request', {\r\n                loadProviderTypes: 'loadProviderTypes',                \r\n                loadPracticeTypes: 'loadPracticeTypes',\r\n                loadFacilityTypes: 'loadFacilityTypes',\r\n                loadSpecialties: 'loadSpecialties',\r\n                loadLanguages: 'loadLanguages',\r\n                loadMHMDApplicationStatuses: 'loadMHMDApplicationStatuses',\r\n                addRequest: 'addRequest',\r\n                }\r\n        ),\r\n\r\n        getSelectedProviderType() {\r\n            return this.optionsProviderTypes\r\n                .find(x => x.Id === this.newRequest.selectedProviderType);\r\n        },\r\n\r\n        getSelectedPracticeType() {\r\n            return this.newRequest.selectedPracticeType === 999 ?\r\n                this.otherPracticeType\r\n                : this.optionsPracticeTypes.find(x => x.Id === this.newRequest.selectedPracticeType);\r\n        },\r\n\r\n        getSelectedFacilityType() {\r\n            return this.newRequest.selectedFacilityType === 999 ?\r\n                this.otherFacilityType\r\n                : this.optionsFacilityTypes.find(x => x.Id === this.newRequest.selectedFacilityType);            \r\n        },\r\n\r\n        getPrimarySpecialty() {\r\n            return this.optionsSpecialties.find(x => x.Id === this.newRequest.primarySpecialty);\r\n        },\r\n        getSecondarySpecialty() {\r\n            return this.optionsSpecialties.find(x => x.Id === this.newRequest.secondarySpecialty);\r\n        },\r\n        \r\n        getMHMDApplicationStatus() {\r\n            return this.optionsMHMDApplicationStatuses.find(x => x.Id === this.newRequest.mhmdApplicationStatus);\r\n        },\r\n\r\n        getSelectedLanguages() {\r\n            return this.optionsLanguages\r\n            .filter(x => this.newRequest.selectedLanguages\r\n                .indexOf(x.Id) >= 0)\r\n                    .sort(function (a, b) {return a.Description - b.Description});\r\n        },\r\n\r\n        zipCodeFormatter(value) {\r\n            var result = \"\";\r\n            if(value.length == 5)\r\n            {\r\n                result = value.substring(0, 5);\r\n            } else if (value.length == 9) { \r\n                result = value.substring(0, 5) + '-' + value.substring(5, 9);\r\n            }\r\n             \r\n            return `${result}`;\r\n        },\r\n\r\n        booleanToYNFormatter(value) {\r\n            return `${(value == null ? \"\" : value == \"true\" ? \"Yes\" : \"No\")}`;\r\n        },\r\n        \r\n        printForm(evt) {\r\n            evt.preventDefault();\r\n            window.print();\r\n        },        \r\n    },\r\n}\r\n</script>\r\n\r\n<style>\r\n.grp-caption {\r\n    font-size: large;\r\n    font-weight: bolder;\r\n    padding-bottom: 5px;\r\n    display:flexbox;\r\n}\r\n.normal-caption {\r\n    font-weight: bolder;\r\n    padding-bottom: 5px;\r\n    display:flexbox;    \r\n}\r\n.normal-text {\r\n    font-weight:normal;\r\n    padding-bottom: 5px;\r\n    display:flexbox;    \r\n}\r\n.textbox-print {\r\n    margin-top: 5px;\r\n    border: 1px solid rgb(206, 212, 218);\r\n    border-radius: 0.25rem;\r\n    padding: 3px;\r\n    /* min-height: 20px; */\r\n    overflow-wrap: break-word;\r\n}\r\n.weekdayCaption {\r\n    padding-top: 18px;\r\n    padding-right: 0px !important;\r\n    text-align: right !important;\r\n}\r\n.weekdayTextContainer {\r\n    padding-top: 12px;\r\n    padding-left: 20px !important;\r\n}\r\n.confirmation-print {\r\n    margin-top: 5px;\r\n    border: 1px solid;\r\n    border-radius: 0.25rem;\r\n    padding: 7px;\r\n}\r\n/* @media print {\r\n  .confirmation-print {\r\n    display: none;\r\n  }\r\n} */\r\nhr.sectionBorder {\r\n  border: 1px dashed black;\r\n}\r\nh6.sectionCaption {\r\n  font-weight: bold;\r\n  text-align: center;\r\n}\r\n</style>","import mod from \"-!../../node_modules/cache-loader/dist/cjs.js??ref--12-0!../../node_modules/thread-loader/dist/cjs.js!../../node_modules/babel-loader/lib/index.js!../../node_modules/cache-loader/dist/cjs.js??ref--0-0!../../node_modules/vue-loader/lib/index.js??vue-loader-options!./PrintRequest.vue?vue&type=script&lang=js&\"; export default mod; export * from \"-!../../node_modules/cache-loader/dist/cjs.js??ref--12-0!../../node_modules/thread-loader/dist/cjs.js!../../node_modules/babel-loader/lib/index.js!../../node_modules/cache-loader/dist/cjs.js??ref--0-0!../../node_modules/vue-loader/lib/index.js??vue-loader-options!./PrintRequest.vue?vue&type=script&lang=js&\"","import { render, staticRenderFns } from \"./PrintRequest.vue?vue&type=template&id=259cbb76&\"\nimport script from \"./PrintRequest.vue?vue&type=script&lang=js&\"\nexport * from \"./PrintRequest.vue?vue&type=script&lang=js&\"\nimport style0 from \"./PrintRequest.vue?vue&type=style&index=0&lang=css&\"\n\n\n/* normalize component */\nimport normalizer from \"!../../node_modules/vue-loader/lib/runtime/componentNormalizer.js\"\nvar component = normalizer(\n  script,\n  render,\n  staticRenderFns,\n  false,\n  null,\n  null,\n  null\n  \n)\n\nexport default component.exports","var render = function () {var _vm=this;var _h=_vm.$createElement;var _c=_vm._self._c||_h;return _c('div',[_c('b-container',{attrs:{\"fluid\":\"\"}},[_c('b-row',{staticClass:\"text-center\",attrs:{\"align-h\":\"center\"}},[_c('b-col',{attrs:{\"cols\":\"10\"}},[(this.$store.state.errorType === 'loading-form-data-error')?_c('div',[_c('br'),_c('h4',[_vm._v(\" \"+_vm._s(this.loadingFormErrorCaption)+\" \")]),_c('br'),_c('span',[_vm._v(_vm._s(this.loadingFormErrorMessage))]),_c('br'),_c('br'),_c('b-button',{attrs:{\"type\":\"submit\",\"variant\":\"primary\"},on:{\"click\":_vm.handleTryAgainClick}},[_vm._v(\"Try Again\")])],1):_c('div',[_c('br'),_c('h4',[_vm._v(\" \"+_vm._s(this.generalErrorCaption)+\" \")]),_c('br'),_c('span',[_vm._v(_vm._s(this.generalErrorMessage))]),_c('br'),_c('br'),_c('b-button',{attrs:{\"type\":\"submit\",\"variant\":\"primary\"},on:{\"click\":_vm.handleTryAgainClick}},[_vm._v(\"Try Again\")])],1)])],1)],1)],1)}\nvar staticRenderFns = []\n\nexport { render, staticRenderFns }","<template>\r\n    <div>\r\n        <b-container fluid>\r\n            <b-row class=\"text-center\" align-h=\"center\">\r\n                <b-col cols=\"10\">\r\n                    <div v-if=\"this.$store.state.errorType === 'loading-form-data-error'\">\r\n                        <br/>\r\n                        <h4>\r\n                            {{ this.loadingFormErrorCaption }}\r\n                        </h4>\r\n                        <br/>\r\n                        <span>{{ this.loadingFormErrorMessage }}</span>\r\n                        <br/><br/>\r\n                        <b-button type=\"submit\" @click=\"handleTryAgainClick\" variant=\"primary\">Try Again</b-button>\r\n                    </div>\r\n                    <div v-else>\r\n                        <br/>\r\n                        <h4>\r\n                            {{ this.generalErrorCaption }}\r\n                        </h4>\r\n                        <br/>\r\n                        <span>{{ this.generalErrorMessage }}</span>\r\n                        <br/><br/>\r\n                        <b-button type=\"submit\" @click=\"handleTryAgainClick\" variant=\"primary\">Try Again</b-button>\r\n                    </div>\r\n\r\n                </b-col>\r\n            </b-row>\r\n        </b-container>\r\n    </div>\r\n</template>\r\n\r\n<script>\r\n\r\nexport default {\r\n    \r\n    data() {\r\n        return {\r\n            loadingFormErrorCaption: 'Difficulties Loading The Request Form',\r\n            loadingFormErrorMessage: 'Sorry but we seem to be experiencing difficulties loading the request form. Please click the Try Again button below to reload the form. If you continue to experience difficulties please contact our Customer Support Center at 713-338-4801.',\r\n            generalErrorCaption: 'Unexpected Error',\r\n            generalErrorMessage: 'Sorry but we seem to be experiencing an unexpected error. Please click the Try Again button below to reload the application. If you continue to experience difficulties please contact our Customer Support Center at 713-338-4801.'\r\n        } \r\n    },\r\n    computed: {\r\n    },\r\n    created () {\r\n    },\r\n    mounted () {\r\n        this.$store.commit('updateDataError', false, { root: true });\r\n    },    \r\n    methods: {\r\n        handleTryAgainClick(evt) {\r\n            evt.preventDefault();\r\n            \r\n            // *** The approach to dealing with an exception when loading the form is to reload the entire application.\r\n            // This is because it is easier to start over with NO STATE than to re-initialize the controls given that\r\n            // controls depend on other controls.\r\n\r\n            var url = process.env.BASE_URL;\r\n            window.location.href = url;\r\n        },\r\n    },\r\n}\r\n</script>\r\n\r\n<style>\r\n.error-message {\r\n    padding-left: 50px !important;\r\n    padding-right: 50px !important;\r\n}\r\n</style>","import mod from \"-!../node_modules/cache-loader/dist/cjs.js??ref--12-0!../node_modules/thread-loader/dist/cjs.js!../node_modules/babel-loader/lib/index.js!../node_modules/cache-loader/dist/cjs.js??ref--0-0!../node_modules/vue-loader/lib/index.js??vue-loader-options!./Error.vue?vue&type=script&lang=js&\"; export default mod; export * from \"-!../node_modules/cache-loader/dist/cjs.js??ref--12-0!../node_modules/thread-loader/dist/cjs.js!../node_modules/babel-loader/lib/index.js!../node_modules/cache-loader/dist/cjs.js??ref--0-0!../node_modules/vue-loader/lib/index.js??vue-loader-options!./Error.vue?vue&type=script&lang=js&\"","import { render, staticRenderFns } from \"./Error.vue?vue&type=template&id=4453fab5&\"\nimport script from \"./Error.vue?vue&type=script&lang=js&\"\nexport * from \"./Error.vue?vue&type=script&lang=js&\"\nimport style0 from \"./Error.vue?vue&type=style&index=0&lang=css&\"\n\n\n/* normalize component */\nimport normalizer from \"!../node_modules/vue-loader/lib/runtime/componentNormalizer.js\"\nvar component = normalizer(\n  script,\n  render,\n  staticRenderFns,\n  false,\n  null,\n  null,\n  null\n  \n)\n\nexport default component.exports","import axios from \"axios\";\r\n\r\n// before a request is made start the nprogress\r\naxios.interceptors.request.use((config) => {\r\n  // eslint-disable-next-line no-undef\r\n  NProgress.start();\r\n\r\n  return config;\r\n});\r\n\r\n// before a response is returned stop nprogress\r\naxios.interceptors.response.use((response) => {\r\n  //Note: Moved to [afterEach()] event of the rounter.\r\n  // eslint-disable-next-line no-undef\r\n  //NProgress.done()\r\n\r\n  return response;\r\n});\r\n\r\nexport default {\r\n  namespaced: true,\r\n  state: {\r\n    newRequest: {\r\n      id: 0,\r\n\r\n      contactName: \"\",\r\n      contactEmail: \"\",\r\n      contactPhone: \"\",\r\n      contactFax: \"\",\r\n\r\n      selectedProviderType: \"\",\r\n      associatedWithCurrentlyContractedEntity: null,\r\n\r\n      selectedPracticeType: \"\",\r\n      otherPracticeTypeDescription: \"\",\r\n\r\n      selectedFacilityType: \"\",\r\n      otherFacilityTypeDescription: \"\",\r\n      serviceAreas: \"\",\r\n\r\n      practitionerName: \"\",\r\n      businessName: \"\",\r\n      taxId: \"\",\r\n      npi: \"\",\r\n      caqh: \"\",\r\n\r\n      businessPhone: \"\",\r\n      businessPhoneExtension: \"\",\r\n      businessFax: \"\",\r\n      businessEmail: \"\",\r\n\r\n      primarySpecialty: null,\r\n      secondarySpecialty: null,\r\n\r\n      primaryAddress: {\r\n        id: 0,\r\n        addressLine1: \"\",\r\n        suite: \"\",\r\n        city: \"\",\r\n        state: \"\",\r\n        zipcode: \"\",\r\n        isPrimary: true,\r\n      },\r\n\r\n      addresses: [],\r\n\r\n      otherPopulationTypeDescription: \"\",\r\n\r\n      selectedLanguages: [],\r\n      otherLanguageDescription: \"\",\r\n\r\n      servesAges_0_2: false,\r\n      servesAges_2_18: false,\r\n      servesAges_18_Plus: false,\r\n      servesAges_Geriatric: false,\r\n      servesAges_Other: false,\r\n\r\n      officeHoursMonday: \"\",\r\n      officeHoursTuesday: \"\",\r\n      officeHoursWednesday: \"\",\r\n      officeHoursThursday: \"\",\r\n      officeHoursFriday: \"\",\r\n      officeHoursSaturday: \"\",\r\n      officeHoursSunday: \"\",\r\n\r\n      mhmdApplied: null,\r\n      mhmdApplicationStatus: \"\",\r\n      mhmdTerminatedDate: \"\",\r\n      otherIPAPHOAffiliations: \"\",\r\n\r\n      credentialingContactName: \"\",\r\n      credentialingContactEmail: \"\",\r\n      credentialingContactPhone: \"\",\r\n      captchaResponse: \"\",\r\n    },\r\n\r\n    providerTypes: [],\r\n\r\n    practiceTypes: [],\r\n    otherPracticeType: {},\r\n\r\n    facilityTypes: [],\r\n    otherFacilityType: {},\r\n\r\n    specialties: [],\r\n\r\n    languages: [],\r\n    otherLanguage: {},\r\n\r\n    MHMDApplicationStatuses: [],\r\n\r\n    newAddress: {\r\n      id: 0,\r\n      addressLine1: \"\",\r\n      suite: \"\",\r\n      city: \"\",\r\n      state: \"\",\r\n      zipcode: \"\",\r\n      isPrimary: false,\r\n    },\r\n  },\r\n  actions: {\r\n    loadAll({ commit }) {\r\n      return axios\r\n        .all([\r\n          axios.get(process.env.VUE_APP_BASE_API_URL + \"PracticeType\"),\r\n          axios.get(process.env.VUE_APP_BASE_API_URL + \"ProviderType\"),\r\n          axios.get(process.env.VUE_APP_BASE_API_URL + \"FacilityType\"),\r\n          axios.get(process.env.VUE_APP_BASE_API_URL + \"Specialty\"),\r\n          axios.get(process.env.VUE_APP_BASE_API_URL + \"Language\"),\r\n          axios.get(process.env.VUE_APP_BASE_API_URL + \"MHMDApplicationStatus\"),\r\n        ])\r\n        .then(\r\n          axios.spread((...responses) => {\r\n            commit(\"updatePracticeTypes\", responses[0].data);\r\n            commit(\"updateProviderTypes\", responses[1].data);\r\n            commit(\"updateFacilityTypes\", responses[2].data);\r\n            commit(\"updateSpecialties\", responses[3].data);\r\n            commit(\"updateLanguages\", responses[4].data);\r\n            commit(\"updateMHMDApplicationStatuses\", responses[5].data);\r\n          })\r\n        )\r\n        .catch((/* error */) => {\r\n          // alert(JSON.stringify(error));\r\n          commit(\"updateDataError\", true, { root: true });\r\n          commit(\"updateErrorType\", \"loading-form-data-error\", { root: true });\r\n        })\r\n        .then(function() {\r\n          // eslint-disable-next-line no-undef\r\n          NProgress.done();\r\n        });\r\n    },\r\n    loadPracticeTypes({ commit }) {\r\n      axios\r\n        .get(process.env.VUE_APP_BASE_API_URL + \"PracticeType\")\r\n        .then((result) => commit(\"updatePracticeTypes\", result.data));\r\n    },\r\n    loadProviderTypes({ commit }) {\r\n      axios\r\n        .get(process.env.VUE_APP_BASE_API_URL + \"ProviderType\")\r\n        .then((result) => commit(\"updateProviderTypes\", result.data));\r\n    },\r\n    loadFacilityTypes({ commit }) {\r\n      axios\r\n        .get(process.env.VUE_APP_BASE_API_URL + \"FacilityType\")\r\n        .then((result) => commit(\"updateFacilityTypes\", result.data));\r\n    },\r\n    loadSpecialties({ commit }) {\r\n      axios\r\n        .get(process.env.VUE_APP_BASE_API_URL + \"Specialty\")\r\n        .then((result) => commit(\"updateSpecialties\", result.data));\r\n    },\r\n    loadLanguages({ commit }) {\r\n      axios\r\n        .get(process.env.VUE_APP_BASE_API_URL + \"Language\")\r\n        .then((result) => commit(\"updateLanguages\", result.data));\r\n    },\r\n    loadMHMDApplicationStatuses({ commit }) {\r\n      axios\r\n        .get(process.env.VUE_APP_BASE_API_URL + \"MHMDApplicationStatus\")\r\n        .then((result) => commit(\"updateMHMDApplicationStatuses\", result.data));\r\n    },\r\n    addRequest({ commit, state, rootState }) {\r\n      //alert(JSON.stringify(state.newRequest));\r\n      return (\r\n        axios\r\n          .post(process.env.VUE_APP_BASE_API_URL + \"Request\", state.newRequest)\r\n          .then((result) => {\r\n            // alert(JSON.stringify(result.data));\r\n            commit(\"updateRequestSubmitCount\", 0, { root: true });\r\n            commit(\"updateRequestAfterSubmission\", result.data);\r\n            commit(\"updateRequestSubmitted\", true, { root: true });\r\n          })\r\n          // eslint-disable-next-line no-unused-vars\r\n          .catch((error) => {\r\n            //alert(JSON.stringify(error));\r\n            // alert(\"There was an error submitting your form.\")\r\n\r\n            //Increment the counter\r\n            commit(\"updateRequestSubmitCount\", 1, { root: true });\r\n            if (rootState.requestSubmitCount > 2) {\r\n              commit(\"updateDataError\", true, { root: true });\r\n              commit(\"updateErrorType\", \"submitting-form-error\", {\r\n                root: true,\r\n              });\r\n            }\r\n          })\r\n          .then(function() {\r\n            // eslint-disable-next-line no-undef\r\n            NProgress.done();\r\n          })\r\n      );\r\n    },\r\n  },\r\n  mutations: {\r\n    updateProviderTypes(state, providerTypes) {\r\n      state.providerTypes = providerTypes;\r\n    },\r\n    updatePracticeTypes(state, practiceTypes) {\r\n      state.practiceTypes = practiceTypes.filter(function(item) {\r\n        return item.Id !== 999;\r\n      });\r\n      state.otherPracticeType = practiceTypes.filter(function(item) {\r\n        return item.Id === 999;\r\n      })[0];\r\n    },\r\n    updateFacilityTypes(state, facilityTypes) {\r\n      state.facilityTypes = facilityTypes.filter(function(item) {\r\n        return item.Id !== 999;\r\n      });\r\n      state.otherFacilityType = facilityTypes.filter(function(item) {\r\n        return item.Id === 999;\r\n      })[0];\r\n    },\r\n    updateSpecialties(state, specialties) {\r\n      state.specialties = specialties;\r\n    },\r\n    updateLanguages(state, languages) {\r\n      state.languages = languages.filter(function(item) {\r\n        return item.Id !== 999;\r\n      });\r\n      state.otherLanguage = languages.filter(function(item) {\r\n        return item.Id === 999;\r\n      })[0];\r\n    },\r\n    updateMHMDApplicationStatuses(state, MHMDApplicationStatuses) {\r\n      state.MHMDApplicationStatuses = MHMDApplicationStatuses;\r\n    },\r\n\r\n    resetNewAddress(state) {\r\n      state.newAddress.id = 0;\r\n      state.newAddress.addressLine1 = \"\";\r\n      state.newAddress.suite = \"\";\r\n      state.newAddress.city = \"\";\r\n      state.newAddress.state = \"\";\r\n      state.newAddress.zipcode = \"\";\r\n      state.newAddress.isPrimary = false;\r\n    },\r\n    addAddress(state, address) {\r\n      state.newRequest.addresses.push(address);\r\n    },\r\n    loadAddress(state, id) {\r\n      for (let i = 0; i < state.newRequest.addresses.length; i++) {\r\n        if (state.newRequest.addresses[i].id === id) {\r\n          state.newAddress.id = state.newRequest.addresses[i].id;\r\n          state.newAddress.addressLine1 =\r\n            state.newRequest.addresses[i].addressLine1;\r\n          state.newAddress.suite = state.newRequest.addresses[i].suite;\r\n          state.newAddress.city = state.newRequest.addresses[i].city;\r\n          state.newAddress.state = state.newRequest.addresses[i].state;\r\n          state.newAddress.zipcode = state.newRequest.addresses[i].zipcode;\r\n          state.newAddress.isPrimary = state.newRequest.addresses[i].isPrimary;\r\n          break;\r\n        }\r\n      }\r\n    },\r\n    updateAddress(state, address) {\r\n      for (let i = 0; i < state.newRequest.addresses.length; i++) {\r\n        if (state.newRequest.addresses[i].id === address.id) {\r\n          state.newRequest.addresses[i].addressLine1 = address.addressLine1;\r\n          state.newRequest.addresses[i].suite = address.suite;\r\n          state.newRequest.addresses[i].city = address.city;\r\n          state.newRequest.addresses[i].state = address.state;\r\n          state.newRequest.addresses[i].zipcode = address.zipcode;\r\n          state.newRequest.addresses[i].isPrimary = address.isPrimary;\r\n          break;\r\n        }\r\n      }\r\n    },\r\n    deleteAddress(state, id) {\r\n      for (let i = 0; i < state.newRequest.addresses.length; i++) {\r\n        if (state.newRequest.addresses[i].id === id) {\r\n          state.newRequest.addresses.splice(i, 1);\r\n          break;\r\n        }\r\n      }\r\n    },\r\n    updateRequestAfterSubmission(state, submittedRequest) {\r\n      state.newRequest.id = submittedRequest.Id;\r\n    },\r\n\r\n    // initializeStateWithData(state) {\r\n    //   state.newRequest.contactName = \"Contact Names\";\r\n    //   state.newRequest.contactEmail = \"david.cantu@memorialhermann.org\";\r\n    //   state.newRequest.contactPhone = \"(713) 555-1111\";\r\n    //   state.newRequest.contactFax = \"(713) 555-2222\";\r\n\r\n    //   state.newRequest.selectedProviderType = \"\";\r\n\r\n    //   state.newRequest.selectedPracticeType = \"\";\r\n    //   state.newRequest.otherPracticeTypeDescription = \"\";\r\n\r\n    //   state.newRequest.selectedFacilityType = \"\";\r\n    //   state.newRequest.otherFacilityTypeDescription = \"\";\r\n\r\n    //   state.newRequest.serviceAreas = \"\";\r\n\r\n    //   state.newRequest.practitionerName = \"Practitioner Name\";\r\n\r\n    //   state.newRequest.businessName = \"Business Name\";\r\n    //   state.newRequest.taxId = \"12-3456789\";\r\n    //   state.newRequest.npi = \"1234567890\";\r\n    //   state.newRequest.caqh = \"12345678\";\r\n\r\n    //   state.newRequest.businessPhone = \"(713) 555-3333\";\r\n    //   state.newRequest.businessPhoneExtension = \"123456\";\r\n    //   state.newRequest.businessFax = \"(713) 555-4444\";\r\n    //   state.newRequest.businessEmail = \"businessemail@email.com\";\r\n\r\n    //   state.newRequest.mhmdApplied = \"N\";\r\n    //   // state.newRequest.mhmdApplicationStatus = 7;\r\n    //   // state.newRequest.mhmdTerminatedDate = '03/03/2020';\r\n    //   // state.newRequest.otherIPAPHOAffiliations = 'Other IPA/PHO Affiliations';\r\n\r\n    //   state.newRequest.primarySpecialty = \"\";\r\n    //   state.newRequest.secondarySpecialty = \"\";\r\n\r\n    //   (state.newRequest.primaryAddress.id = 1),\r\n    //     (state.newRequest.primaryAddress.addressLine1 = \"First\");\r\n    //   state.newRequest.primaryAddress.suite = \"111\";\r\n    //   state.newRequest.primaryAddress.city = \"Houston\";\r\n    //   state.newRequest.primaryAddress.state = \"TX\";\r\n    //   state.newRequest.primaryAddress.zipcode = \"77077\";\r\n    //   state.newRequest.primaryAddress.isPrimary = true;\r\n\r\n    //   //state.newRequest.addresses.push({id: 2, addressLine1: 'Second', suite: '222', city: 'Katy', state: 'TX', zipcode: '77450', isPrimary: false, });\r\n    //   //state.newRequest.addresses.push({id: 3, addressLine1: 'Third', suite: '333', city: 'Lake Jackson', state: 'TX', zipcode: '77777', isPrimary: false, });\r\n\r\n    //   state.newRequest.servesAges_0_2 = false;\r\n    //   state.newRequest.servesAges_2_18 = false;\r\n    //   state.newRequest.servesAges_18_Plus = false;\r\n    //   state.newRequest.servesAges_Geriatric = false;\r\n    //   state.newRequest.servesAges_Other = false;\r\n    //   state.newRequest.otherPopulationTypeDescription = \"\";\r\n\r\n    //   (state.newRequest.selectedLanguages = [2]),\r\n    //     (state.newRequest.otherLanguageDescription = \"\");\r\n\r\n    //   state.newRequest.officeHoursMonday = \"9-5\";\r\n    //   state.newRequest.officeHoursTuesday = \"9-5\";\r\n    //   state.newRequest.officeHoursWednesday = \"9-2, 4-8\";\r\n    //   state.newRequest.officeHoursThursday = \"9-5\";\r\n    //   state.newRequest.officeHoursFriday = \"9-2\";\r\n    //   state.newRequest.officeHoursSaturday = \"closed\";\r\n    //   state.newRequest.officeHoursSunday = \"closed\";\r\n\r\n    //   state.newRequest.credentialingContactName = \"Credentialing Contact Name\";\r\n    //   state.newRequest.credentialingContactEmail =\r\n    //     \"credentialingContactEmail@email.com\";\r\n    //   state.newRequest.credentialingContactPhone = \"(713) 555-5555\";\r\n    // },\r\n  },\r\n  getters: {\r\n    getSecondaryAddresses(state) {\r\n      return state.newRequest.addresses.filter(function(address) {\r\n        return address.isPrimary === false;\r\n      });\r\n    },\r\n  },\r\n};\r\n","import Vue from \"vue\";\r\nimport Vuex from \"vuex\";\r\n\r\nimport requestModule from \"./modules/request\";\r\n\r\nVue.use(Vuex);\r\n\r\nexport default new Vuex.Store({\r\n  state: {\r\n    requestStatus: \"request\",\r\n    requestSubmitCount: 0,\r\n    requestSubmitted: false,\r\n    dataError: false,\r\n    errorType: \"loading-form-data-error\", // Values: 'loading-form-data-error' | 'submitting-form-error'  | 'general-error'\r\n  },\r\n  actions: {\r\n    udpateStatus({ commit }, value) {\r\n      commit(\"updateRequestStatus\", value);\r\n    },\r\n    updateSubmitCount({ commit }, value) {\r\n      commit(\"updateRequestSubmitCount\", value);\r\n    },\r\n  },\r\n  mutations: {\r\n    updateRequestStatus(state, value) {\r\n      state.requestStatus = value;\r\n    },\r\n    updateRequestSubmitCount(state, value) {\r\n      state.requestSubmitCount += value;\r\n    },\r\n    updateRequestSubmitted(state, value) {\r\n      state.requestSubmitted = value;\r\n    },\r\n    updateDataError(state, value) {\r\n      state.dataError = value;\r\n    },\r\n    updateErrorType(state, value) {\r\n      state.errorType = value;\r\n    },\r\n  },\r\n  modules: {\r\n    request: requestModule,\r\n  },\r\n});\r\n","import Vue from \"vue\";\r\nimport Router from \"vue-router\";\r\n\r\nimport SubmitRequest from \"../request/SubmitRequest.vue\";\r\nimport PrintRequest from \"../request/PrintRequest.vue\";\r\nimport Error from \"../Error.vue\";\r\n\r\nimport store from \"../store\";\r\n\r\nVue.use(Router);\r\n\r\nconst router = new Router({\r\n  mode: \"hash\",\r\n  routes: [\r\n    {\r\n      path: \"/\",\r\n      redirect: \"/submitRequest\",\r\n    },\r\n    {\r\n      path: \"/submitrequest\",\r\n      name: \"SubmitRequest\",\r\n      component: SubmitRequest,\r\n      beforeEnter(to, from, next) {\r\n        if (store.state.requestStatus === \"request\") {\r\n          window.scrollTo(0, 0);\r\n          next();\r\n          return;\r\n        }\r\n\r\n        next(false);\r\n        return;\r\n      },\r\n    },\r\n    {\r\n      path: \"/printRequest\",\r\n      name: \"PrintRequest\",\r\n      component: PrintRequest,\r\n      beforeEnter(to, from, next) {\r\n        if (store.state.requestStatus === \"print\") {\r\n          window.scrollTo(0, 0);\r\n          next();\r\n          return;\r\n        }\r\n\r\n        next(false);\r\n        return;\r\n      },\r\n    },\r\n    {\r\n      path: \"/error\",\r\n      name: \"Error\",\r\n      component: Error,\r\n      beforeEnter(to, from, next) {\r\n        if (store.state.requestStatus === \"error\") {\r\n          window.scrollTo(0, 0);\r\n          next();\r\n          return;\r\n        }\r\n\r\n        next(false);\r\n        return;\r\n      },\r\n    },\r\n  ],\r\n});\r\n\r\nrouter.beforeResolve((to, from, next) => {\r\n  if (to.name) {\r\n    // eslint-disable-next-line no-undef\r\n    NProgress.start();\r\n  }\r\n  next();\r\n});\r\n// eslint-disable-next-line no-unused-vars\r\nrouter.afterEach((to, from) => {\r\n  if (to.name) {\r\n    // eslint-disable-next-line no-undef\r\n    NProgress.done();\r\n  }\r\n});\r\n\r\nexport default router;\r\n","var render = function () {var _vm=this;var _h=_vm.$createElement;var _c=_vm._self._c||_h;return _c('div',{attrs:{\"id\":\"app\"}},[_c('header',{staticClass:\"headerbar\"},[_c('nav',[_c('ul',[_c('li',{staticClass:\"nav-item\"},[_c('a',{attrs:{\"href\":this.rooturl}},[_c('img',{staticClass:\"logo\",attrs:{\"width\":\"139\",\"height\":\"61\",\"src\":\"https://healthplan.memorialhermann.org/assets/images/logo-healthplan.png\",\"aria-hidden\":\"true\"}})])])])])]),_c('main',[_vm._m(0),_c('router-view')],1)])}\nvar staticRenderFns = [function () {var _vm=this;var _h=_vm.$createElement;var _c=_vm._self._c||_h;return _c('div',[_c('h5',{staticClass:\"titleCaption\"},[_vm._v(\"REQUEST TO PARTICIPATE\")])])}]\n\nexport { render, staticRenderFns }","<template>\n  <div id=\"app\">\n    <header class=\"headerbar\">\n      <nav>\n        <ul>\n          <li class=\"nav-item\">\n            <!-- <router-link class=\"nav-link\" :to=\"{name: 'SubmitRequest'}\" exact> -->\n            <a :href=\"this.rooturl\">\n              <img class=\"logo\" width=\"139\" height=\"61\" src=\"https://healthplan.memorialhermann.org/assets/images/logo-healthplan.png\" aria-hidden=\"true\" />\n            </a>\n            <!-- </router-link> -->\n          </li>\n        </ul>\n      </nav>\n    </header>\n    <main>\n      <div>\n        <h5 class=\"titleCaption\">REQUEST TO PARTICIPATE</h5>\n      </div>\n      <router-view />\n    </main>    \n  </div>\n</template>\n\n<script>\nexport default {\n  name: 'app',\n data() {\n        return {\n          rooturl: process.env.VUE_APP_PUBLIC_PATH\n        } \n    },  \n  components: {\n  }\n}\n</script>\n\n<style>\nhr.titleBorder {\n  border: 2px solid black;\n  border-radius: 2px;\n}\nh5.titleCaption {\n  font-weight: bolder;\n}\nbody{\n background-attachment: fixed;\n}\n#app {\n  font-family: 'Avenir', Helvetica, Arial, sans-serif;\n}\nmain {\n  margin: 0 auto;\n  padding: 30px;\n  background-color: white;\n  width: 1184px;\n  min-height: 300px;\n}\nheader.headerbar {\n  width: 1184px;\n  margin: 0 auto;\n}\nul {\n  padding: 3px;\n  display: flex;\n}\n.nav-item {\n  display: inline-block;\n  padding: 5px 10px;\n  font-size: 22px;\n}\n.nav-item.cart {\n  position: relative;\n  margin-left: auto;\n  border-right: none;\n}\n.logo {\n  vertical-align: middle;\n}\n.nav-link {\n  text-decoration: none;\n  color: inherit;\n  font-size: inherit;\n}\n.container {\n  display: flex;\n  margin: 10px auto 0 auto;\n}\n.aside {\n  padding: 30px;\n  background-color: #aaa;\n  width: 100px;\n  min-height: 300px;\n}\n.cart-items {\n  position: absolute;\n  top: -5px;\n  right: -9px;\n  font-size: 18px;\n  width: 20px;\n  text-align: center;\n  display: inline-block;\n  border-radius: 100px;\n  background-color: mediumseagreen;\n}</style>\n","import mod from \"-!../node_modules/cache-loader/dist/cjs.js??ref--12-0!../node_modules/thread-loader/dist/cjs.js!../node_modules/babel-loader/lib/index.js!../node_modules/cache-loader/dist/cjs.js??ref--0-0!../node_modules/vue-loader/lib/index.js??vue-loader-options!./App.vue?vue&type=script&lang=js&\"; export default mod; export * from \"-!../node_modules/cache-loader/dist/cjs.js??ref--12-0!../node_modules/thread-loader/dist/cjs.js!../node_modules/babel-loader/lib/index.js!../node_modules/cache-loader/dist/cjs.js??ref--0-0!../node_modules/vue-loader/lib/index.js??vue-loader-options!./App.vue?vue&type=script&lang=js&\"","import { render, staticRenderFns } from \"./App.vue?vue&type=template&id=05ec21c4&\"\nimport script from \"./App.vue?vue&type=script&lang=js&\"\nexport * from \"./App.vue?vue&type=script&lang=js&\"\nimport style0 from \"./App.vue?vue&type=style&index=0&lang=css&\"\n\n\n/* normalize component */\nimport normalizer from \"!../node_modules/vue-loader/lib/runtime/componentNormalizer.js\"\nvar component = normalizer(\n  script,\n  render,\n  staticRenderFns,\n  false,\n  null,\n  null,\n  null\n  \n)\n\nexport default component.exports","// For a complete list of dependencies refer to the dependencies in package.json.\n\n// Added to support older IE, Android, and iOS device web browsers: See link below for more details\n// https://bootstrap-vue.js.org/docs/#browser-support\nimport \"core-js/stable\";\nimport \"regenerator-runtime/runtime\";\nimport \"intersection-observer\"; // Note: This is optional\n\nimport Vue from \"vue\";\n\n// https://bootstrap-vue.org/\nimport BootstrapVue from \"bootstrap-vue\";\nimport \"bootstrap/dist/css/bootstrap.css\";\nimport \"bootstrap-vue/dist/bootstrap-vue.css\";\n\n// https://vuelidate.js.org/\nimport Vuelidate from \"vuelidate\";\n\n// https://www.npmjs.com/package/vue-inputmask\nimport VueInputMask from \"vue-inputmask\";\n\n// https://router.vuejs.org/\nimport router from \"./router\";\n\n// https://vuex.vuejs.org/\nimport store from \"./store\";\n\nimport App from \"./App.vue\";\n\nVue.config.productionTip = false;\n\nVue.use(BootstrapVue);\nVue.use(Vuelidate);\nVue.use(VueInputMask.default);\n\nnew Vue({\n  render: (h) => h(App),\n  router,\n  store,\n}).$mount(\"#app\");\n","import mod from \"-!../../node_modules/mini-css-extract-plugin/dist/loader.js??ref--6-oneOf-1-0!../../node_modules/css-loader/dist/cjs.js??ref--6-oneOf-1-1!../../node_modules/vue-loader/lib/loaders/stylePostLoader.js!../../node_modules/postcss-loader/src/index.js??ref--6-oneOf-1-2!../../node_modules/cache-loader/dist/cjs.js??ref--0-0!../../node_modules/vue-loader/lib/index.js??vue-loader-options!./PrintRequest.vue?vue&type=style&index=0&lang=css&\"; export default mod; export * from \"-!../../node_modules/mini-css-extract-plugin/dist/loader.js??ref--6-oneOf-1-0!../../node_modules/css-loader/dist/cjs.js??ref--6-oneOf-1-1!../../node_modules/vue-loader/lib/loaders/stylePostLoader.js!../../node_modules/postcss-loader/src/index.js??ref--6-oneOf-1-2!../../node_modules/cache-loader/dist/cjs.js??ref--0-0!../../node_modules/vue-loader/lib/index.js??vue-loader-options!./PrintRequest.vue?vue&type=style&index=0&lang=css&\"","import mod from \"-!../node_modules/mini-css-extract-plugin/dist/loader.js??ref--6-oneOf-1-0!../node_modules/css-loader/dist/cjs.js??ref--6-oneOf-1-1!../node_modules/vue-loader/lib/loaders/stylePostLoader.js!../node_modules/postcss-loader/src/index.js??ref--6-oneOf-1-2!../node_modules/cache-loader/dist/cjs.js??ref--0-0!../node_modules/vue-loader/lib/index.js??vue-loader-options!./Error.vue?vue&type=style&index=0&lang=css&\"; export default mod; export * from \"-!../node_modules/mini-css-extract-plugin/dist/loader.js??ref--6-oneOf-1-0!../node_modules/css-loader/dist/cjs.js??ref--6-oneOf-1-1!../node_modules/vue-loader/lib/loaders/stylePostLoader.js!../node_modules/postcss-loader/src/index.js??ref--6-oneOf-1-2!../node_modules/cache-loader/dist/cjs.js??ref--0-0!../node_modules/vue-loader/lib/index.js??vue-loader-options!./Error.vue?vue&type=style&index=0&lang=css&\"","import mod from \"-!../../node_modules/mini-css-extract-plugin/dist/loader.js??ref--6-oneOf-1-0!../../node_modules/css-loader/dist/cjs.js??ref--6-oneOf-1-1!../../node_modules/vue-loader/lib/loaders/stylePostLoader.js!../../node_modules/postcss-loader/src/index.js??ref--6-oneOf-1-2!../../node_modules/cache-loader/dist/cjs.js??ref--0-0!../../node_modules/vue-loader/lib/index.js??vue-loader-options!./SubmitRequest.vue?vue&type=style&index=0&id=03816b10&scoped=true&lang=css&\"; export default mod; export * from \"-!../../node_modules/mini-css-extract-plugin/dist/loader.js??ref--6-oneOf-1-0!../../node_modules/css-loader/dist/cjs.js??ref--6-oneOf-1-1!../../node_modules/vue-loader/lib/loaders/stylePostLoader.js!../../node_modules/postcss-loader/src/index.js??ref--6-oneOf-1-2!../../node_modules/cache-loader/dist/cjs.js??ref--0-0!../../node_modules/vue-loader/lib/index.js??vue-loader-options!./SubmitRequest.vue?vue&type=style&index=0&id=03816b10&scoped=true&lang=css&\""],"sourceRoot":""}