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| 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 | 72x 1x 32x 1x | import {
DatePicker,
FormControl,
FormField,
FormItem,
FormLabel,
FormMessage,
Input,
RequiredIndicator,
SpaIdFormattingDesc,
} from "@/components";
import { ActionForm } from "@/components/ActionForm";
import { AttachmentFileFormatInstructions } from "@/components/ActionForm/actionForm.components";
import { formSchemas } from "@/formSchemas";
import { FAQ_TAB } from "@/router";
import { Link } from "react-router";
export const MedicaidForm = () => (
<ActionForm
schema={formSchemas["new-medicaid-submission"]}
title="Medicaid SPA Details"
breadcrumbText="Submit new Medicaid SPA"
fields={({ control }) => (
<>
<FormField
control={control}
name="id"
render={({ field }) => (
<FormItem>
<div className="flex gap-4">
<FormLabel className="font-semibold" data-testid="spaid-label">
SPA ID <RequiredIndicator />
</FormLabel>
<Link
to="/faq/spa-id-format"
target={FAQ_TAB}
rel="noopener noreferrer"
className="text-blue-900 underline"
>
What is my SPA ID?
</Link>
</div>
<SpaIdFormattingDesc />
<FormControl>
<Input
className="max-w-sm"
ref={field.ref}
value={field.value}
onChange={(e) => field.onChange(e.currentTarget.value.toUpperCase())}
/>
</FormControl>
<FormMessage />
</FormItem>
)}
/>
<FormField
control={control}
name="proposedEffectiveDate"
render={({ field }) => (
<FormItem className="max-w-md">
<FormLabel
className="text-lg font-semibold block"
data-testid="proposedEffectiveDate-label"
>
Proposed Effective Date of Medicaid SPA <RequiredIndicator />
</FormLabel>
<FormControl>
<DatePicker
onChange={(date) => field.onChange(date.getTime())}
date={field.value ? new Date(field.value) : undefined}
dataTestId="proposedEffectiveDate"
/>
</FormControl>
<FormMessage />
</FormItem>
)}
/>
</>
)}
defaultValues={{ id: "" }}
attachments={{
instructions: [
<p data-testid="attachments-instructions">
Maximum file size of 80 MB per attachment.{" "}
<span className="font-bold">
You can add multiple files per attachment type except for the CMS Form 179.
</span>{" "}
Read the description for each of the attachment types on the{" "}
<Link
to="/faq/medicaid-spa-attachments"
target={FAQ_TAB}
rel="noopener noreferrer"
className="text-blue-900 underline"
>
FAQ Page
</Link>
.
</p>,
<AttachmentFileFormatInstructions />,
],
}}
documentPollerArgs={{
property: "id",
documentChecker: (check) => check.recordExists,
}}
/>
);
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