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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 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 | 72x 59x 44x 1x | import {
ActionForm,
DatePicker,
FormControl,
FormField,
FormItem,
FormLabel,
FormMessage,
Input,
RequiredIndicator,
} from "@/components";
import { formSchemas } from "@/formSchemas";
import { FAQ_TAB } from "@/router";
import { Link } from "react-router";
import { getFAQLinkForAttachments } from "../../faqLinks";
interface AmendmentFormProps {
waiverId?: string;
}
export const AmendmentForm = ({ waiverId }: AmendmentFormProps) => {
return (
<ActionForm
schema={formSchemas["capitated-amendment"]}
title="1915(b) Comprehensive (Capitated) Waiver Amendment Details"
breadcrumbText="1915(b) Comprehensive (Capitated) Waiver Amendment"
fields={({ control }) => (
<>
<div className="flex flex-col">
<FormLabel className="font-semibold" htmlFor="1975b">
Waiver Authority
</FormLabel>
<span className="text-lg font-thin" id="1975b">
1915(b)
</span>
</div>
{waiverId !== undefined ? (
<div>
<p className="font-semibold">Existing Waiver Number to Amend</p>
<p className="text-lg font-thin" data-testid="existing-waiver-id">
{waiverId}
</p>
</div>
) : (
<FormField
control={control}
name="waiverNumber"
render={({ field }) => (
<FormItem>
<FormLabel className="font-semibold" data-testid="existing-waiver-label">
Existing Waiver Number to Amend <RequiredIndicator />
</FormLabel>
<p className="text-neutral-500">
Enter the existing waiver number you are seeking to amend in the format it was
approved, using a dash after the two character state abbreviation.
</p>
<FormControl className="max-w-sm">
<Input
ref={field.ref}
value={field.value}
onChange={(e) => field.onChange(e.currentTarget.value.toUpperCase())}
/>
</FormControl>
<FormMessage />
</FormItem>
)}
/>
)}
<FormField
control={control}
name="id"
render={({ field }) => (
<FormItem>
<div className="flex gap-4">
<FormLabel className="font-semibold" data-testid="1915b-waiver-amendment-label">
1915(b) Waiver Amendment Number <RequiredIndicator />
</FormLabel>
<Link
to="/faq/waiver-amendment-id-format"
target={FAQ_TAB}
rel="noopener noreferrer"
className="text-blue-900 underline"
>
What is my 1915(b) Waiver Amendment Number?
</Link>
</div>
<p className="text-neutral-500">
The Waiver Number must be in the format of SS-####.R##.## or SS-#####.R##.##. For
amendments, the last two digits start with {"'01'"} and ascends.
</p>
<FormControl className="max-w-sm">
<Input
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-lg">
<FormLabel className="text-lg font-semibold block">
Proposed Effective Date of 1915(b) Waiver Amendment <RequiredIndicator />
</FormLabel>
<FormControl className="max-w-sm">
<DatePicker
onChange={(date) => field.onChange(date.getTime())}
date={field.value ? new Date(field.value) : undefined}
dataTestId="proposedEffectiveDate"
/>
</FormControl>
<FormMessage />
</FormItem>
)}
/>
</>
)}
attachments={{
faqLink: getFAQLinkForAttachments("capitated-amendment"),
}}
defaultValues={{ id: "", waiverNumber: waiverId ?? "" }}
documentPollerArgs={{
property: "id",
documentChecker: (check) => check.recordExists,
}}
/>
);
};
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