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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 | 72x 1x 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";
export const InitialForm = () => (
<ActionForm
schema={formSchemas["capitated-initial"]}
title="1915(b) Comprehensive (Capitated) Initial Waiver Details"
breadcrumbText="1915(b) Comprehensive (Capitated) Initial Waiver"
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>
<FormField
control={control}
name="id"
render={({ field }) => (
<FormItem>
<div className="flex gap-4">
<FormLabel
className="text-lg font-semibold mr-1"
data-testid="1915b-waiver-initial-label"
>
Initial Waiver Number <RequiredIndicator />
</FormLabel>
<Link
to={"/faq/initial-waiver-id-format"}
target={FAQ_TAB}
rel="noopener noreferrer"
className="text-blue-900 underline"
>
What is my Initial Waiver Number?
</Link>
</div>
<p className="text-neutral-500" id="waiver-number-format">
Must be a new initial number with the format SS-####.R00.00 or SS-#####.R00.00
</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) Initial Waiver <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-initial"),
}}
defaultValues={{ id: "" }}
documentPollerArgs={{
property: "id",
documentChecker: (check) => check.recordExists,
}}
/>
);
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