﻿<?xml version="1.0" encoding="utf-8" ?>
<Form>
<Table>
<tr>
<td>Date:</td>
<td type="date" member="date" style="readonly"></td>
</tr>
<tr>
<td>Medicaid:</td>
<td type="text" member="medicaid" style="readonly"></td>
</tr>
<tr>
<td>Provider:</td>
<td type="text" member="provider" style="readonly"></td>
</tr>
<tr>
<td>Program:</td>
<td type="text" member="program" style="readonly"></td>
</tr>
<tr>
<td>Units:</td>
<td type="text" member="units"></td>
</tr>
<tr>
<td>Rate:</td>
<td type="text" member="rate"></td>
</tr>
<tr>
<td>Amount:</td>
<td type="text" member="amount" style="readonly"></td>
</tr>
<tr>
<td>Transactions:</td>
<td type="text" member="tcnlist" style="multi" height="150"></td>
</tr>
<tr>
<td>Visits:</td>
<td type="checklist" member="visits" key="Id" mask="SimpleClientText" width="500" height="200" style="onecol"></td>
</tr>
<tr>
<td type="button" name="btnSave" mask="Save and Exit" colspan="2"></td>
</tr>
<tr>
<td type="button" name="btnDelete" mask="Delete" colspan="2"></td>
</tr>
<tr><td></td><td></td></tr>
</Table>
</Form>