@php
    $moduleName = 'New Insurance Claim';
    $arName = 'إنشاء مطالبة تأمين جديدة';
@endphp
<x-app-layout>
    <x-slot name="header">
        <h2 class="font-semibold text-xl text-black leading-tight">
            {{ \App\Helpers\TranslationHelper::transFromDatabase($moduleName, __($arName)) }}
        </h2>
    </x-slot>

    <div class="py-12">
        <div class="max-w-7xl mx-auto sm:px-6 lg:px-8">
            <div class="bg-white overflow-hidden shadow-sm sm:rounded-lg">
                <div class="p-6 text-black">
                    <form action="{{ route('healthcare.insurance.claims.store') }}" method="POST">
                        @csrf
                        
                        <div class="mb-4">
                            <label for="patient_id" class="block text-sm font-medium text-black">{{ __('Patient') }} / {{ __('المريض') }}</label>
                            <select name="patient_id" id="patient_id" class="select2 mt-1 block w-full rounded-md border-gray-300 shadow-sm focus:border-indigo-500 focus:ring-indigo-500" required>
                                <option value="">{{ __('Select Patient') }} / {{ __('اختر المريض') }}</option>
                                @foreach($patients as $patient)
                                    <option value="{{ $patient->id }}">{{ $patient->name }} ({{ $patient->mrn }})</option>
                                @endforeach
                            </select>
                            @error('patient_id')
                                <p class="text-red-500 text-xs mt-1">{{ $message }}</p>
                            @enderror
                        </div>

                        <div class="mb-4">
                            <label for="provider_id" class="block text-sm font-medium text-black">{{ __('Insurance Provider') }} / {{ __('جهة التأمين') }}</label>
                            <select name="provider_id" id="provider_id" class="select2 mt-1 block w-full rounded-md border-gray-300 shadow-sm focus:border-indigo-500 focus:ring-indigo-500" required>
                                <option value="">{{ __('Select Provider') }} / {{ __('اختر جهة التأمين') }}</option>
                                @foreach($providers as $provider)
                                    <option value="{{ $provider->id }}">{{ $provider->name }}</option>
                                @endforeach
                            </select>
                            @error('provider_id')
                                <p class="text-red-500 text-xs mt-1">{{ $message }}</p>
                            @enderror
                        </div>

                        <div class="mb-4">
                            <label for="claimed_amount" class="block text-sm font-medium text-black">{{ __('Claimed Amount') }} / {{ __('المبلغ المطلوب') }}</label>
                            <input type="number" name="claimed_amount" id="claimed_amount" step="0.01" class="mt-1 block w-full rounded-md border-gray-300 shadow-sm focus:border-indigo-500 focus:ring-indigo-500" required>
                            @error('claimed_amount')
                                <p class="text-red-500 text-xs mt-1">{{ $message }}</p>
                            @enderror
                        </div>

                        <div class="flex items-center justify-end mt-4">
                            <a href="{{ route('healthcare.insurance.claims') }}" class="text-black hover:text-black mr-4">
                                {{ __('Cancel') }} / {{ __('إلغاء') }}
                            </a>
                            <button type="submit" class="bg-blue-600 text-white px-4 py-2 rounded hover:bg-blue-700">
                                {{ __('Create Claim') }} / {{ __('إنشاء مطالبة') }}
                            </button>
                        </div>
                    </form>
                </div>
            </div>
        </div>
    </div>
</x-app-layout>