<%= form_with(model: card_provider, class: "contents") do |form| %>
  <% if card_provider.errors.any? %>
    <div id="error_explanation" class="bg-red-50 text-red-500 px-3 py-2 font-medium rounded-md mt-3">
      <h2><%= pluralize(card_provider.errors.count, "error") %> prohibited this card_provider from being saved:</h2>

      <ul class="list-disc ml-6">
        <% card_provider.errors.each do |error| %>
          <li><%= error.full_message %></li>
        <% end %>
      </ul>
    </div>
  <% end %>

  <div class="my-5">
    <%= form.label :provider_code %>
    <%= form.text_field :provider_code, class: ["block shadow-sm rounded-md border px-3 py-2 mt-2 w-full", {"border-gray-400 focus:outline-blue-600": card_provider.errors[:provider_code].none?, "border-red-400 focus:outline-red-600": card_provider.errors[:provider_code].any?}] %>
  </div>

  <div class="my-5">
    <%= form.label :provider_line_1 %>
    <%= form.text_field :provider_line_1, class: ["block shadow-sm rounded-md border px-3 py-2 mt-2 w-full", {"border-gray-400 focus:outline-blue-600": card_provider.errors[:provider_line_1].none?, "border-red-400 focus:outline-red-600": card_provider.errors[:provider_line_1].any?}] %>
  </div>

  <div class="my-5">
    <%= form.label :provider_line_2 %>
    <%= form.text_field :provider_line_2, class: ["block shadow-sm rounded-md border px-3 py-2 mt-2 w-full", {"border-gray-400 focus:outline-blue-600": card_provider.errors[:provider_line_2].none?, "border-red-400 focus:outline-red-600": card_provider.errors[:provider_line_2].any?}] %>
  </div>

  <div class="my-5">
    <%= form.label :provider_line_3 %>
    <%= form.text_field :provider_line_3, class: ["block shadow-sm rounded-md border px-3 py-2 mt-2 w-full", {"border-gray-400 focus:outline-blue-600": card_provider.errors[:provider_line_3].none?, "border-red-400 focus:outline-red-600": card_provider.errors[:provider_line_3].any?}] %>
  </div>

  <div class="my-5">
    <%= form.label :provider_line_4 %>
    <%= form.text_field :provider_line_4, class: ["block shadow-sm rounded-md border px-3 py-2 mt-2 w-full", {"border-gray-400 focus:outline-blue-600": card_provider.errors[:provider_line_4].none?, "border-red-400 focus:outline-red-600": card_provider.errors[:provider_line_4].any?}] %>
  </div>

  <div class="my-5">
    <%= form.label :provider_line_5 %>
    <%= form.text_field :provider_line_5, class: ["block shadow-sm rounded-md border px-3 py-2 mt-2 w-full", {"border-gray-400 focus:outline-blue-600": card_provider.errors[:provider_line_5].none?, "border-red-400 focus:outline-red-600": card_provider.errors[:provider_line_5].any?}] %>
  </div>

  <div class="my-5">
    <%= form.label :mail_to %>
    <%= form.text_field :mail_to, class: ["block shadow-sm rounded-md border px-3 py-2 mt-2 w-full", {"border-gray-400 focus:outline-blue-600": card_provider.errors[:mail_to].none?, "border-red-400 focus:outline-red-600": card_provider.errors[:mail_to].any?}] %>
  </div>

  <div class="my-5">
    <%= form.label :mail_to_2 %>
    <%= form.text_field :mail_to_2, class: ["block shadow-sm rounded-md border px-3 py-2 mt-2 w-full", {"border-gray-400 focus:outline-blue-600": card_provider.errors[:mail_to_2].none?, "border-red-400 focus:outline-red-600": card_provider.errors[:mail_to_2].any?}] %>
  </div>

  <div class="my-5">
    <%= form.label :contact_line_1 %>
    <%= form.text_field :contact_line_1, class: ["block shadow-sm rounded-md border px-3 py-2 mt-2 w-full", {"border-gray-400 focus:outline-blue-600": card_provider.errors[:contact_line_1].none?, "border-red-400 focus:outline-red-600": card_provider.errors[:contact_line_1].any?}] %>
  </div>

  <div class="my-5">
    <%= form.label :contact_line_2 %>
    <%= form.text_field :contact_line_2, class: ["block shadow-sm rounded-md border px-3 py-2 mt-2 w-full", {"border-gray-400 focus:outline-blue-600": card_provider.errors[:contact_line_2].none?, "border-red-400 focus:outline-red-600": card_provider.errors[:contact_line_2].any?}] %>
  </div>

  <div class="my-5">
    <%= form.label :contact_line_3 %>
    <%= form.text_field :contact_line_3, class: ["block shadow-sm rounded-md border px-3 py-2 mt-2 w-full", {"border-gray-400 focus:outline-blue-600": card_provider.errors[:contact_line_3].none?, "border-red-400 focus:outline-red-600": card_provider.errors[:contact_line_3].any?}] %>
  </div>

  <div class="my-5">
    <%= form.label :group_number %>
    <%= form.text_field :group_number, class: ["block shadow-sm rounded-md border px-3 py-2 mt-2 w-full", {"border-gray-400 focus:outline-blue-600": card_provider.errors[:group_number].none?, "border-red-400 focus:outline-red-600": card_provider.errors[:group_number].any?}] %>
  </div>

  <div class="my-5">
    <%= form.label :claim_to_1 %>
    <%= form.text_field :claim_to_1, class: ["block shadow-sm rounded-md border px-3 py-2 mt-2 w-full", {"border-gray-400 focus:outline-blue-600": card_provider.errors[:claim_to_1].none?, "border-red-400 focus:outline-red-600": card_provider.errors[:claim_to_1].any?}] %>
  </div>

  <div class="my-5">
    <%= form.label :claim_to_2 %>
    <%= form.text_field :claim_to_2, class: ["block shadow-sm rounded-md border px-3 py-2 mt-2 w-full", {"border-gray-400 focus:outline-blue-600": card_provider.errors[:claim_to_2].none?, "border-red-400 focus:outline-red-600": card_provider.errors[:claim_to_2].any?}] %>
  </div>

  <div class="my-5">
    <%= form.label :claim_to_3 %>
    <%= form.text_field :claim_to_3, class: ["block shadow-sm rounded-md border px-3 py-2 mt-2 w-full", {"border-gray-400 focus:outline-blue-600": card_provider.errors[:claim_to_3].none?, "border-red-400 focus:outline-red-600": card_provider.errors[:claim_to_3].any?}] %>
  </div>

  <div class="my-5">
    <%= form.label :claim_to_4 %>
    <%= form.text_field :claim_to_4, class: ["block shadow-sm rounded-md border px-3 py-2 mt-2 w-full", {"border-gray-400 focus:outline-blue-600": card_provider.errors[:claim_to_4].none?, "border-red-400 focus:outline-red-600": card_provider.errors[:claim_to_4].any?}] %>
  </div>

  <div class="my-5">
    <%= form.label :claim_to_5 %>
    <%= form.text_field :claim_to_5, class: ["block shadow-sm rounded-md border px-3 py-2 mt-2 w-full", {"border-gray-400 focus:outline-blue-600": card_provider.errors[:claim_to_5].none?, "border-red-400 focus:outline-red-600": card_provider.errors[:claim_to_5].any?}] %>
  </div>

  <div class="my-5">
    <%= form.label :claim_to_6 %>
    <%= form.text_field :claim_to_6, class: ["block shadow-sm rounded-md border px-3 py-2 mt-2 w-full", {"border-gray-400 focus:outline-blue-600": card_provider.errors[:claim_to_6].none?, "border-red-400 focus:outline-red-600": card_provider.errors[:claim_to_6].any?}] %>
  </div>

  <div class="my-5">
    <%= form.label :claim_to_7 %>
    <%= form.text_field :claim_to_7, class: ["block shadow-sm rounded-md border px-3 py-2 mt-2 w-full", {"border-gray-400 focus:outline-blue-600": card_provider.errors[:claim_to_7].none?, "border-red-400 focus:outline-red-600": card_provider.errors[:claim_to_7].any?}] %>
  </div>

  <div class="my-5">
    <%= form.label :claim_to_8 %>
    <%= form.text_field :claim_to_8, class: ["block shadow-sm rounded-md border px-3 py-2 mt-2 w-full", {"border-gray-400 focus:outline-blue-600": card_provider.errors[:claim_to_8].none?, "border-red-400 focus:outline-red-600": card_provider.errors[:claim_to_8].any?}] %>
  </div>

  <div class="my-5">
    <%= form.label :claim_to_9 %>
    <%= form.text_field :claim_to_9, class: ["block shadow-sm rounded-md border px-3 py-2 mt-2 w-full", {"border-gray-400 focus:outline-blue-600": card_provider.errors[:claim_to_9].none?, "border-red-400 focus:outline-red-600": card_provider.errors[:claim_to_9].any?}] %>
  </div>

  <div class="my-5">
    <%= form.label :claim_to_10 %>
    <%= form.text_field :claim_to_10, class: ["block shadow-sm rounded-md border px-3 py-2 mt-2 w-full", {"border-gray-400 focus:outline-blue-600": card_provider.errors[:claim_to_10].none?, "border-red-400 focus:outline-red-600": card_provider.errors[:claim_to_10].any?}] %>
  </div>

  <div class="my-5">
    <%= form.label :claim_to_11 %>
    <%= form.text_field :claim_to_11, class: ["block shadow-sm rounded-md border px-3 py-2 mt-2 w-full", {"border-gray-400 focus:outline-blue-600": card_provider.errors[:claim_to_11].none?, "border-red-400 focus:outline-red-600": card_provider.errors[:claim_to_11].any?}] %>
  </div>

  <div class="my-5">
    <%= form.label :provider_line_6 %>
    <%= form.text_field :provider_line_6, class: ["block shadow-sm rounded-md border px-3 py-2 mt-2 w-full", {"border-gray-400 focus:outline-blue-600": card_provider.errors[:provider_line_6].none?, "border-red-400 focus:outline-red-600": card_provider.errors[:provider_line_6].any?}] %>
  </div>

  <div class="my-5">
    <%= form.label :provider_line_7 %>
    <%= form.text_field :provider_line_7, class: ["block shadow-sm rounded-md border px-3 py-2 mt-2 w-full", {"border-gray-400 focus:outline-blue-600": card_provider.errors[:provider_line_7].none?, "border-red-400 focus:outline-red-600": card_provider.errors[:provider_line_7].any?}] %>
  </div>

  <div class="my-5">
    <%= form.label :provider_line_8 %>
    <%= form.text_field :provider_line_8, class: ["block shadow-sm rounded-md border px-3 py-2 mt-2 w-full", {"border-gray-400 focus:outline-blue-600": card_provider.errors[:provider_line_8].none?, "border-red-400 focus:outline-red-600": card_provider.errors[:provider_line_8].any?}] %>
  </div>

  <div class="my-5">
    <%= form.label :provider_line_9 %>
    <%= form.text_field :provider_line_9, class: ["block shadow-sm rounded-md border px-3 py-2 mt-2 w-full", {"border-gray-400 focus:outline-blue-600": card_provider.errors[:provider_line_9].none?, "border-red-400 focus:outline-red-600": card_provider.errors[:provider_line_9].any?}] %>
  </div>

  <div class="my-5">
    <%= form.label :provider_line_10 %>
    <%= form.text_field :provider_line_10, class: ["block shadow-sm rounded-md border px-3 py-2 mt-2 w-full", {"border-gray-400 focus:outline-blue-600": card_provider.errors[:provider_line_10].none?, "border-red-400 focus:outline-red-600": card_provider.errors[:provider_line_10].any?}] %>
  </div>

  <div class="my-5">
    <%= form.label :provider_line_11 %>
    <%= form.text_field :provider_line_11, class: ["block shadow-sm rounded-md border px-3 py-2 mt-2 w-full", {"border-gray-400 focus:outline-blue-600": card_provider.errors[:provider_line_11].none?, "border-red-400 focus:outline-red-600": card_provider.errors[:provider_line_11].any?}] %>
  </div>

  <div class="my-5">
    <%= form.label :rx_group_id %>
    <%= form.text_field :rx_group_id, class: ["block shadow-sm rounded-md border px-3 py-2 mt-2 w-full", {"border-gray-400 focus:outline-blue-600": card_provider.errors[:rx_group_id].none?, "border-red-400 focus:outline-red-600": card_provider.errors[:rx_group_id].any?}] %>
  </div>

  <div class="my-5">
    <%= form.label :rx_contact %>
    <%= form.text_field :rx_contact, class: ["block shadow-sm rounded-md border px-3 py-2 mt-2 w-full", {"border-gray-400 focus:outline-blue-600": card_provider.errors[:rx_contact].none?, "border-red-400 focus:outline-red-600": card_provider.errors[:rx_contact].any?}] %>
  </div>

  <div class="my-5">
    <%= form.label :provider_lookup_1 %>
    <%= form.text_field :provider_lookup_1, class: ["block shadow-sm rounded-md border px-3 py-2 mt-2 w-full", {"border-gray-400 focus:outline-blue-600": card_provider.errors[:provider_lookup_1].none?, "border-red-400 focus:outline-red-600": card_provider.errors[:provider_lookup_1].any?}] %>
  </div>

  <div class="my-5">
    <%= form.label :provider_lookup_2 %>
    <%= form.text_field :provider_lookup_2, class: ["block shadow-sm rounded-md border px-3 py-2 mt-2 w-full", {"border-gray-400 focus:outline-blue-600": card_provider.errors[:provider_lookup_2].none?, "border-red-400 focus:outline-red-600": card_provider.errors[:provider_lookup_2].any?}] %>
  </div>

  <div class="my-5">
    <%= form.label :precert_1 %>
    <%= form.text_field :precert_1, class: ["block shadow-sm rounded-md border px-3 py-2 mt-2 w-full", {"border-gray-400 focus:outline-blue-600": card_provider.errors[:precert_1].none?, "border-red-400 focus:outline-red-600": card_provider.errors[:precert_1].any?}] %>
  </div>

  <div class="my-5">
    <%= form.label :precert_2 %>
    <%= form.text_field :precert_2, class: ["block shadow-sm rounded-md border px-3 py-2 mt-2 w-full", {"border-gray-400 focus:outline-blue-600": card_provider.errors[:precert_2].none?, "border-red-400 focus:outline-red-600": card_provider.errors[:precert_2].any?}] %>
  </div>

  <div class="my-5">
    <%= form.label :precert_3 %>
    <%= form.text_field :precert_3, class: ["block shadow-sm rounded-md border px-3 py-2 mt-2 w-full", {"border-gray-400 focus:outline-blue-600": card_provider.errors[:precert_3].none?, "border-red-400 focus:outline-red-600": card_provider.errors[:precert_3].any?}] %>
  </div>

  <div class="my-5">
    <%= form.label :precert_4 %>
    <%= form.text_field :precert_4, class: ["block shadow-sm rounded-md border px-3 py-2 mt-2 w-full", {"border-gray-400 focus:outline-blue-600": card_provider.errors[:precert_4].none?, "border-red-400 focus:outline-red-600": card_provider.errors[:precert_4].any?}] %>
  </div>

  <div class="my-5">
    <%= form.label :precert_5 %>
    <%= form.text_field :precert_5, class: ["block shadow-sm rounded-md border px-3 py-2 mt-2 w-full", {"border-gray-400 focus:outline-blue-600": card_provider.errors[:precert_5].none?, "border-red-400 focus:outline-red-600": card_provider.errors[:precert_5].any?}] %>
  </div>

  <div class="my-5">
    <%= form.label :precert_6 %>
    <%= form.text_field :precert_6, class: ["block shadow-sm rounded-md border px-3 py-2 mt-2 w-full", {"border-gray-400 focus:outline-blue-600": card_provider.errors[:precert_6].none?, "border-red-400 focus:outline-red-600": card_provider.errors[:precert_6].any?}] %>
  </div>

  <div class="my-5">
    <%= form.label :provider_line_12 %>
    <%= form.text_field :provider_line_12, class: ["block shadow-sm rounded-md border px-3 py-2 mt-2 w-full", {"border-gray-400 focus:outline-blue-600": card_provider.errors[:provider_line_12].none?, "border-red-400 focus:outline-red-600": card_provider.errors[:provider_line_12].any?}] %>
  </div>

  <div class="my-5">
    <%= form.label :claim_to_12 %>
    <%= form.text_field :claim_to_12, class: ["block shadow-sm rounded-md border px-3 py-2 mt-2 w-full", {"border-gray-400 focus:outline-blue-600": card_provider.errors[:claim_to_12].none?, "border-red-400 focus:outline-red-600": card_provider.errors[:claim_to_12].any?}] %>
  </div>

  <div class="inline">
    <%= form.submit class: "w-full sm:w-auto rounded-md px-3.5 py-2.5 bg-blue-600 hover:bg-blue-500 text-white inline-block font-medium cursor-pointer" %>
  </div>
<% end %>
