<%= 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?}] %>

<%= 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?}] %>

<%= 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?}] %>

<%= 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?}] %>

<%= 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?}] %>

<%= 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?}] %>

<%= 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?}] %>

<%= 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?}] %>

<%= 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?}] %>

<%= 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?}] %>

<%= 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?}] %>

<%= 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?}] %>

<%= 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?}] %>

<%= 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?}] %>

<%= 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?}] %>

<%= 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?}] %>

<%= 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?}] %>

<%= 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?}] %>

<%= 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?}] %>

<%= 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?}] %>

<%= 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?}] %>

<%= 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?}] %>

<%= 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?}] %>

<%= 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?}] %>

<%= 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?}] %>

<%= 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?}] %>

<%= 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?}] %>

<%= 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?}] %>

<%= 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?}] %>

<%= 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?}] %>

<%= 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?}] %>

<%= 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?}] %>

<%= 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?}] %>

<%= 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?}] %>

<%= 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?}] %>

<%= 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?}] %>

<%= 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?}] %>

<%= 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?}] %>

<%= 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?}] %>

<%= 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?}] %>

<%= 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?}] %>