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jasper/web/reports/idcards/ToDoTemplates/TPAIDCardTan.jrxml
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2026-05-06 14:57:03 -04:00

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<?xml version="1.0" encoding="UTF-8"?>
<jasperReport xmlns="http://jasperreports.sourceforge.net/jasperreports" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xsi:schemaLocation="http://jasperreports.sourceforge.net/jasperreports http://jasperreports.sourceforge.net/xsd/jasperreport.xsd" name="IDCard" pageWidth="612" pageHeight="792" columnWidth="572" leftMargin="20" rightMargin="20" topMargin="20" bottomMargin="20" uuid="477346fd-960f-44d2-84f5-bd25202741fc">
<property name="ireport.zoom" value="2.0"/>
<property name="ireport.x" value="32"/>
<property name="ireport.y" value="0"/>
<parameter name="FamilyId" class="java.lang.String">
<defaultValueExpression><![CDATA["227217649"]]></defaultValueExpression>
</parameter>
<parameter name="BackImage" class="java.lang.String">
<defaultValueExpression><![CDATA["C:\\images\\All_3_Logo.png"]]></defaultValueExpression>
</parameter>
<queryString>
<![CDATA[Select * From HLIDCardEggData Where FamilyId = $P{FamilyId}]]>
</queryString>
<field name="ID" class="java.lang.Integer"/>
<field name="Facility" class="java.lang.String"/>
<field name="Division" class="java.lang.String"/>
<field name="FullName" class="java.lang.String"/>
<field name="SSN" class="java.lang.String"/>
<field name="MedicalCoverage" class="java.lang.String"/>
<field name="MedicalEffDate" class="java.lang.String"/>
<field name="MedicalGroupNum" class="java.lang.String"/>
<field name="DentalCoverage" class="java.lang.String"/>
<field name="DentalEffDate" class="java.lang.String"/>
<field name="DentalGroupNum" class="java.lang.String"/>
<field name="CardType" class="java.lang.String"/>
<field name="ProviderCode" class="java.lang.String"/>
<field name="ProviderLine1" class="java.lang.String"/>
<field name="ProviderLine2" class="java.lang.String"/>
<field name="ProviderLine3" class="java.lang.String"/>
<field name="ProviderLine4" class="java.lang.String"/>
<field name="ProviderLine5" class="java.lang.String"/>
<field name="ProviderLine6" class="java.lang.String"/>
<field name="ProviderLine7" class="java.lang.String"/>
<field name="ProviderLine8" class="java.lang.String"/>
<field name="ProviderLine9" class="java.lang.String"/>
<field name="ProviderLine10" class="java.lang.String"/>
<field name="ProviderLine11" class="java.lang.String"/>
<field name="MailTo" class="java.lang.String"/>
<field name="MailTo2" class="java.lang.String"/>
<field name="ClaimTo1" class="java.lang.String"/>
<field name="ClaimTo2" class="java.lang.String"/>
<field name="ClaimTo3" class="java.lang.String"/>
<field name="ClaimTo4" class="java.lang.String"/>
<field name="ClaimTo5" class="java.lang.String"/>
<field name="ClaimTo6" class="java.lang.String"/>
<field name="ClaimTo7" class="java.lang.String"/>
<field name="ClaimTo8" class="java.lang.String"/>
<field name="ClaimTo9" class="java.lang.String"/>
<field name="ClaimTo10" class="java.lang.String"/>
<field name="ClaimTo11" class="java.lang.String"/>
<field name="ContactLine1" class="java.lang.String"/>
<field name="ContactLine2" class="java.lang.String"/>
<field name="ContactLine3" class="java.lang.String"/>
<field name="GroupNumber" class="java.lang.String"/>
<field name="FamilyId" class="java.lang.String"/>
<field name="GroupNo" class="java.lang.String"/>
<field name="RXGroupID" class="java.lang.String"/>
<field name="HelpDesk" class="java.lang.String"/>
<field name="CustomerService" class="java.lang.String"/>
<field name="WebUrl" class="java.lang.String"/>
<field name="Expr1" class="java.lang.String"/>
<field name="Line3" class="java.lang.String"/>
<field name="Dependent1" class="java.lang.String"/>
<field name="Dependent2" class="java.lang.String"/>
<field name="Dependent3" class="java.lang.String"/>
<field name="Dependent4" class="java.lang.String"/>
<field name="Dependent5" class="java.lang.String"/>
<field name="Dependent6" class="java.lang.String"/>
<field name="BenDesc1" class="java.lang.String"/>
<field name="Ben1" class="java.lang.String"/>
<field name="BenDesc2" class="java.lang.String"/>
<field name="Ben2" class="java.lang.String"/>
<field name="BenDesc3" class="java.lang.String"/>
<field name="Ben3" class="java.lang.String"/>
<field name="BenDesc4" class="java.lang.String"/>
<field name="Ben4" class="java.lang.String"/>
<field name="BenDesc5" class="java.lang.String"/>
<field name="Ben5" class="java.lang.String"/>
<field name="BenDesc6" class="java.lang.String"/>
<field name="Ben6" class="java.lang.String"/>
<field name="BenDesc7" class="java.lang.String"/>
<field name="Ben7" class="java.lang.String"/>
<field name="BenDesc8" class="java.lang.String"/>
<field name="Ben8" class="java.lang.String"/>
<field name="PLPlanKey" class="java.lang.Integer"/>
<field name="PrimaryMBMemberKey" class="java.lang.Integer"/>
<field name="PPOLookup1" class="java.lang.String"/>
<field name="PPOLookup2" class="java.lang.String"/>
<field name="Precert1" class="java.lang.String"/>
<field name="Precert2" class="java.lang.String"/>
<field name="Precert3" class="java.lang.String"/>
<field name="Precert4" class="java.lang.String"/>
<field name="Precert5" class="java.lang.String"/>
<field name="Precert6" class="java.lang.String"/>
<background>
<band splitType="Stretch"/>
</background>
<title>
<band splitType="Stretch"/>
</title>
<pageHeader>
<band splitType="Stretch"/>
</pageHeader>
<columnHeader>
<band splitType="Stretch"/>
</columnHeader>
<detail>
<band height="156" splitType="Immediate">
<rectangle>
<reportElement uuid="4a5b91ca-ebdb-45be-8c16-f6ab6529dae7" x="439" y="15" width="102" height="109"/>
</rectangle>
<rectangle>
<reportElement uuid="7335a19a-8a74-445f-aaa4-e015e3c186f8" mode="Transparent" x="296" y="1" width="250" height="155" forecolor="#00CCFF"/>
<graphicElement>
<pen lineWidth="0.5" lineStyle="Dashed"/>
</graphicElement>
</rectangle>
<rectangle>
<reportElement uuid="08937bdf-e64e-4836-b222-490c0843272b" mode="Transparent" x="35" y="1" width="250" height="155" forecolor="#00CCFF"/>
<graphicElement>
<pen lineWidth="0.5" lineStyle="Dashed"/>
</graphicElement>
</rectangle>
<rectangle>
<reportElement uuid="e762ee84-c013-417b-a78f-54f6f1f6a1a3" x="41" y="15" width="122" height="90"/>
</rectangle>
<rectangle>
<reportElement uuid="66e1721c-c7fd-40cf-8f45-10b5f6b4c22d" x="41" y="117" width="122" height="34"/>
</rectangle>
<rectangle>
<reportElement uuid="ad8b04e0-5993-4f1c-b6b1-f2c11320be29" x="169" y="15" width="110" height="136"/>
</rectangle>
<rectangle>
<reportElement uuid="777f7302-b52c-48fd-9cf7-6bce02846f86" x="302" y="15" width="133" height="74"/>
</rectangle>
<rectangle>
<reportElement uuid="c654c4f4-6d8f-4678-9a39-99f7394d2690" x="302" y="6" width="53" height="8" backcolor="#000000"/>
</rectangle>
<rectangle>
<reportElement uuid="5c229560-d2d4-4752-95a0-b562e786d29e" x="169" y="6" width="58" height="8" backcolor="#000000"/>
</rectangle>
<rectangle>
<reportElement uuid="014fd155-bf62-4aa6-8a1a-894c0b5855ac" x="41" y="6" width="60" height="8" backcolor="#000000"/>
</rectangle>
<rectangle>
<reportElement uuid="2a360f63-7815-4b72-9ff1-9339cc530b94" x="41" y="108" width="60" height="8" backcolor="#000000"/>
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<staticText>
<reportElement uuid="8417fc69-fdb9-483e-8c7f-9d5a0b91cbc5" x="43" y="6" width="39" height="10" forecolor="#FFFFFF"/>
<textElement>
<font size="6" isUnderline="false"/>
</textElement>
<text><![CDATA[Eligibility]]></text>
</staticText>
<staticText>
<reportElement uuid="393d9b02-933b-46d8-850b-4d69d148aa86" x="43" y="108" width="58" height="11" forecolor="#FFFFFF"/>
<textElement>
<font size="6" isUnderline="false" isPdfEmbedded="false"/>
</textElement>
<text><![CDATA[Utilization / Pre-Cert]]></text>
</staticText>
<image scaleImage="FillFrame">
<reportElement uuid="7445dc43-933e-4b42-bef0-1772e9b85ba4" x="442" y="17" width="97" height="23"/>
<imageExpression><![CDATA["C:\\images\\TandemLocLogo.png"]]></imageExpression>
</image>
<staticText>
<reportElement uuid="5e18e17a-d437-434d-ad97-fe131a7f2850" x="171" y="6" width="56" height="11" forecolor="#FFFFFF"/>
<textElement>
<font size="6" isUnderline="false" isPdfEmbedded="false"/>
</textElement>
<text><![CDATA[Claims Submission]]></text>
</staticText>
<staticText>
<reportElement uuid="99f47ca3-1456-4fc7-bb08-a98f460120ce" x="441" y="40" width="98" height="34"/>
<textElement textAlignment="Center" verticalAlignment="Middle">
<font size="6" isBold="true" isItalic="false"/>
</textElement>
<text><![CDATA[Administered by:
Britton Benefit Services, LLC
1.800.676.1182]]></text>
</staticText>
<staticText>
<reportElement uuid="75aa6426-2374-4c07-9556-63dab683cb11" x="41" y="16" width="122" height="17"/>
<textElement textAlignment="Center" verticalAlignment="Middle">
<font size="6" isBold="false" isItalic="false"/>
</textElement>
<text><![CDATA[To confirm eligibility, verify benefits,
or check claim:
]]></text>
</staticText>
<staticText>
<reportElement uuid="8307c61b-9927-4bcc-a825-fec29b5ba605" x="41" y="33" width="122" height="17"/>
<textElement textAlignment="Center" verticalAlignment="Middle">
<font size="6" isBold="false" isItalic="false"/>
</textElement>
<text><![CDATA[Britton Benefit Services, LLC]]></text>
</staticText>
<staticText>
<reportElement uuid="46c394a4-7df2-4f23-b17e-d8e186e99f5e" x="41" y="50" width="122" height="50"/>
<textElement textAlignment="Center" verticalAlignment="Middle">
<font size="6" isBold="false" isItalic="false"/>
</textElement>
<text><![CDATA[Call:
1.800.676.1182 (8am 5pm)
Online:
www.bbstpa.com (24/7)
This card does not guarantee
eligibility or payment
]]></text>
</staticText>
<textField>
<reportElement uuid="10b2b729-cb2f-4507-99d4-d3286e5ca8ed" x="171" y="16" width="52" height="7"/>
<textElement verticalAlignment="Middle">
<font size="5"/>
</textElement>
<textFieldExpression><![CDATA[$F{ClaimTo1}]]></textFieldExpression>
</textField>
<textField>
<reportElement uuid="0f23b912-da97-4297-b142-8c47d3332037" x="171" y="21" width="52" height="7"/>
<textElement verticalAlignment="Middle">
<font size="5"/>
</textElement>
<textFieldExpression><![CDATA[$F{ClaimTo2}]]></textFieldExpression>
</textField>
<textField>
<reportElement uuid="6664081c-30df-4e12-a563-e286fb71935a" x="171" y="26" width="52" height="7"/>
<textElement verticalAlignment="Middle">
<font size="5"/>
</textElement>
<textFieldExpression><![CDATA[$F{ClaimTo3}]]></textFieldExpression>
</textField>
<textField>
<reportElement uuid="e957833e-54e9-4145-b41b-1a72d0ddadf3" x="171" y="31" width="52" height="7"/>
<textElement verticalAlignment="Middle">
<font size="5"/>
</textElement>
<textFieldExpression><![CDATA[$F{ClaimTo4}]]></textFieldExpression>
</textField>
<textField>
<reportElement uuid="a49dbbb0-791e-4930-b99a-dfa39ee3e3d9" x="171" y="40" width="52" height="7"/>
<textElement>
<font size="5"/>
</textElement>
<textFieldExpression><![CDATA[$F{ClaimTo5}]]></textFieldExpression>
</textField>
<textField>
<reportElement uuid="0b0c6791-76a7-4a76-9695-59fff6544f8f" x="171" y="45" width="52" height="7"/>
<textElement>
<font size="5"/>
</textElement>
<textFieldExpression><![CDATA[$F{ClaimTo6}]]></textFieldExpression>
</textField>
<textField>
<reportElement uuid="f1ce64f0-b5fd-499e-a419-e0ef4b1e32e0" x="171" y="50" width="52" height="7"/>
<textElement>
<font size="5"/>
</textElement>
<textFieldExpression><![CDATA[$F{ClaimTo7}]]></textFieldExpression>
</textField>
<textField>
<reportElement uuid="2abffded-f4c1-4bfd-bf83-95550d8e1aa3" x="171" y="55" width="52" height="7"/>
<textElement>
<font size="5"/>
</textElement>
<textFieldExpression><![CDATA[$F{ClaimTo8}]]></textFieldExpression>
</textField>
<textField>
<reportElement uuid="ed2733a7-5906-4544-a4a6-1e4465c94f70" x="171" y="64" width="52" height="7"/>
<textElement>
<font size="5"/>
</textElement>
<textFieldExpression><![CDATA[$F{ClaimTo9}]]></textFieldExpression>
</textField>
<textField>
<reportElement uuid="cc95f964-4572-46b1-b092-964c9f19e7f6" x="171" y="70" width="52" height="7"/>
<textElement>
<font size="5"/>
</textElement>
<textFieldExpression><![CDATA[$F{ClaimTo10}]]></textFieldExpression>
</textField>
<textField>
<reportElement uuid="6becfb6d-cb5b-4262-991d-e8d5bc9153c1" x="171" y="76" width="52" height="7"/>
<textElement>
<font size="5"/>
</textElement>
<textFieldExpression><![CDATA[$F{ClaimTo11}]]></textFieldExpression>
</textField>
<image scaleImage="RetainShape" hAlign="Center" vAlign="Middle">
<reportElement uuid="ece00572-ba7a-4374-9eed-447db3b11a5c" x="175" y="92" width="97" height="52"/>
<imageExpression><![CDATA["c:\\images\\MedCostLogo.png"]]></imageExpression>
</image>
<textField>
<reportElement uuid="94749044-5ec6-4eb4-8f6d-e52ce5e215da" x="227" y="16" width="52" height="7"/>
<textElement>
<font size="5"/>
</textElement>
<textFieldExpression><![CDATA[$F{ProviderLine1}]]></textFieldExpression>
</textField>
<textField>
<reportElement uuid="25cbc687-a185-4894-97f4-11d57c8ad84c" x="227" y="21" width="52" height="7"/>
<textElement>
<font size="5"/>
</textElement>
<textFieldExpression><![CDATA[$F{ProviderLine2}]]></textFieldExpression>
</textField>
<textField>
<reportElement uuid="527837e8-6ecb-4eba-8b3c-c1fee8e58b52" x="227" y="26" width="52" height="7"/>
<textElement>
<font size="5"/>
</textElement>
<textFieldExpression><![CDATA[$F{ProviderLine3}]]></textFieldExpression>
</textField>
<textField>
<reportElement uuid="96e1ff12-6c27-4bd9-b706-050a283ea1a8" x="227" y="31" width="52" height="7"/>
<textElement>
<font size="5"/>
</textElement>
<textFieldExpression><![CDATA[$F{ProviderLine4}]]></textFieldExpression>
</textField>
<textField>
<reportElement uuid="c209866f-c8db-455d-8118-ae0aa51204a8" x="227" y="40" width="52" height="7"/>
<textElement>
<font size="5"/>
</textElement>
<textFieldExpression><![CDATA[$F{ProviderLine5}]]></textFieldExpression>
</textField>
<textField>
<reportElement uuid="22bcf3ce-6edc-4390-9c63-f169623fdf58" x="227" y="45" width="52" height="7"/>
<textElement>
<font size="5"/>
</textElement>
<textFieldExpression><![CDATA[$F{ProviderLine6}]]></textFieldExpression>
</textField>
<textField>
<reportElement uuid="b8bd2df8-9ad2-4cde-9c67-b0e32425c00b" x="227" y="50" width="52" height="7"/>
<textElement>
<font size="5"/>
</textElement>
<textFieldExpression><![CDATA[$F{ProviderLine7}]]></textFieldExpression>
</textField>
<textField>
<reportElement uuid="e5d86062-d78f-42b5-b578-cd14dcc071ca" x="227" y="55" width="52" height="7"/>
<textElement>
<font size="5"/>
</textElement>
<textFieldExpression><![CDATA[$F{ProviderLine8}]]></textFieldExpression>
</textField>
<textField>
<reportElement uuid="8b542cf4-f0e7-4019-90cf-4b3a826184bf" x="227" y="64" width="52" height="7"/>
<textElement>
<font size="5"/>
</textElement>
<textFieldExpression><![CDATA[$F{ProviderLine9}]]></textFieldExpression>
</textField>
<textField>
<reportElement uuid="b154a117-b385-4eac-b53a-51f349d2e9a6" x="227" y="69" width="52" height="7"/>
<textElement>
<font size="5"/>
</textElement>
<textFieldExpression><![CDATA[$F{ProviderLine10}]]></textFieldExpression>
</textField>
<textField>
<reportElement uuid="d30067fe-8185-4854-a4da-615d8bb59f4a" x="227" y="76" width="52" height="7"/>
<textElement>
<font size="5"/>
</textElement>
<textFieldExpression><![CDATA[$F{ProviderLine11}]]></textFieldExpression>
</textField>
<staticText>
<reportElement uuid="8bbea900-0c43-40d8-ad68-2f478aabd3c1" x="305" y="6" width="50" height="11" forecolor="#FFFFFF"/>
<textElement>
<font size="6" isUnderline="false" isPdfEmbedded="false"/>
</textElement>
<text><![CDATA[Health Benefit Plan]]></text>
</staticText>
<rectangle>
<reportElement uuid="4ecd4a82-edd1-4166-abf9-85d66ebb8b37" x="439" y="6" width="44" height="8" backcolor="#000000"/>
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<staticText>
<reportElement uuid="4ddf1be3-c752-46e0-8197-f4d64b5484b0" x="442" y="6" width="41" height="11" forecolor="#FFFFFF"/>
<textElement>
<font size="6" isUnderline="false" isPdfEmbedded="false"/>
</textElement>
<text><![CDATA[Medical Plan]]></text>
</staticText>
<rectangle>
<reportElement uuid="1b74e177-da54-47c1-a801-ac0331d2cd11" x="302" y="100" width="133" height="51"/>
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<rectangle>
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<staticText>
<reportElement uuid="fa26d6b7-51d2-4f9e-9d05-9a4513c66eed" x="305" y="92" width="50" height="11" forecolor="#FFFFFF"/>
<textElement>
<font size="6" isUnderline="false" isPdfEmbedded="false"/>
</textElement>
<text><![CDATA[Pharmacy Plan]]></text>
</staticText>
<staticText>
<reportElement uuid="5c39d2a5-fb6b-427a-ade9-f09c04c1144c" x="304" y="16" width="40" height="8"/>
<textElement>
<font size="6" isBold="true"/>
</textElement>
<text><![CDATA[Group #/ID:]]></text>
</staticText>
<staticText>
<reportElement uuid="26d1f156-d150-4837-9bba-1390a8199fb4" x="304" y="23" width="30" height="8"/>
<textElement>
<font size="6" isBold="true"/>
</textElement>
<text><![CDATA[Name:]]></text>
</staticText>
<staticText>
<reportElement uuid="8c0fbf41-d7b6-482b-996d-0b48ee2b0ff7" x="304" y="30" width="30" height="8"/>
<textElement>
<font size="6" isBold="true"/>
</textElement>
<text><![CDATA[Policy #:]]></text>
</staticText>
<staticText>
<reportElement uuid="da2ecd13-2381-494c-9d69-745b2496587e" x="304" y="37" width="50" height="8"/>
<textElement>
<font size="6" isBold="true"/>
</textElement>
<text><![CDATA[Effective Date:]]></text>
</staticText>
<staticText>
<reportElement uuid="58ce6f59-01b7-457a-aee6-0be9d7ae868e" x="304" y="44" width="40" height="8"/>
<textElement>
<font size="6" isBold="true"/>
</textElement>
<text><![CDATA[Employer:]]></text>
</staticText>
<textField>
<reportElement uuid="1361e8b7-6ea2-4f2b-a6fd-781b1fa521e8" x="346" y="16" width="88" height="8"/>
<textElement>
<font size="6"/>
</textElement>
<textFieldExpression><![CDATA[$F{GroupNo}]]></textFieldExpression>
</textField>
<textField>
<reportElement uuid="c2877613-bc27-4175-b080-5ab67f1d781c" x="346" y="23" width="88" height="8"/>
<textElement>
<font size="6"/>
</textElement>
<textFieldExpression><![CDATA[$F{FullName}]]></textFieldExpression>
</textField>
<textField>
<reportElement uuid="acea13af-f269-47da-b9cc-ba0ea22df29f" x="346" y="30" width="88" height="8"/>
<textElement>
<font size="6"/>
</textElement>
<textFieldExpression><![CDATA[$F{PrimaryMBMemberKey}]]></textFieldExpression>
</textField>
<textField>
<reportElement uuid="eaa738bf-1ced-4c86-8a31-9acc09a88abe" x="346" y="37" width="88" height="8"/>
<textElement>
<font size="6"/>
</textElement>
<textFieldExpression><![CDATA[$F{MedicalEffDate}]]></textFieldExpression>
</textField>
<textField>
<reportElement uuid="f559a5a0-cd09-46e5-9a6c-0b4458ddd8b2" x="346" y="44" width="88" height="18"/>
<textElement>
<font size="6"/>
</textElement>
<textFieldExpression><![CDATA[$F{Division}]]></textFieldExpression>
</textField>
<staticText>
<reportElement uuid="cf1ce1ca-5cef-436c-b2d6-26bd3e1015b4" x="304" y="61" width="76" height="8"/>
<textElement>
<font size="6" isBold="true"/>
</textElement>
<text><![CDATA[Covered Dependents:]]></text>
</staticText>
<textField>
<reportElement uuid="848389f8-98f1-41da-962e-cc29aeac91d1" x="305" y="67" width="63" height="7"/>
<textElement>
<font size="5"/>
</textElement>
<textFieldExpression><![CDATA[$F{Dependent1}]]></textFieldExpression>
</textField>
<textField>
<reportElement uuid="adee7873-b80c-4be4-9568-533471bab640" x="305" y="74" width="63" height="7"/>
<textElement>
<font size="5"/>
</textElement>
<textFieldExpression><![CDATA[$F{Dependent2}]]></textFieldExpression>
</textField>
<textField>
<reportElement uuid="53ed1fe8-89ed-42a2-98bb-9ad75418f543" x="305" y="81" width="63" height="7"/>
<textElement>
<font size="5"/>
</textElement>
<textFieldExpression><![CDATA[$F{Dependent3}]]></textFieldExpression>
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