<!DOCTYPE html>
<html>
<head>
<title>Superbill Generator</title>
<script src="https://cdnjs.cloudflare.com/ajax/libs/jspdf/2.4.0/jspdf.umd.min.js"></script>
</head>
<body>
<h2>Superbill Generator</h2>
<form id="superbillForm">
<label>Date of Service:</label>
<input type="date" id="date_of_service" required><br><br>
<label>Procedure/CPT Code:</label>
<input type="text" id="cpt_code" required><br><br>
<label>Fee per Session:</label>
<input type="number" id="fee" required><br><br>
<label>Amount Paid:</label>
<input type="number" id="amount_paid" required><br><br>
<label>Total Amount Due:</label>
<input type="number" id="total_due" required><br><br>
<label>ICD-10 Code:</label>
<input type="text" id="icd_code" required><br><br>
<label>Date:</label>
<input type="date" id="superbill_date" required><br><br>
<button type="button" onclick="generateSuperbill()">Generate Superbill</button>
</form>
<script>
function generateSuperbill() {
const { jsPDF } = window.jspdf;
const doc = new jsPDF();
doc.setFontSize(14);
doc.text("Poppy Peak Therapy - SUPERBILL", 20, 20);
doc.setFontSize(12);
doc.text(`Date of Service: ${document.getElementById('date_of_service').value}`, 20, 40);
doc.text(`CPT Code: ${document.getElementById('cpt_code').value}`, 20, 50);
doc.text(`Fee per Session: $${document.getElementById('fee').value}`, 20, 60);
doc.text(`Amount Paid: $${document.getElementById('amount_paid').value}`, 20, 70);
doc.text(`Total Amount Due: $${document.getElementById('total_due').value}`, 20, 80);
doc.text(`ICD-10 Code: ${document.getElementById('icd_code').value}`, 20, 90);
doc.text(`Date: ${document.getElementById('superbill_date').value}`, 20, 100);
doc.text("Provider: Kristina Bartek, MA, LMFT", 20, 120);
doc.text("License #: 84302", 20, 130);
doc.text("Provider NPI: 1689965907", 20, 140);
doc.text("Phone: 626-790-8221", 20, 150);
doc.save("Superbill.pdf");
}
</script>
</body>
</html>