{!! Form::model($provider, ['method' => 'PATCH', 'url' => 'provider/'.$provider_type.'/'.$provider->id.'/unconfirm-facility',  'id' => 'fm-provider-unconfirm', 'class' => 'form-horizontal', 'role' => 'form']) !!}

{!! Form::hidden('id', null, ['id' => 'provider_id']) !!}

<div class = "form-group">
    {!! Form::label('password', 'Password:', ['class' => 'control-label col-sm-3']) !!}
    <div class="col-sm-9">
    {!! Form::password('password', ['class' => 'form-control']) !!}
    </div>
</div>


<div class = "form-group">
    {!! Form::label('facility_unconfirm_date', 'Effective date:', ['class' => 'control-label col-sm-3']) !!}
    <div class="col-sm-9">
        <div class='input-group datepicker'>
            {!! Form::formattedDate('facility_unconfirm_date', ['class' => 'form-control', 'type'=> 'text', 'required']) !!}
            <span class="input-group-addon">
                <span class="glyphicon glyphicon-calendar"></span>
             </span>
        </div>
    </div>
</div>

{!! Form::close() !!}