{
  "description": "A form to request access to health and care services on behalf of someone else.",
  "_filename": "examples/NationalProxy-Questionnaire-ProxyAccessRequest-Example.json",
  "package_name": "fhir.r4.nhsengland.programme",
  "subjectType": [ "RelatedPerson" ],
  "date": "2024-07-12",
  "meta": {
    "versionId": "52",
    "lastUpdated": "2024-08-30T13:36:50.663Z"
  },
  "publisher": "NHS England",
  "jurisdiction": [ {
    "coding": [ {
      "code": "001",
      "system": "http://unstats.un.org/unsd/methods/m49/m49.htm"
    } ]
  } ],
  "purpose": "Add someone to your NHS account",
  "name": "Consent",
  "item": [ {
    "item": [ {
      "text": "NHS number",
      "type": "string",
      "linkId": "relatedPerson_identifier",
      "prefix": "1.1",
      "readOnly": false,
      "required": true,
      "maxLength": 10,
      "definition": "http://hl7.org/fhir/StructureDefinition/RelatedPerson#identifier"
    }, {
      "item": [ {
        "text": "First name",
        "type": "string",
        "linkId": "relatedPerson_name_first",
        "prefix": "1.2.1",
        "repeats": false,
        "readOnly": false,
        "required": true,
        "definition": "http://hl7.org/fhir/StructureDefinition/RelatedPerson#name.given"
      }, {
        "text": "Last name",
        "type": "string",
        "linkId": "relatedPerson_name_family",
        "prefix": "1.2.2",
        "repeats": false,
        "readOnly": false,
        "required": true,
        "definition": "http://hl7.org/fhir/StructureDefinition/RelatedPerson#name.family"
      } ],
      "text": "Name",
      "type": "group",
      "linkId": "relatedPerson_name",
      "prefix": "1.2",
      "required": false,
      "definition": "http://hl7.org/fhir/StructureDefinition/RelatedPerson#name"
    }, {
      "text": "Date of birth",
      "type": "date",
      "linkId": "relatedPerson_birthDate",
      "prefix": "1.3",
      "repeats": false,
      "readOnly": false,
      "required": false,
      "definition": "http://hl7.org/fhir/StructureDefinition/RelatedPerson#birthDate"
    }, {
      "definition": "http://hl7.org/fhir/StructureDefinition/RelatedPerson#relationship",
      "linkId": "relatedPerson_basisForAccess",
      "repeats": false,
      "type": "choice",
      "answerOption": [ {
        "valueCoding": {
          "code": "PRN",
          "system": "http://terminology.hl7.org/CodeSystem/v3-RoleCode",
          "display": "Parent"
        }
      }, {
        "valueCoding": {
          "code": "Personal",
          "system": "https://fhir.hl7.org.uk/CodeSystem/UKCore-AdditionalPersonRelationshipRole",
          "display": "Personal relationship with the patient"
        }
      }, {
        "valueCoding": {
          "code": "002",
          "system": "https://fhir.nhs.uk/STU3/CodeSystem/RARecord-ProxyRole-1",
          "display": "Best interest decision made on behalf of the patient (Mental Capacity Act 2005)"
        }
      } ],
      "prefix": "1.4",
      "extension": [ {
        "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
        "valueCodeableConcept": {
          "coding": [ {
            "code": "drop-down",
            "system": "http://hl7.org/fhir/questionnaire-item-control",
            "display": "Drop down"
          } ]
        }
      } ],
      "readOnly": false,
      "code": [ {
        "code": "722011000000106",
        "system": "http://snomed.info/sct",
        "display": "Relationship (qualifier value)"
      } ],
      "required": true,
      "text": "Basis for Access"
    }, {
      "definition": "http://hl7.org/fhir/StructureDefinition/RelatedPerson#relationship",
      "linkId": "relatedPerson_relationship",
      "repeats": false,
      "type": "choice",
      "answerOption": [ {
        "valueCoding": {
          "code": "PRN",
          "system": "http://terminology.hl7.org/CodeSystem/v3-RoleCode",
          "display": "Parent"
        }
      }, {
        "valueCoding": {
          "code": "CHILD",
          "system": "http://terminology.hl7.org/CodeSystem/v3-RoleCode",
          "display": "Child"
        }
      }, {
        "valueCoding": {
          "code": "SPS",
          "system": "http://terminology.hl7.org/CodeSystem/v3-RoleCode",
          "display": "Partner, wife or husband"
        }
      }, {
        "valueCoding": {
          "code": "FAMMEMB",
          "system": "http://terminology.hl7.org/CodeSystem/v3-RoleCode",
          "display": "Other family member"
        }
      }, {
        "valueCoding": {
          "code": "FRND",
          "system": "http://terminology.hl7.org/CodeSystem/v3-RoleCode",
          "display": "Friend, neighbour or housemate"
        }
      }, {
        "valueCoding": {
          "code": "CAREGIVER",
          "system": "http://terminology.hl7.org/CodeSystem/v3-RoleClass",
          "display": "Paid carer or support worker"
        }
      }, {
        "valueCoding": {
          "code": "SIGOTHR",
          "system": "http://terminology.hl7.org/CodeSystem/v3-RoleCode",
          "display": "Other"
        }
      } ],
      "prefix": "1.5",
      "extension": [ {
        "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
        "valueCodeableConcept": {
          "coding": [ {
            "code": "drop-down",
            "system": "http://hl7.org/fhir/questionnaire-item-control",
            "display": "Drop down"
          } ]
        }
      } ],
      "readOnly": false,
      "code": [ {
        "code": "722011000000106",
        "system": "http://snomed.info/sct",
        "display": "Relationship (qualifier value)"
      } ],
      "required": true,
      "text": "Relationship"
    }, {
      "text": "Relationship - Further information",
      "type": "string",
      "linkId": "9759901615580",
      "prefix": "1.6",
      "repeats": false,
      "readOnly": false,
      "required": false,
      "maxLength": 2000
    } ],
    "text": "Proxy details",
    "type": "group",
    "linkId": "relatedPerson",
    "prefix": "1",
    "readOnly": false,
    "required": true
  }, {
    "item": [ {
      "linkId": "parentalApplicationSupplementaryDetails_evidenceOfResponsibility",
      "repeats": false,
      "type": "choice",
      "answerOption": [ {
        "valueCoding": {
          "code": "BRTH",
          "system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-EvidenceOfResponsibility",
          "display": "Birth certificate"
        }
      }, {
        "valueCoding": {
          "code": "ADPT",
          "system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-EvidenceOfResponsibility",
          "display": "Adoption certificate"
        }
      }, {
        "valueCoding": {
          "code": "PRNA",
          "system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-EvidenceOfResponsibility",
          "display": "Court-witnessed parental responsibility agreement"
        }
      }, {
        "valueCoding": {
          "code": "SPRNA",
          "system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-EvidenceOfResponsibility",
          "display": "Court-witnessed step-parent parental responsibility agreement"
        }
      }, {
        "valueCoding": {
          "code": "PORD",
          "system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-EvidenceOfResponsibility",
          "display": "Parental order"
        }
      }, {
        "valueCoding": {
          "code": "SGORD",
          "system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-EvidenceOfResponsibility",
          "display": "Special guardianship order"
        }
      }, {
        "valueCoding": {
          "code": "OTHCOURT",
          "system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-EvidenceOfResponsibility",
          "display": "Other court order"
        }
      }, {
        "valueCoding": {
          "code": "OTHR",
          "system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-EvidenceOfResponsibility",
          "display": "Other"
        }
      } ],
      "prefix": "2.1",
      "extension": [ {
        "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
        "valueCodeableConcept": {
          "coding": [ {
            "code": "radio-button",
            "system": "http://hl7.org/fhir/questionnaire-item-control",
            "display": "Radio Button"
          } ]
        }
      } ],
      "readOnly": false,
      "required": true,
      "text": "Evidence of parental responsibility"
    }, {
      "enableBehavior": "all",
      "linkId": "parentalApplicationSupplementaryDetails_evidenceOfResponsibilityMoreinfo",
      "repeats": false,
      "type": "string",
      "enableWhen": [ {
        "operator": "=",
        "question": "parentalApplicationSupplementaryDetails_evidenceOfResponsibility",
        "answerCoding": {
          "code": "OTHR",
          "system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-EvidenceOfResponsibility",
          "display": "Other"
        }
      } ],
      "prefix": "2.2",
      "readOnly": false,
      "maxLength": 2000,
      "required": false,
      "text": "Evidence of responsibility - Further Information"
    }, {
      "text": "Is current address confirmed?",
      "type": "boolean",
      "linkId": "parentalApplicationSupplementaryDetails_isCurrentAddressConfirmed",
      "prefix": "2.3",
      "repeats": false,
      "readOnly": false,
      "required": true
    }, {
      "item": [ {
        "text": "Address line 1",
        "type": "string",
        "linkId": "parentalApplicationSupplementaryDetails_line1",
        "prefix": "2.4.1",
        "readOnly": false,
        "required": false,
        "definition": "http://hl7.org/fhir/datatypes-definitions.html#Address.line"
      }, {
        "text": "Address line 2",
        "type": "string",
        "linkId": "parentalApplicationSupplementaryDetails_line2",
        "prefix": "2.4.2",
        "readOnly": false,
        "required": false,
        "definition": "http://hl7.org/fhir/datatypes-definitions.html#Address.line"
      }, {
        "text": "Address line 3",
        "type": "string",
        "linkId": "parentalApplicationSupplementaryDetails_line3",
        "prefix": "2.4.3",
        "readOnly": false,
        "required": false,
        "definition": "http://hl7.org/fhir/datatypes-definitions.html#Address.line"
      }, {
        "text": "Town / City",
        "type": "string",
        "linkId": "parentalApplicationSupplementaryDetails_city",
        "prefix": "2.4.4",
        "readOnly": false,
        "required": false,
        "definition": "http://hl7.org/fhir/datatypes-definitions.html#Address.city"
      }, {
        "text": "County",
        "type": "string",
        "linkId": "parentalApplicationSupplementaryDetails_district",
        "prefix": "2.4.5",
        "readOnly": false,
        "required": false,
        "definition": "http://hl7.org/fhir/datatypes-definitions.html#Address.district"
      }, {
        "text": "Postcode",
        "type": "string",
        "linkId": "parentalApplicationSupplementaryDetails_postalCode",
        "prefix": "2.4.6",
        "readOnly": false,
        "required": false,
        "definition": "http://hl7.org/fhir/datatypes-definitions.html#Address.postalCode"
      } ],
      "text": "New address",
      "type": "group",
      "linkId": "parentalApplicationSupplementaryDetails_newAddress",
      "prefix": "2.4",
      "repeats": false,
      "readOnly": false,
      "required": false
    }, {
      "text": "Do adult and child live at the same address?",
      "type": "boolean",
      "linkId": "parentalApplicationSupplementaryDetails_liveAtSameAddress",
      "prefix": "2.5",
      "repeats": false,
      "readOnly": false,
      "required": true
    }, {
      "text": "Can the child consent?",
      "type": "boolean",
      "linkId": "parentalApplicationSupplementaryDetails_canChildConsent",
      "prefix": "2.6",
      "repeats": false,
      "readOnly": false,
      "required": false
    }, {
      "enableBehavior": "all",
      "linkId": "parentalApplicationSupplementaryDetails_reasonNoChildConsent",
      "repeats": false,
      "type": "string",
      "enableWhen": [ {
        "operator": "=",
        "question": "parentalApplicationSupplementaryDetails_canChildConsent",
        "answerBoolean": false
      } ],
      "prefix": "2.7",
      "readOnly": false,
      "required": false,
      "text": "Reason the child cannot consent?"
    } ],
    "text": "Parental Application Supplementary Details",
    "type": "group",
    "linkId": "parentalApplicationSupplementaryDetails",
    "prefix": "2",
    "readOnly": false,
    "required": false
  }, {
    "item": [ {
      "definition": "http://hl7.org/fhir/StructureDefinition/Patient#identifier",
      "linkId": "patient_identifier",
      "repeats": false,
      "type": "string",
      "prefix": "3.1",
      "readOnly": false,
      "maxLength": 10,
      "required": true,
      "text": "NHS number"
    }, {
      "item": [ {
        "text": "First name",
        "type": "string",
        "linkId": "patient_name_first",
        "prefix": "3.2.1",
        "repeats": false,
        "readOnly": false,
        "required": true,
        "definition": "http://hl7.org/fhir/StructureDefinition/Patient#name.given"
      }, {
        "text": "Last name",
        "type": "string",
        "linkId": "patient_name_family",
        "prefix": "3.2.2",
        "repeats": false,
        "readOnly": false,
        "required": true,
        "definition": "http://hl7.org/fhir/StructureDefinition/Patient#name.family"
      } ],
      "text": "Name",
      "type": "group",
      "linkId": "patient_name",
      "prefix": "3.2",
      "required": false,
      "definition": "http://hl7.org/fhir/StructureDefinition/Patient#name"
    }, {
      "text": "Date of birth",
      "type": "date",
      "linkId": "patient_birthDate",
      "prefix": "3.3",
      "repeats": false,
      "readOnly": false,
      "required": false,
      "definition": "http://hl7.org/fhir/StructureDefinition/Patient#birthDate"
    } ],
    "text": "Patient details",
    "type": "group",
    "linkId": "patient",
    "prefix": "3",
    "required": true
  }, {
    "item": [ {
      "linkId": "requestedAccess_accessLevel",
      "repeats": true,
      "type": "choice",
      "answerOption": [ {
        "valueCoding": {
          "code": "APPT",
          "system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-RequestedAccess",
          "display": "Appointment Booking"
        }
      }, {
        "valueCoding": {
          "code": "CNTCT",
          "system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-RequestedAccess",
          "display": "Contacting Surgery"
        }
      }, {
        "valueCoding": {
          "code": "RECRD",
          "system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-RequestedAccess",
          "display": "Medical Records Access"
        }
      }, {
        "valueCoding": {
          "code": "TEST",
          "system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-RequestedAccess",
          "display": "Test Results"
        }
      }, {
        "valueCoding": {
          "code": "VACC",
          "system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-RequestedAccess",
          "display": "Vaccination Records"
        }
      }, {
        "valueCoding": {
          "code": "PRESCR",
          "system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-RequestedAccess",
          "display": "Request and manage repeat prescriptions"
        }
      } ],
      "prefix": "4.1",
      "extension": [ {
        "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
        "valueCodeableConcept": {
          "coding": [ {
            "code": "check-box",
            "system": "http://hl7.org/fhir/questionnaire-item-control",
            "display": "Check-box"
          } ]
        }
      } ],
      "readOnly": false,
      "required": true,
      "text": "Requested access level"
    }, {
      "enableBehavior": "all",
      "linkId": "requestedAccess_accessLevelMoreinfo",
      "repeats": false,
      "type": "string",
      "enableWhen": [ {
        "operator": "=",
        "question": "requestedAccess_accessLevel",
        "answerCoding": {
          "code": "RECRD",
          "system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-RequestedAccess",
          "display": "Medical Records Access"
        }
      } ],
      "prefix": "4.2",
      "readOnly": false,
      "maxLength": 2000,
      "required": false,
      "text": "Requested access level - further information"
    }, {
      "linkId": "requestedAccess_reasonsForAccess",
      "repeats": true,
      "type": "choice",
      "answerOption": [ {
        "valueCoding": {
          "code": "COMB",
          "system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-ReasonForAccess",
          "display": "Communication Barriers"
        }
      }, {
        "valueCoding": {
          "code": "MHEA",
          "system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-ReasonForAccess",
          "display": "Mental Health Condition"
        }
      }, {
        "valueCoding": {
          "code": "PHYS",
          "system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-ReasonForAccess",
          "display": "Physical Condition"
        }
      }, {
        "valueCoding": {
          "code": "PRAC",
          "system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-ReasonForAccess",
          "display": "Practical Reasons"
        }
      }, {
        "valueCoding": {
          "code": "TECH",
          "system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-ReasonForAccess",
          "display": "Technical Barriers"
        }
      }, {
        "valueCoding": {
          "code": "NEUR",
          "system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-ReasonForAccess",
          "display": "Neurodiverse"
        }
      }, {
        "valueCoding": {
          "code": "LRN",
          "system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-ReasonForAccess",
          "display": "Learning Disability"
        }
      }, {
        "valueCoding": {
          "code": "OTHR",
          "system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-ReasonForAccess",
          "display": "Other"
        }
      }, {
        "valueCoding": {
          "code": "NotSpecified",
          "system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-ReasonForAccess",
          "display": "Prefer not to say"
        }
      } ],
      "prefix": "4.3",
      "extension": [ {
        "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
        "valueCodeableConcept": {
          "coding": [ {
            "code": "check-box",
            "system": "http://hl7.org/fhir/questionnaire-item-control",
            "display": "Check-box"
          } ]
        }
      } ],
      "readOnly": false,
      "required": false,
      "text": "Reason for access"
    }, {
      "enableBehavior": "all",
      "linkId": "requestedAccess_reasonsForAccessMoreinfo",
      "repeats": false,
      "type": "string",
      "enableWhen": [ {
        "operator": "=",
        "question": "requestedAccess_reasonsForAccess",
        "answerCoding": {
          "code": "OTHR",
          "system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-ReasonForAccess",
          "display": "Other"
        }
      } ],
      "prefix": "4.4",
      "readOnly": false,
      "maxLength": 2000,
      "required": false,
      "text": "Reason for access - further information"
    } ],
    "text": "Requested access",
    "type": "group",
    "linkId": "requestedAccess",
    "prefix": "4",
    "required": true
  } ],
  "useContext": [ {
    "code": {
      "code": "task",
      "system": "http://terminology.hl7.org/CodeSystem/usage-context-type"
    },
    "valueCodeableConcept": {
      "coding": [ {
        "code": "887031000000108",
        "system": "http://snomed.info/sct",
        "display": "Consent for information sharing"
      } ]
    }
  } ],
  "type": null,
  "experimental": null,
  "resourceType": "Questionnaire",
  "title": "Questionnaire Proxy Access Request",
  "package_version": "0.3.0-pre-release",
  "status": "draft",
  "id": "30b5536f-cbbd-4554-b202-2bc30983763d",
  "kind": null,
  "url": "https://fhir.nhs.uk/England/Questionnaire/ProxyAccessRequest",
  "version": "0.0.1-current",
  "contact": [ {
    "telecom": [ {
      "value": "https://www.ihe.net/ihe_domains/it_infrastructure/",
      "system": "url"
    } ]
  }, {
    "telecom": [ {
      "value": "iti@ihe.net",
      "system": "email"
    } ]
  }, {
    "name": "NHS England",
    "telecom": [ {
      "value": "iti@ihe.net",
      "system": "email"
    } ]
  } ]
}