{
  "description": "For the Prior Authorization Questionnaire Use Case, this type of in-context information is expected to be known already so it wouldn't typically be in a Questionnaire. This example illustrates how to get this information if it is needed.",
  "_filename": "Questionnaire-ExamplePatientAndCoverageQuestionnaire.json",
  "package_name": "hl7.fhir.us.cql.r4b",
  "date": "2024-09-16T00:00:00+00:00",
  "publisher": "HL7 International / Clinical Decision Support",
  "jurisdiction": [ {
    "coding": [ {
      "code": "US",
      "system": "urn:iso:std:iso:3166",
      "display": "United States of America"
    } ]
  } ],
  "name": "ExamplePatientAndCoverageQuestionnaire",
  "item": [ {
    "item": [ {
      "text": "Name",
      "type": "string",
      "linkId": "patient-info|patient-name",
      "extension": [ {
        "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression": {
          "language": "text/cql-identifier",
          "expression": "Patient Name"
        }
      } ]
    }, {
      "text": "Date of Birth",
      "type": "date",
      "linkId": "patient-info|date-of-birth",
      "extension": [ {
        "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression": {
          "language": "text/cql-identifier",
          "expression": "Date of Birth"
        }
      } ]
    }, {
      "text": "Birth Sex",
      "type": "choice",
      "linkId": "patient-info|birth-sex",
      "extension": [ {
        "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression": {
          "language": "text/cql-identifier",
          "expression": "Birth Sex"
        }
      } ],
      "answerValueSet": "http://hl7.org/fhir/us/core/ValueSet/birthsex"
    }, {
      "text": "Medical Record Number",
      "type": "string",
      "linkId": "patient-info|medical-record-number",
      "extension": [ {
        "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression": {
          "language": "text/cql-identifier",
          "expression": "Medical Record Number"
        }
      } ]
    }, {
      "text": "Phone Number",
      "type": "string",
      "linkId": "patient-info|phone-number",
      "extension": [ {
        "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression": {
          "language": "text/cql-identifier",
          "expression": "Phone Number"
        }
      } ]
    }, {
      "text": "Email Address",
      "type": "string",
      "linkId": "patient-info|email-address",
      "extension": [ {
        "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression": {
          "language": "text/cql-identifier",
          "expression": "Email Address"
        }
      } ]
    }, {
      "text": "Address",
      "type": "string",
      "linkId": "patient-info|address",
      "extension": [ {
        "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression": {
          "language": "text/cql-identifier",
          "expression": "Address"
        }
      } ]
    }, {
      "text": "City",
      "type": "string",
      "linkId": "patient-info|city",
      "extension": [ {
        "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression": {
          "language": "text/cql-identifier",
          "expression": "City"
        }
      } ]
    }, {
      "text": "State",
      "type": "string",
      "linkId": "patient-info|state",
      "extension": [ {
        "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression": {
          "language": "text/cql-identifier",
          "expression": "State"
        }
      } ]
    }, {
      "text": "Postal Code",
      "type": "string",
      "linkId": "patient-info|postal-code",
      "extension": [ {
        "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression": {
          "language": "text/cql-identifier",
          "expression": "Postal Code"
        }
      } ]
    } ],
    "text": "Patient Information",
    "type": "group",
    "linkId": "patient-info"
  }, {
    "item": [ {
      "text": "Member ID",
      "type": "string",
      "linkId": "coverage-info|member-id",
      "extension": [ {
        "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression": {
          "language": "text/cql-identifier",
          "expression": "Member ID"
        }
      } ]
    }, {
      "text": "Policy Number",
      "type": "string",
      "linkId": "completing-form|patient-info|policy-number",
      "extension": [ {
        "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression": {
          "language": "text/cql-identifier",
          "expression": "Policy Number"
        }
      } ]
    } ],
    "text": "Coverage Information",
    "type": "group",
    "linkId": "coverage-info"
  }, {
    "item": [ {
      "text": "Requesting provider name",
      "type": "string",
      "linkId": "provider-info|name",
      "extension": [ {
        "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression": {
          "language": "text/cql-identifier",
          "expression": "Requesting Provider Name"
        }
      } ]
    }, {
      "text": "Phone",
      "type": "string",
      "linkId": "provider-info|phone-number",
      "extension": [ {
        "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression": {
          "language": "text/cql-identifier",
          "expression": "Requesting Provider Phone"
        }
      } ]
    }, {
      "text": "Ordering provider address",
      "type": "string",
      "linkId": "provider-info|address",
      "extension": [ {
        "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression": {
          "language": "text/cql-identifier",
          "expression": "Requesting Provider Address"
        }
      } ]
    }, {
      "text": "Ordering provider Tax ID/NPI #",
      "type": "string",
      "linkId": "provider-info|npi",
      "extension": [ {
        "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression": {
          "language": "text/cql-identifier",
          "expression": "Requesting Provider NPI"
        }
      } ]
    }, {
      "text": "Fax",
      "type": "string",
      "linkId": "provider-info|fax",
      "extension": [ {
        "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression": {
          "language": "text/cql-identifier",
          "expression": "Requesting Provider Fax"
        }
      } ]
    } ],
    "text": "Requesting Provider Information",
    "type": "group",
    "linkId": "provider-info"
  }, {
    "item": [ {
      "text": "Servicing Provider name",
      "type": "string",
      "linkId": "servicing-provider|name",
      "extension": [ {
        "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression": {
          "language": "text/cql-identifier",
          "expression": "Servicing Provider Name"
        }
      } ]
    }, {
      "text": "Phone",
      "type": "string",
      "linkId": "servicing-provider|phone-number",
      "extension": [ {
        "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression": {
          "language": "text/cql-identifier",
          "expression": "Servicing Provider Phone"
        }
      } ]
    }, {
      "text": "Ordering provider address",
      "type": "string",
      "linkId": "servicing-provider|address",
      "extension": [ {
        "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression": {
          "language": "text/cql-identifier",
          "expression": "Servicing Provider Address"
        }
      } ]
    }, {
      "text": "Ordering provider Tax ID/NPI #",
      "type": "string",
      "linkId": "servicing-provider|npi",
      "extension": [ {
        "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression": {
          "language": "text/cql-identifier",
          "expression": "Servicing Provider NPI"
        }
      } ]
    }, {
      "text": "Fax",
      "type": "string",
      "linkId": "servicing-provider|fax",
      "extension": [ {
        "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression": {
          "language": "text/cql-identifier",
          "expression": "Servicing Provider Fax"
        }
      } ]
    } ],
    "text": "Laboratory performing testing/Servicing Provider",
    "type": "group",
    "linkId": "servicing-provider"
  } ],
  "type": null,
  "experimental": "true",
  "resourceType": "Questionnaire",
  "title": "Example Patient and Coverage Questionnaire",
  "package_version": "1.0.0-ballot",
  "extension": [ {
    "url": "http://hl7.org/fhir/StructureDefinition/cqf-library",
    "valueCanonical": "http://hl7.org/fhir/us/cql/Library/ExamplePatientAndCoverageInitialExpressions"
  }, {
    "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-launchContext",
    "extension": [ {
      "url": "name",
      "valueCoding": {
        "code": "patient",
        "system": "http://hl7.org/fhir/uv/sdc/CodeSystem/launchContext",
        "display": "Patient"
      }
    }, {
      "url": "type",
      "valueCode": "Patient"
    }, {
      "url": "description",
      "valueString": "The patient that is to be used to pre-populate the form"
    } ]
  }, {
    "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-launchContext",
    "extension": [ {
      "url": "name",
      "valueCoding": {
        "code": "Coverage",
        "system": "http://hl7.org/fhir/uv/sdc/CodeSystem/launchContext",
        "display": "Coverage"
      }
    }, {
      "url": "type",
      "valueCode": "Coverage"
    }, {
      "url": "description",
      "valueString": "The coverage that is to be used to pre-populate the form"
    } ]
  }, {
    "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-launchContext",
    "extension": [ {
      "url": "name",
      "valueCoding": {
        "code": "ServiceRequest",
        "system": "http://hl7.org/fhir/uv/sdc/CodeSystem/launchContext",
        "display": "ServiceRequest"
      }
    }, {
      "url": "type",
      "valueCode": "ServiceRequest"
    }, {
      "url": "description",
      "valueString": "The ServiceRequest that is to be used to pre-populate the form"
    } ]
  }, {
    "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg",
    "valueCode": "cds"
  }, {
    "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status",
    "valueCode": "informative",
    "_valueCode": {
      "extension": [ {
        "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom",
        "valueCanonical": "http://hl7.org/fhir/us/cql/ImplementationGuide/hl7.fhir.us.cql"
      } ]
    }
  } ],
  "status": "active",
  "id": "edc1146a-7a8d-4c97-a721-89a2417bb198",
  "kind": null,
  "url": "http://hl7.org/fhir/us/cql/Questionnaire/ExamplePatientAndCoverageQuestionnaire",
  "version": "1.0.0-ballot",
  "contact": [ {
    "telecom": [ {
      "value": "http://www.hl7.org/Special/committees/dss",
      "system": "url"
    } ]
  } ]
}