# $questionnaire-package Input Parameters Example - Da Vinci - Documentation Templates and Rules v2.2.0

## Example Parameters: $questionnaire-package Input Parameters Example



## Resource Content

```json
{
  "resourceType" : "Parameters",
  "id" : "QuestionnairePackageInputParamsExample",
  "meta" : {
    "profile" : ["http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/dtr-qpackage-input-parameters"]
  },
  "language" : "en",
  "parameter" : [{
    "name" : "coverage",
    "resource" : {
      "resourceType" : "Coverage",
      "id" : "CoverageExample",
      "meta" : {
        "profile" : ["http://hl7.org/fhir/us/davinci-crd/StructureDefinition/profile-coverage"]
      },
      "contained" : [{
        "resourceType" : "Organization",
        "id" : "OrgExample",
        "meta" : {
          "profile" : ["http://hl7.org/fhir/us/davinci-crd/StructureDefinition/profile-organization"]
        },
        "identifier" : [{
          "system" : "urn:oid:2.16.840.1.113883.4.7",
          "value" : "10D0202020"
        }],
        "active" : true,
        "type" : [{
          "coding" : [{
            "system" : "http://terminology.hl7.org/CodeSystem/organization-type",
            "code" : "pay",
            "display" : "Payer"
          }]
        }],
        "name" : "Insurance Company",
        "telecom" : [{
          "system" : "phone",
          "value" : "860-547-5001",
          "use" : "work"
        }],
        "address" : [{
          "line" : ["680 Asylum Street"],
          "city" : "Hartford",
          "state" : "CT",
          "postalCode" : "06155",
          "country" : "US"
        }]
      }],
      "status" : "active",
      "subscriber" : {
        "reference" : "Patient/examplepatient"
      },
      "subscriberId" : "PFP123450000",
      "beneficiary" : {
        "reference" : "Patient/examplepatient"
      },
      "relationship" : {
        "coding" : [{
          "system" : "http://terminology.hl7.org/CodeSystem/subscriber-relationship",
          "code" : "self",
          "display" : "Self"
        }]
      },
      "period" : {
        "start" : "2022-01-01",
        "end" : "2023-01-01"
      },
      "payor" : [{
        "reference" : "#OrgExample"
      }],
      "class" : [{
        "type" : {
          "coding" : [{
            "system" : "http://terminology.hl7.org/CodeSystem/coverage-class",
            "code" : "plan",
            "display" : "Plan"
          }]
        },
        "value" : "Premim Family Plus",
        "name" : "Premim Family Plus Plan"
      }]
    }
  },
  {
    "name" : "order",
    "resource" : {
      "resourceType" : "ServiceRequest",
      "id" : "ServiceRequestExample",
      "meta" : {
        "profile" : ["http://hl7.org/fhir/us/davinci-crd/StructureDefinition/profile-servicerequest"]
      },
      "status" : "active",
      "intent" : "original-order",
      "code" : {
        "coding" : [{
          "system" : "http://loinc.org",
          "code" : "24338-6"
        }],
        "text" : "Gas panel - Blood"
      },
      "subject" : {
        "reference" : "Patient/examplepatient"
      },
      "occurrenceDateTime" : "2019-05-08T09:33:27+07:00",
      "authoredOn" : "2019-09-18T07:53:21+07:00",
      "requester" : {
        "reference" : "Practitioner/PractitionerExample"
      },
      "reasonCode" : [{
        "coding" : [{
          "system" : "http://snomed.info/sct",
          "code" : "4565000"
        }],
        "text" : "Decreased oxygen affinity"
      }]
    }
  },
  {
    "name" : "questionnaire",
    "valueCanonical" : "http://hl7.org/fhir/us/davinci-dtr/Questionnaire/home-o2-std-questionnaire"
  }]
}

```
