Common CQL Artifacts for FHIR (US-Based)
2.0.0-cibuild - Informative 2 - CI Build
Common CQL Artifacts for FHIR (US-Based)
2.0.0-cibuild - Informative 2 - CI Build
Common CQL Artifacts for FHIR (US-Based), published by HL7 International / Clinical Decision Support. This guide is not an authorized publication; it is the continuous build for version 2.0.0-cibuild built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/us-cql-ig/ and changes regularly. See the Directory of published versions
| Page standards status: Informative |
@prefix fhir: <http://hl7.org/fhir/> . @prefix owl: <http://www.w3.org/2002/07/owl#> . @prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> . @prefix xsd: <http://www.w3.org/2001/XMLSchema#> . # - resource ------------------------------------------------------------------- <http://hl7.org/fhir/Questionnaire/UPPARFQuestionnaire> a fhir:Questionnaire ; fhir:nodeRole fhir:treeRoot ; fhir:Resource.id [ fhir:value "UPPARFQuestionnaire"] ; fhir:Resource.language [ fhir:value "en"] ; fhir:DomainResource.text [ fhir:Narrative.status [ fhir:value "extensions" ] ; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: Questionnaire UPPARFQuestionnaire</b></p><a name=\"UPPARFQuestionnaire\"> </a><a name=\"hcUPPARFQuestionnaire\"> </a><b>Structure</b><table border=\"1\" cellpadding=\"0\" cellspacing=\"0\" style=\"border: 1px #F0F0F0 solid; font-size: 11px; font-family: verdana; vertical-align: top;\"><tr style=\"border: 2px #F0F0F0 solid; font-size: 11px; font-family: verdana; vertical-align: top\"><th style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; padding-top: 3px; padding-bottom: 3px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/formats.html#table\" title=\"The linkID for the item\">LinkID</a></th><th style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; padding-top: 3px; padding-bottom: 3px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/formats.html#table\" title=\"Text for the item\">Text</a></th><th style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; padding-top: 3px; padding-bottom: 3px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/formats.html#table\" title=\"Minimum and Maximum # of times the item can appear in the instance\">Cardinality</a></th><th style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; padding-top: 3px; padding-bottom: 3px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/formats.html#table\" title=\"The type of the item\">Type</a></th><th style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; padding-top: 3px; padding-bottom: 3px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/formats.html#table\" title=\"Additional information about the item\">Description & Constraints</a><span style=\"float: right\"><a href=\"https://hl7.org/fhir/R4/formats.html#table\" title=\"Legend for this format\"><img src=\"data:image/png;base64,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\" alt=\"doco\" style=\"background-color: inherit\"/></a></span></th></tr><tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck1.png)\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon_q_root.gif\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"QuestionnaireRoot\" class=\"hierarchy\"/> UPPARFQuestionnaire</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">This is an example of a prior authorization questionnaire developed based on an existing industry prior authorization form.</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Questionnaire</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">http://hl7.org/fhir/us/cql/Questionnaire/UPPARFQuestionnaire#2.0.0-cibuild</td></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck10.png)\" id=\"item.urgency\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-coding.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"coding\" class=\"hierarchy\"/> urgency</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Urgency</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-choice\">choice</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Options: <a href=\"#opt-item.urgency\">2 options</a></td></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck11.png)\" id=\"item.drug-info\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-group.png\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"group\" class=\"hierarchy\"/> drug-info</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Drug Information</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-group\">group</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck110.png)\" id=\"item.drug-info|drug-name\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vline.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-string.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"string\" class=\"hierarchy\"/> drug-info|drug-name</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Requested Drug Name</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string\">string</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck101.png)\" id=\"item.drug-info|drug-intention-opioid\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vline.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin_end.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-boolean.png\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"boolean\" class=\"hierarchy\"/> drug-info|drug-intention-opioid</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Is this drug intended to treat opioid dependence?</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-boolean\">boolean</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck1010.png)\" id=\"item.drug-info|drug-intention-opioid|first-prior-authentication\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vline.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-boolean.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"boolean\" class=\"hierarchy\"/> drug-info|drug-intention-opioid|first-prior-authentication</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Is this a first request for prior authorization for this drug?</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-boolean\">boolean</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Enable When: <span><a href=\"#item.drug-info|drug-intention-opioid\">drug-info|drug-intention-opioid</a> = true</span></td></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck1010.png)\" id=\"item.drug-info|drug-intention-opioid|date-first-request\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vline.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-date.png\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"date\" class=\"hierarchy\"/> drug-info|drug-intention-opioid|date-first-request</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">What was the date of the first request?</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-date\">date</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Enable When: <span><a href=\"#item.drug-info|drug-intention-opioid|first-prior-authentication\">drug-info|drug-intention-opioid|first-prior-authentication</a> = false</span></td></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck1000.png)\" id=\"item.drug-info|drug-intention-opioid|twelve-months-since-request\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vline.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin_end.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-boolean.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"boolean\" class=\"hierarchy\"/> drug-info|drug-intention-opioid|twelve-months-since-request</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Has the date of the first request been greater than twelve months ago?</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-boolean\">boolean</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Enable When: <span><a href=\"#item.drug-info|drug-intention-opioid|first-prior-authentication\">drug-info|drug-intention-opioid|first-prior-authentication</a> = false</span></td></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck01.png)\" id=\"item.completing-form\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin_end.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-group.png\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"group\" class=\"hierarchy\"/> completing-form</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Prior authentication is required and this form needs to be completed</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-group\">group</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Enable When: <ul><li><a href=\"#item.drug-info|drug-intention-opioid\">drug-info|drug-intention-opioid</a> = false</li><li><a href=\"#item.drug-info|drug-intention-opioid|twelve-months-since-request\">drug-info|drug-intention-opioid|twelve-months-since-request</a> = false</li></ul></td></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck011.png)\" id=\"item.completing-form|patient-info\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-group.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"group\" class=\"hierarchy\"/> completing-form|patient-info</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Patient Info</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-group\">group</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck0100.png)\" id=\"item.completing-form|patient-info|prescription-date\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vline.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin_end.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-string.png\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"string\" class=\"hierarchy\"/> completing-form|patient-info|prescription-date</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Prescription Date</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string\">string</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck011.png)\" id=\"item.completing-form|prescriber-info\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-group.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"group\" class=\"hierarchy\"/> completing-form|prescriber-info</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Prescriber Info</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-group\">group</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck0110.png)\" id=\"item.completing-form|prescriber-info|prescriber-name\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vline.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-string.png\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"string\" class=\"hierarchy\"/> completing-form|prescriber-info|prescriber-name</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Prescriber Name</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string\">string</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck0110.png)\" id=\"item.completing-form|prescriber-info|prescriber-fax\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vline.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-string.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"string\" class=\"hierarchy\"/> completing-form|prescriber-info|prescriber-fax</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Prescriber Fax</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string\">string</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck0110.png)\" id=\"item.completing-form|prescriber-info|prescriber-phone\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vline.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-string.png\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"string\" class=\"hierarchy\"/> completing-form|prescriber-info|prescriber-phone</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Prescriber Phone</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string\">string</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck0110.png)\" id=\"item.completing-form|prescriber-info|prescriber-pager\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vline.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-string.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"string\" class=\"hierarchy\"/> completing-form|prescriber-info|prescriber-pager</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Prescriber Pager</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string\">string</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck0110.png)\" id=\"item.completing-form|prescriber-info|prescriber-address\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vline.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-string.png\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"string\" class=\"hierarchy\"/> completing-form|prescriber-info|prescriber-address</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Prescriber Address</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string\">string</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck0110.png)\" id=\"item.completing-form|prescriber-info|prescriber-contact\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vline.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-string.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"string\" class=\"hierarchy\"/> completing-form|prescriber-info|prescriber-contact</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Prescriber Office Contact</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string\">string</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck0110.png)\" id=\"item.completing-form|prescriber-info|prescriber-npi\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vline.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-string.png\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"string\" class=\"hierarchy\"/> completing-form|prescriber-info|prescriber-npi</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Prescriber NPI</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string\">string</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck0110.png)\" id=\"item.completing-form|prescriber-info|prescriber-dea\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vline.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-string.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"string\" class=\"hierarchy\"/> completing-form|prescriber-info|prescriber-dea</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Prescriber DEA</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string\">string</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck0110.png)\" id=\"item.completing-form|prescriber-info|prescriber-tax-id\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vline.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-string.png\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"string\" class=\"hierarchy\"/> completing-form|prescriber-info|prescriber-tax-id</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Prescriber Tax ID</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string\">string</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck0110.png)\" id=\"item.completing-form|prescriber-info|prescriber-specialty\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vline.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-string.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"string\" class=\"hierarchy\"/> completing-form|prescriber-info|prescriber-specialty</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Specialty/Facility Name If applicable</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string\">string</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck0100.png)\" id=\"item.completing-form|prescriber-info|prescriber-email\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vline.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin_end.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-string.png\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"string\" class=\"hierarchy\"/> completing-form|prescriber-info|prescriber-email</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Email Address</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string\">string</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck001.png)\" id=\"item.completing-form|drug-benefit\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin_end.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-group.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"group\" class=\"hierarchy\"/> completing-form|drug-benefit</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Prior Authorization Request for Drug Benefit</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-group\">group</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck0010.png)\" id=\"item.completing-form|drug-benefit|request-type\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-coding.png\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"coding\" class=\"hierarchy\"/> completing-form|drug-benefit|request-type</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">New Request</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-choice\">choice</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Options: <a href=\"#opt-item.completing-form|drug-benefit|request-type\">2 options</a></td></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck0010.png)\" id=\"item.completing-form|drug-benefit|diagnosis-codes\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-coding.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"coding\" class=\"hierarchy\"/> completing-form|drug-benefit|diagnosis-codes</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Patient ICD Diagnostic Codes</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..*</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-open-choice\">open-choice</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Value Set: <a href=\"http://hl7.org/fhir/R4/valueset-icd-10.html\">ICD-10 Codes</a></td></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck0010.png)\" id=\"item.completing-form|drug-benefit|diagnosis-descriptions\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-string.png\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"string\" class=\"hierarchy\"/> completing-form|drug-benefit|diagnosis-descriptions</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Patient Diagnosis</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..*</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string\">string</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck0010.png)\" id=\"item.completing-form|drug-benefit|drugs\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-string.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"string\" class=\"hierarchy\"/> completing-form|drug-benefit|drugs</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Drugs Requested with J-Code; if applicable</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..*</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string\">string</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck0010.png)\" id=\"item.completing-form|drug-benefit|strength-route-frequency\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-string.png\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"string\" class=\"hierarchy\"/> completing-form|drug-benefit|strength-route-frequency</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Strength/Route/Frequency</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string\">string</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck0010.png)\" id=\"item.completing-form|drug-benefit|unit-volume\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-string.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"string\" class=\"hierarchy\"/> completing-form|drug-benefit|unit-volume</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Unit/Volume of Named Drugs</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string\">string</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck0010.png)\" id=\"item.completing-form|drug-benefit|start-length\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-string.png\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"string\" class=\"hierarchy\"/> completing-form|drug-benefit|start-length</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Start Date and Length of Therapy</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string\">string</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck0010.png)\" id=\"item.completing-form|drug-benefit|location\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-string.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"string\" class=\"hierarchy\"/> completing-form|drug-benefit|location</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Location of Treatment e.g. provider office; facility; home health; etc. including name; Type 2 NPI if applicable; address and tax ID:</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string\">string</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck0010.png)\" id=\"item.completing-form|drug-benefit|criteria\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-string.png\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"string\" class=\"hierarchy\"/> completing-form|drug-benefit|criteria</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Clinical Criteria for Approval; Including other Pertinent Information to Support the Request; other Medications Tried; Their Names; Duration; and Patient Response:</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string\">string</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck0010.png)\" id=\"item.completing-form|drug-benefit|for-trial\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-boolean.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"boolean\" class=\"hierarchy\"/> completing-form|drug-benefit|for-trial</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">For use in clinical trial?</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-boolean\">boolean</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck0010.png)\" id=\"item.completing-form|drug-benefit|for-trial|registration-number\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-string.png\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"string\" class=\"hierarchy\"/> completing-form|drug-benefit|for-trial|registration-number</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Provide trial name and registration number</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string\">string</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Enable When: <span><a href=\"#item.completing-form|drug-benefit|for-trial\">completing-form|drug-benefit|for-trial</a> = true</span></td></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck0010.png)\" id=\"item.completing-form|drug-benefit|drug-name\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-string.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"string\" class=\"hierarchy\"/> completing-form|drug-benefit|drug-name</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Drug Name Brand Name and Scientific Name/Strength:</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string\">string</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck0010.png)\" id=\"item.completing-form|drug-benefit|dose\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-string.png\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"string\" class=\"hierarchy\"/> completing-form|drug-benefit|dose</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Dose</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string\">string</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck0010.png)\" id=\"item.completing-form|drug-benefit|route\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-string.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"string\" class=\"hierarchy\"/> completing-form|drug-benefit|route</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Route</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string\">string</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck0010.png)\" id=\"item.completing-form|drug-benefit|frequency\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-string.png\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"string\" class=\"hierarchy\"/> completing-form|drug-benefit|frequency</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Frequency</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string\">string</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck0010.png)\" id=\"item.completing-form|drug-benefit|quantity\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-quantity.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"quantity\" class=\"hierarchy\"/> completing-form|drug-benefit|quantity</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Quantity</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-quantity\">quantity</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck0010.png)\" id=\"item.completing-form|drug-benefit|refills\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-integer.png\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"integer\" class=\"hierarchy\"/> completing-form|drug-benefit|refills</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Number of Refills</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-integer\">integer</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck0010.png)\" id=\"item.completing-form|drug-benefit|delivery\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-coding.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"coding\" class=\"hierarchy\"/> completing-form|drug-benefit|delivery</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Product will be delivered to:</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-choice\">choice</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Options: <a href=\"#opt-item.completing-form|drug-benefit|delivery\">3 options</a></td></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck0010.png)\" id=\"item.completing-form|drug-benefit|signature\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-attachment.png\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"attachment\" class=\"hierarchy\"/> completing-form|drug-benefit|signature</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Prescriber or Authorized Signature:</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-attachment\">attachment</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck0010.png)\" id=\"item.completing-form|drug-benefit|pharmacy\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-string.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"string\" class=\"hierarchy\"/> completing-form|drug-benefit|pharmacy</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Dispensing Pharmacy Name and Phone Number:</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string\">string</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck0000.png)\" id=\"item.completing-form|drug-benefit|date\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin_end.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-date.png\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"date\" class=\"hierarchy\"/> completing-form|drug-benefit|date</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Date</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-date\">date</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr><td colspan=\"5\" class=\"hierarchy\"><br/><a href=\"https://hl7.org/fhir/R4/formats.html#table\" title=\"Legend for this format\"><img src=\"data:image/png;base64,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\" alt=\"doco\" style=\"background-color: inherit\"/> Documentation for this format</a></td></tr></table><hr/><p><b>Options Sets</b></p><a name=\"opt-item.urgency\"> </a><p><b>Answer options for urgency </b></p><ul><li style=\"font-size: 11px\">http://example.org/fhir/CodeSystem/UPPARFQuestionnaire-urgency#urgent (\"Urgent\")</li><li style=\"font-size: 11px\">http://example.org/fhir/CodeSystem/UPPARFQuestionnaire-urgency#routine (\"Non-Urgent\")</li></ul><a name=\"opt-item.completing-form|drug-benefit|request-type\"> </a><p><b>Answer options for completing-form|drug-benefit|request-type </b></p><ul><li style=\"font-size: 11px\">New Request</li><li style=\"font-size: 11px\">Reauthorization</li></ul><a name=\"opt-item.completing-form|drug-benefit|delivery\"> </a><p><b>Answer options for completing-form|drug-benefit|delivery </b></p><ul><li style=\"font-size: 11px\">Patient's Home</li><li style=\"font-size: 11px\">Physician Office</li><li style=\"font-size: 11px\">Other</li></ul><h2>Contained Resources</h2><hr/>\n <table class=\"narrative-table\">\n <tbody>\n<tr>\n\n\n<th colspan=\"2\" scope=\"row\" class=\"row-header\">Metadata</th>\n\n\n</tr>\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n<tr>\n\n\n<th scope=\"row\" class=\"row-header\">Type</th>\n\n\n\n<td class=\"content-container\">\n module-definition from <a href=\"http://terminology.hl7.org/7.2.0/CodeSystem-library-type.html\">http://terminology.hl7.org/CodeSystem/library-type</a> \n\n\n</td>\n\n\n</tr>\n\n\n\n<tr>\n \n \n \n \n \n\n<th scope=\"row\" class=\"row-header\">Dependency</th>\n\n\n \n \n <td class=\"content-container\">\n \n <em>Description</em>: USCore model information\n \n <br/>\n \n \n \n \n \n \n <em>Resource</em>: <a href=\"Library-USCore-ModelInfo.html\">US Core Model Information</a> version: 6.1.0-derived\n <br/>\n <em>Canonical URL</em>: <tt>http://hl7.org/fhir/us/cql/Library/USCore-ModelInfo|6.1.0-derived</tt>\n \n \n \n </td>\n</tr>\n\n<tr>\n \n \n \n \n \n\n<th scope=\"row\" class=\"row-header\">Dependency</th>\n\n\n \n \n <td class=\"content-container\">\n \n <em>Description</em>: FHIR model information\n \n <br/>\n \n \n \n \n \n \n <em>Resource</em>: <a href=\"http://hl7.org/fhir/uv/cql/STU2/Library-FHIR-ModelInfo.html\">http://hl7.org/fhir/uv/cql/Library/FHIR-ModelInfo|4.0.1</a>\n <br/>\n <em>Canonical URL</em>: <tt>http://hl7.org/fhir/uv/cql/Library/FHIR-ModelInfo|4.0.1</tt>\n \n \n \n </td>\n</tr>\n\n<tr>\n \n \n \n \n \n\n<th scope=\"row\" class=\"row-header\">Dependency</th>\n\n\n \n \n <td class=\"content-container\">\n \n <em>Description</em>: Library FHIRHelpers\n \n <br/>\n \n \n \n \n \n \n <em>Resource</em>: <a href=\"http://hl7.org/fhir/uv/cql/STU2/Library-FHIRHelpers.html\">http://hl7.org/fhir/uv/cql/Library/FHIRHelpers|4.0.1</a>\n <br/>\n <em>Canonical URL</em>: <tt>http://hl7.org/fhir/uv/cql/Library/FHIRHelpers|4.0.1</tt>\n \n \n \n </td>\n</tr>\n\n\n\n\n\n\n\n\n<tr>\n <th scope=\"row\" class=\"row-header\">Data Requirement</th>\n <td class=\"content-container\">\n <em>Type</em>: MedicationRequest\n <br/>\n \n <em>Profile(s)</em>: \n \n <a href=\"http://hl7.org/fhir/us/core/STU7/StructureDefinition-us-core-medicationrequest.html\">US Core MedicationRequest Profile</a>\n <br/> \n \n \n \n <em>Must Support Elements</em>: id\n <br/>\n \n \n </td>\n</tr>\n\n<tr>\n\n\n<th colspan=\"2\" scope=\"row\" class=\"row-header\"><a name=\"parameters\"> </a>Parameters</th>\n\n\n</tr>\n\n<tr>\n \n\n<th scope=\"row\" class=\"row-header\"/>\n\n\n <td class=\"content-container\">\n <table>\n <thead>\n <tr>\n <td><em>Name</em></td>\n <td><em>Use</em></td>\n <td><em>Card.</em></td>\n <td><em>Type</em></td>\n <td>Documentation</td>\n </tr>\n </thead>\n <tbody>\n \n <tr>\n <td>MedicationRequest</td>\n <td>In</td>\n <td>0..1</td>\n <td>Resource</td>\n <td/>\n </tr>\n \n <tr>\n <td>Urgency</td>\n <td>Out</td>\n <td>0..1</td>\n <td>string</td>\n <td/>\n </tr>\n \n </tbody>\n </table>\n </td>\n</tr>\n\n\n\n\n\n<tr>\n <th colspan=\"2\" scope=\"row\" class=\"row-header\">Generated using version 0.5.3-cibuild of the sample-content-ig Liquid templates</th>\n</tr>\n\n </tbody>\n </table>\n</div>" ] ; fhir:DomainResource.contained [ a fhir:Library ; fhir:index -1 ; fhir:Resource.id [ fhir:value "effective-data-requirements" ] ; fhir:DomainResource.extension [ fhir:index -1 ; fhir:Element.extension [ fhir:index -1 ; fhir:Extension.url [ fhir:value "libraryName" ] ; fhir:Extension.valueString [ fhir:value "UPPARFInitialExpressions" ] ], [ fhir:index -1 ; fhir:Extension.url [ fhir:value "name" ] ; fhir:Extension.valueString [ fhir:value "Retrieve Medication Request test parameter" ] ], [ fhir:index -1 ; fhir:Extension.url [ fhir:value "statement" ] ; fhir:Extension.valueString [ fhir:value "define \"Retrieve Medication Request test parameter\":\n // The VSCode extension doesn't support parameters\n // When executing CQL with the VSCode extension retrieve the resource specific for the test case\n // the list of resource ids match the resources from the test case folders\n singleton from ([USCore.MedicationRequestProfile] MR where MR.id in { \n 'reference-nizatidine', // from tests/library/UPPARFInitialExpressions/example/MedicationRequest-new-reference-nizatidine.json\n 'MedicationRequest-1-nizatidine', // from tests/library/UPPARFInitialExpressions/Patient-example-UPPARF-1/MedicationRequest-1-nizatidine.json\n 'MedicationRequest-lisinopril-example' // from tests/library/UPPARFInitialExpressions/Patient-example-UPPARF-2/MedicationRequest-lisinopril-example.json\n })" ] ], [ fhir:index -1 ; fhir:Extension.url [ fhir:value "displaySequence" ] ; fhir:Extension.valueInteger [ fhir:value "0"^^xsd:integer ] ] ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition" ] ], [ fhir:index -1 ; fhir:Element.extension [ fhir:index -1 ; fhir:Extension.url [ fhir:value "libraryName" ] ; fhir:Extension.valueString [ fhir:value "UPPARFInitialExpressions" ] ], [ fhir:index -1 ; fhir:Extension.url [ fhir:value "name" ] ; fhir:Extension.valueString [ fhir:value "Medication Request" ] ], [ fhir:index -1 ; fhir:Extension.url [ fhir:value "statement" ] ; fhir:Extension.valueString [ fhir:value "define \"Medication Request\":\n Coalesce(\n MedicationRequest,\n \"Retrieve Medication Request test parameter\"\n )" ] ], [ fhir:index -1 ; fhir:Extension.url [ fhir:value "displaySequence" ] ; fhir:Extension.valueInteger [ fhir:value "1"^^xsd:integer ] ] ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition" ] ], [ fhir:index -1 ; fhir:Element.extension [ fhir:index -1 ; fhir:Extension.url [ fhir:value "libraryName" ] ; fhir:Extension.valueString [ fhir:value "UPPARFInitialExpressions" ] ], [ fhir:index -1 ; fhir:Extension.url [ fhir:value "name" ] ; fhir:Extension.valueString [ fhir:value "Most Recent Medication Request" ] ], [ fhir:index -1 ; fhir:Extension.url [ fhir:value "statement" ] ; fhir:Extension.valueString [ fhir:value "define \"Most Recent Medication Request\":\n \"Medication Request\"" ] ], [ fhir:index -1 ; fhir:Extension.url [ fhir:value "displaySequence" ] ; fhir:Extension.valueInteger [ fhir:value "2"^^xsd:integer ] ] ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition" ] ], [ fhir:index -1 ; fhir:Element.extension [ fhir:index -1 ; fhir:Extension.url [ fhir:value "libraryName" ] ; fhir:Extension.valueString [ fhir:value "UPPARFInitialExpressions" ] ], [ fhir:index -1 ; fhir:Extension.url [ fhir:value "name" ] ; fhir:Extension.valueString [ fhir:value "Urgency" ] ], [ fhir:index -1 ; fhir:Extension.url [ fhir:value "statement" ] ; fhir:Extension.valueString [ fhir:value "define \"Urgency\":\n\"Most Recent Medication Request\".priority P\n return (\n if P != 'routine' then 'Urgent'\n else 'Not Urgent'\n )" ] ], [ fhir:index -1 ; fhir:Extension.url [ fhir:value "displaySequence" ] ; fhir:Extension.valueInteger [ fhir:value "3"^^xsd:integer ] ] ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition" ] ], [ fhir:index -1 ; fhir:Element.extension [ fhir:index -1 ; fhir:Extension.url [ fhir:value "libraryName" ] ; fhir:Extension.valueString [ fhir:value "FHIRHelpers" ] ], [ fhir:index -1 ; fhir:Extension.url [ fhir:value "name" ] ; fhir:Extension.valueString [ fhir:value "ToString" ] ], [ fhir:index -1 ; fhir:Extension.url [ fhir:value "statement" ] ; fhir:Extension.valueString [ fhir:value "define function ToString(value string): value.value" ] ], [ fhir:index -1 ; fhir:Extension.url [ fhir:value "displaySequence" ] ; fhir:Extension.valueInteger [ fhir:value "4"^^xsd:integer ] ] ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition" ] ], [ fhir:index -1 ; fhir:Element.extension [ fhir:index -1 ; fhir:Extension.url [ fhir:value "libraryName" ] ; fhir:Extension.valueString [ fhir:value "FHIRHelpers" ] ], [ fhir:index -1 ; fhir:Extension.url [ fhir:value "name" ] ; fhir:Extension.valueString [ fhir:value "ToString" ] ], [ fhir:index -1 ; fhir:Extension.url [ fhir:value "statement" ] ; fhir:Extension.valueString [ fhir:value "define function ToString(value MedicationRequestPriority): value.value" ] ], [ fhir:index -1 ; fhir:Extension.url [ fhir:value "displaySequence" ] ; fhir:Extension.valueInteger [ fhir:value "5"^^xsd:integer ] ] ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition" ] ] ; fhir:Library.name [ fhir:value "EffectiveDataRequirements" ] ; fhir:Library.status [ fhir:value "active" ] ; fhir:Library.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/library-type" ] ; fhir:Coding.code [ fhir:value "module-definition" ] ] ] ; fhir:Library.relatedArtifact [ fhir:index -1 ; fhir:RelatedArtifact.type [ fhir:value "depends-on" ] ; fhir:RelatedArtifact.display [ fhir:value "USCore model information" ] ; fhir:RelatedArtifact.resource [ fhir:value "http://hl7.org/fhir/us/cql/Library/USCore-ModelInfo|6.1.0-derived" ; fhir:link <http://hl7.org/fhir/us/cql/Library/USCore-ModelInfo|6.1.0-derived> ] ], [ fhir:index -1 ; fhir:RelatedArtifact.type [ fhir:value "depends-on" ] ; fhir:RelatedArtifact.display [ fhir:value "FHIR model information" ] ; fhir:RelatedArtifact.resource [ fhir:value "http://hl7.org/fhir/uv/cql/Library/FHIR-ModelInfo|4.0.1" ; fhir:link <http://hl7.org/fhir/uv/cql/Library/FHIR-ModelInfo|4.0.1> ] ], [ fhir:index -1 ; fhir:RelatedArtifact.type [ fhir:value "depends-on" ] ; fhir:RelatedArtifact.display [ fhir:value "Library FHIRHelpers" ] ; fhir:RelatedArtifact.resource [ fhir:value "http://hl7.org/fhir/uv/cql/Library/FHIRHelpers|4.0.1" ; fhir:link <http://hl7.org/fhir/uv/cql/Library/FHIRHelpers|4.0.1> ] ] ; fhir:Library.parameter [ fhir:index -1 ; fhir:ParameterDefinition.name [ fhir:value "MedicationRequest" ] ; fhir:ParameterDefinition.use [ fhir:value "in" ] ; fhir:ParameterDefinition.min [ fhir:value "0"^^xsd:integer ] ; fhir:ParameterDefinition.max [ fhir:value "1" ] ; fhir:ParameterDefinition.type [ fhir:value "Resource" ] ], [ fhir:index -1 ; fhir:ParameterDefinition.name [ fhir:value "Urgency" ] ; fhir:ParameterDefinition.use [ fhir:value "out" ] ; fhir:ParameterDefinition.min [ fhir:value "0"^^xsd:integer ] ; fhir:ParameterDefinition.max [ fhir:value "1" ] ; fhir:ParameterDefinition.type [ fhir:value "string" ] ] ; fhir:Library.dataRequirement [ fhir:index -1 ; fhir:DataRequirement.type [ fhir:value "MedicationRequest" ] ; fhir:DataRequirement.profile [ fhir:value "http://hl7.org/fhir/us/core/StructureDefinition/us-core-medicationrequest" ; fhir:index -1 ; fhir:link <http://hl7.org/fhir/us/core/StructureDefinition/us-core-medicationrequest> ] ; fhir:DataRequirement.mustSupport [ fhir:value "id" ; fhir:index -1 ] ], [ fhir:index -1 ; fhir:DataRequirement.type [ fhir:value "MedicationRequest" ] ; fhir:DataRequirement.profile [ fhir:value "http://hl7.org/fhir/us/core/StructureDefinition/us-core-medicationrequest" ; fhir:index -1 ; fhir:link <http://hl7.org/fhir/us/core/StructureDefinition/us-core-medicationrequest> ] ; fhir:DataRequirement.mustSupport [ fhir:value "id" ; fhir:index -1 ] ] ] ; fhir:DomainResource.extension [ fhir:index -1 ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/StructureDefinition/cqf-library" ] ; fhir:Extension.valueCanonical [ fhir:value "http://hl7.org/fhir/us/cql/Library/UPPARFInitialExpressions" ; fhir:link <http://hl7.org/fhir/us/cql/Library/UPPARFInitialExpressions> ] ], [ fhir:index -1 ; fhir:Element.extension [ fhir:index -1 ; fhir:Extension.url [ fhir:value "name" ] ; fhir:Extension.valueCoding [ fhir:Coding.system [ fhir:value "http://hl7.org/fhir/uv/sdc/CodeSystem/launchContext" ] ; fhir:Coding.code [ fhir:value "patient" ] ; fhir:Coding.display [ fhir:value "Patient" ] ] ], [ fhir:index -1 ; fhir:Extension.url [ fhir:value "type" ] ; fhir:Extension.valueCode [ fhir:value "Patient" ] ], [ fhir:index -1 ; fhir:Extension.url [ fhir:value "description" ] ; fhir:Extension.valueString [ fhir:value "The patient that is to be used to pre-populate the form" ] ] ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-launchContext" ] ], [ fhir:index -1 ; fhir:Element.extension [ fhir:index -1 ; fhir:Extension.url [ fhir:value "name" ] ; fhir:Extension.valueCoding [ fhir:Coding.system [ fhir:value "http://example.org/fhir/CodeSystem/additionalLaunchContext" ] ; fhir:Coding.code [ fhir:value "MedicationRequest" ] ; fhir:Coding.display [ fhir:value "MedicationRequest" ] ] ], [ fhir:index -1 ; fhir:Extension.url [ fhir:value "type" ] ; fhir:Extension.valueCode [ fhir:value "MedicationRequest" ] ], [ fhir:index -1 ; fhir:Extension.url [ fhir:value "description" ] ; fhir:Extension.valueString [ fhir:value "The MedicationRequest that is to be used to pre-populate the form" ] ] ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-launchContext" ] ], [ fhir:index -1 ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg" ] ; fhir:Extension.valueCode [ fhir:value "cds" ] ], [ fhir:index -1 ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/uv/crmi/StructureDefinition/crmi-effectiveDataRequirements" ] ; fhir:Extension.valueCanonical [ fhir:value "#effective-data-requirements" ] ], [ fhir:index -1 ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status" ] ; fhir:Extension.valueCode [ fhir:value "informative" ; fhir:Element.extension [ fhir:index -1 ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom" ] ; fhir:Extension.valueCanonical [ fhir:value "http://hl7.org/fhir/us/cql/ImplementationGuide/hl7.fhir.us.cql" ; fhir:link <http://hl7.org/fhir/us/cql/ImplementationGuide/hl7.fhir.us.cql> ] ] ] ] ; fhir:Questionnaire.url [ fhir:value "http://hl7.org/fhir/us/cql/Questionnaire/UPPARFQuestionnaire"] ; fhir:Questionnaire.version [ fhir:value "2.0.0-cibuild"] ; fhir:Questionnaire.name [ fhir:value "UPPARFQuestionnaire"] ; fhir:Questionnaire.title [ fhir:value "Example Uniform Pharmacy Prior Authorization Request Form"] ; fhir:Questionnaire.status [ fhir:value "active"] ; fhir:Questionnaire.experimental [ fhir:value "true"^^xsd:boolean] ; fhir:Questionnaire.date [ fhir:value "2023-10-19T00:00:00+00:00"^^xsd:dateTime] ; fhir:Questionnaire.publisher [ fhir:value "HL7 International / Clinical Decision Support"] ; fhir:Questionnaire.contact [ fhir:index -1 ; fhir:ContactDetail.telecom [ fhir:index -1 ; fhir:ContactPoint.system [ fhir:value "url" ] ; fhir:ContactPoint.value [ fhir:value "http://www.hl7.org/Special/committees/dss" ] ] ] ; fhir:Questionnaire.description [ fhir:value "This is an example of a prior authorization questionnaire developed based on an existing industry prior authorization form."] ; fhir:Questionnaire.jurisdiction [ fhir:index -1 ; fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "urn:iso:std:iso:3166" ] ; fhir:Coding.code [ fhir:value "US" ] ; fhir:Coding.display [ fhir:value "United States of America" ] ] ] ; fhir:Questionnaire.copyright [ fhir:value "This content is informed by the following source, used with permission: https://docushare-web.apps.external.pioneer.humana.com/Marketing/docushare-app?file=4136509"] ; fhir:Questionnaire.item [ fhir:index -1 ; fhir:Element.extension [ fhir:index -1 ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression" ] ; fhir:Extension.valueExpression [ fhir:Expression.language [ fhir:value "text/cql-identifier" ] ; fhir:Expression.expression [ fhir:value "Urgency" ] ] ] ; fhir:Questionnaire.item.linkId [ fhir:value "urgency" ] ; fhir:Questionnaire.item.text [ fhir:value "Urgency" ] ; fhir:Questionnaire.item.type [ fhir:value "choice" ] ; fhir:Questionnaire.item.answerOption [ fhir:index -1 ; fhir:Questionnaire.item.answerOption.valueCoding [ fhir:Coding.system [ fhir:value "http://example.org/fhir/CodeSystem/UPPARFQuestionnaire-urgency" ] ; fhir:Coding.code [ fhir:value "urgent" ] ; fhir:Coding.display [ fhir:value "Urgent" ] ] ], [ fhir:index -1 ; fhir:Questionnaire.item.answerOption.valueCoding [ fhir:Coding.system [ fhir:value "http://example.org/fhir/CodeSystem/UPPARFQuestionnaire-urgency" ] ; fhir:Coding.code [ fhir:value "routine" ] ; fhir:Coding.display [ fhir:value "Non-Urgent" ] ] ] ], [ fhir:index -1 ; fhir:Questionnaire.item.linkId [ fhir:value "drug-info" ] ; fhir:Questionnaire.item.text [ fhir:value "Drug Information" ] ; fhir:Questionnaire.item.type [ fhir:value "group" ] ; fhir:Questionnaire.item.item [ fhir:index -1 ; fhir:Element.extension [ fhir:index -1 ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression" ] ; fhir:Extension.valueExpression [ fhir:Expression.language [ fhir:value "text/cql-identifier" ] ; fhir:Expression.expression [ fhir:value "Most Recent Medication Name" ] ] ] ; fhir:Questionnaire.item.linkId [ fhir:value "drug-info|drug-name" ] ; fhir:Questionnaire.item.text [ fhir:value "Requested Drug Name" ] ; fhir:Questionnaire.item.type [ fhir:value "string" ] ], [ fhir:index -1 ; fhir:Element.extension [ fhir:index -1 ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression" ] ; fhir:Extension.valueExpression [ fhir:Expression.language [ fhir:value "text/cql-identifier" ] ; fhir:Expression.expression [ fhir:value "Is Opioid Treatment" ] ] ] ; fhir:Questionnaire.item.linkId [ fhir:value "drug-info|drug-intention-opioid" ] ; fhir:Questionnaire.item.text [ fhir:value "Is this drug intended to treat opioid dependence?" ] ; fhir:Questionnaire.item.type [ fhir:value "boolean" ] ; fhir:Questionnaire.item.item [ fhir:index -1 ; fhir:Element.extension [ fhir:index -1 ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression" ] ; fhir:Extension.valueExpression [ fhir:Expression.language [ fhir:value "text/cql-identifier" ] ; fhir:Expression.expression [ fhir:value "Is First Prior Authentication" ] ] ] ; fhir:Questionnaire.item.linkId [ fhir:value "drug-info|drug-intention-opioid|first-prior-authentication" ] ; fhir:Questionnaire.item.text [ fhir:value "Is this a first request for prior authorization for this drug?" ] ; fhir:Questionnaire.item.type [ fhir:value "boolean" ] ; fhir:Questionnaire.item.enableWhen [ fhir:index -1 ; fhir:Questionnaire.item.enableWhen.question [ fhir:value "drug-info|drug-intention-opioid" ] ; fhir:Questionnaire.item.enableWhen.operator [ fhir:value "=" ] ; fhir:Questionnaire.item.enableWhen.answerBoolean [ fhir:value "true"^^xsd:boolean ] ] ], [ fhir:index -1 ; fhir:Element.extension [ fhir:index -1 ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression" ] ; fhir:Extension.valueExpression [ fhir:Expression.language [ fhir:value "text/cql-identifier" ] ; fhir:Expression.expression [ fhir:value "Initial Request Date" ] ] ] ; fhir:Questionnaire.item.linkId [ fhir:value "drug-info|drug-intention-opioid|date-first-request" ] ; fhir:Questionnaire.item.text [ fhir:value "What was the date of the first request?" ] ; fhir:Questionnaire.item.type [ fhir:value "date" ] ; fhir:Questionnaire.item.enableWhen [ fhir:index -1 ; fhir:Questionnaire.item.enableWhen.question [ fhir:value "drug-info|drug-intention-opioid|first-prior-authentication" ] ; fhir:Questionnaire.item.enableWhen.operator [ fhir:value "=" ] ; fhir:Questionnaire.item.enableWhen.answerBoolean [ fhir:value "false"^^xsd:boolean ] ] ], [ fhir:index -1 ; fhir:Element.extension [ fhir:index -1 ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression" ] ; fhir:Extension.valueExpression [ fhir:Expression.language [ fhir:value "text/cql-identifier" ] ; fhir:Expression.expression [ fhir:value "Is First Request > 12 Months" ] ] ] ; fhir:Questionnaire.item.linkId [ fhir:value "drug-info|drug-intention-opioid|twelve-months-since-request" ] ; fhir:Questionnaire.item.text [ fhir:value "Has the date of the first request been greater than twelve months ago?" ] ; fhir:Questionnaire.item.type [ fhir:value "boolean" ] ; fhir:Questionnaire.item.enableWhen [ fhir:index -1 ; fhir:Questionnaire.item.enableWhen.question [ fhir:value "drug-info|drug-intention-opioid|first-prior-authentication" ] ; fhir:Questionnaire.item.enableWhen.operator [ fhir:value "=" ] ; fhir:Questionnaire.item.enableWhen.answerBoolean [ fhir:value "false"^^xsd:boolean ] ] ] ] ], [ fhir:index -1 ; fhir:Questionnaire.item.linkId [ fhir:value "completing-form" ] ; fhir:Questionnaire.item.text [ fhir:value "Prior authentication is required and this form needs to be completed" ] ; fhir:Questionnaire.item.type [ fhir:value "group" ] ; fhir:Questionnaire.item.enableWhen [ fhir:index -1 ; fhir:Questionnaire.item.enableWhen.question [ fhir:value "drug-info|drug-intention-opioid" ] ; fhir:Questionnaire.item.enableWhen.operator [ fhir:value "=" ] ; fhir:Questionnaire.item.enableWhen.answerBoolean [ fhir:value "false"^^xsd:boolean ] ], [ fhir:index -1 ; fhir:Questionnaire.item.enableWhen.question [ fhir:value "drug-info|drug-intention-opioid|twelve-months-since-request" ] ; fhir:Questionnaire.item.enableWhen.operator [ fhir:value "=" ] ; fhir:Questionnaire.item.enableWhen.answerBoolean [ fhir:value "false"^^xsd:boolean ] ] ; fhir:Questionnaire.item.enableBehavior [ fhir:value "any" ] ; fhir:Questionnaire.item.item [ fhir:index -1 ; fhir:Questionnaire.item.linkId [ fhir:value "completing-form|patient-info" ] ; fhir:Questionnaire.item.text [ fhir:value "Patient Info" ] ; fhir:Questionnaire.item.type [ fhir:value "group" ] ; fhir:Questionnaire.item.item [ fhir:index -1 ; fhir:Element.extension [ fhir:index -1 ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression" ] ; fhir:Extension.valueExpression [ fhir:Expression.language [ fhir:value "text/cql-identifier" ] ; fhir:Expression.expression [ fhir:value "Prescription Date" ] ] ] ; fhir:Questionnaire.item.linkId [ fhir:value "completing-form|patient-info|prescription-date" ] ; fhir:Questionnaire.item.text [ fhir:value "Prescription Date" ] ; fhir:Questionnaire.item.type [ fhir:value "string" ] ] ], [ fhir:index -1 ; fhir:Questionnaire.item.linkId [ fhir:value "completing-form|prescriber-info" ] ; fhir:Questionnaire.item.text [ fhir:value "Prescriber Info" ] ; fhir:Questionnaire.item.type [ fhir:value "group" ] ; fhir:Questionnaire.item.item [ fhir:index -1 ; fhir:Element.extension [ fhir:index -1 ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression" ] ; fhir:Extension.valueExpression [ fhir:Expression.language [ fhir:value "text/cql-identifier" ] ; fhir:Expression.expression [ fhir:value "Prescriber Name" ] ] ] ; fhir:Questionnaire.item.linkId [ fhir:value "completing-form|prescriber-info|prescriber-name" ] ; fhir:Questionnaire.item.text [ fhir:value "Prescriber Name" ] ; fhir:Questionnaire.item.type [ fhir:value "string" ] ], [ fhir:index -1 ; fhir:Element.extension [ fhir:index -1 ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression" ] ; fhir:Extension.valueExpression [ fhir:Expression.language [ fhir:value "text/cql-identifier" ] ; fhir:Expression.expression [ fhir:value "Prescriber Fax" ] ] ] ; fhir:Questionnaire.item.linkId [ fhir:value "completing-form|prescriber-info|prescriber-fax" ] ; fhir:Questionnaire.item.text [ fhir:value "Prescriber Fax" ] ; fhir:Questionnaire.item.type [ fhir:value "string" ] ], [ fhir:index -1 ; fhir:Element.extension [ fhir:index -1 ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression" ] ; fhir:Extension.valueExpression [ fhir:Expression.language [ fhir:value "text/cql-identifier" ] ; fhir:Expression.expression [ fhir:value "Prescriber Phone" ] ] ] ; fhir:Questionnaire.item.linkId [ fhir:value "completing-form|prescriber-info|prescriber-phone" ] ; fhir:Questionnaire.item.text [ fhir:value "Prescriber Phone" ] ; fhir:Questionnaire.item.type [ fhir:value "string" ] ], [ fhir:index -1 ; fhir:Element.extension [ fhir:index -1 ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression" ] ; fhir:Extension.valueExpression [ fhir:Expression.language [ fhir:value "text/cql-identifier" ] ; fhir:Expression.expression [ fhir:value "Prescriber Pager" ] ] ] ; fhir:Questionnaire.item.linkId [ fhir:value "completing-form|prescriber-info|prescriber-pager" ] ; fhir:Questionnaire.item.text [ fhir:value "Prescriber Pager" ] ; fhir:Questionnaire.item.type [ fhir:value "string" ] ], [ fhir:index -1 ; fhir:Element.extension [ fhir:index -1 ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression" ] ; fhir:Extension.valueExpression [ fhir:Expression.language [ fhir:value "text/cql-identifier" ] ; fhir:Expression.expression [ fhir:value "Prescriber Address" ] ] ] ; fhir:Questionnaire.item.linkId [ fhir:value "completing-form|prescriber-info|prescriber-address" ] ; fhir:Questionnaire.item.text [ fhir:value "Prescriber Address" ] ; fhir:Questionnaire.item.type [ fhir:value "string" ] ], [ fhir:index -1 ; fhir:Element.extension [ fhir:index -1 ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression" ] ; fhir:Extension.valueExpression [ fhir:Expression.language [ fhir:value "text/cql-identifier" ] ; fhir:Expression.expression [ fhir:value "Prescriber Contact" ] ] ] ; fhir:Questionnaire.item.linkId [ fhir:value "completing-form|prescriber-info|prescriber-contact" ] ; fhir:Questionnaire.item.text [ fhir:value "Prescriber Office Contact" ] ; fhir:Questionnaire.item.type [ fhir:value "string" ] ], [ fhir:index -1 ; fhir:Element.extension [ fhir:index -1 ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression" ] ; fhir:Extension.valueExpression [ fhir:Expression.language [ fhir:value "text/cql-identifier" ] ; fhir:Expression.expression [ fhir:value "Prescriber NPI" ] ] ] ; fhir:Questionnaire.item.linkId [ fhir:value "completing-form|prescriber-info|prescriber-npi" ] ; fhir:Questionnaire.item.text [ fhir:value "Prescriber NPI" ] ; fhir:Questionnaire.item.type [ fhir:value "string" ] ], [ fhir:index -1 ; fhir:Element.extension [ fhir:index -1 ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression" ] ; fhir:Extension.valueExpression [ fhir:Expression.language [ fhir:value "text/cql-identifier" ] ; fhir:Expression.expression [ fhir:value "Prescriber DEA" ] ] ] ; fhir:Questionnaire.item.linkId [ fhir:value "completing-form|prescriber-info|prescriber-dea" ] ; fhir:Questionnaire.item.text [ fhir:value "Prescriber DEA" ] ; fhir:Questionnaire.item.type [ fhir:value "string" ] ], [ fhir:index -1 ; fhir:Element.extension [ fhir:index -1 ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression" ] ; fhir:Extension.valueExpression [ fhir:Expression.language [ fhir:value "text/cql-identifier" ] ; fhir:Expression.expression [ fhir:value "Prescriber Tax ID" ] ] ] ; fhir:Questionnaire.item.linkId [ fhir:value "completing-form|prescriber-info|prescriber-tax-id" ] ; fhir:Questionnaire.item.text [ fhir:value "Prescriber Tax ID" ] ; fhir:Questionnaire.item.type [ fhir:value "string" ] ], [ fhir:index -1 ; fhir:Element.extension [ fhir:index -1 ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression" ] ; fhir:Extension.valueExpression [ fhir:Expression.language [ fhir:value "text/cql-identifier" ] ; fhir:Expression.expression [ fhir:value "Prescriber Specialty" ] ] ] ; fhir:Questionnaire.item.linkId [ fhir:value "completing-form|prescriber-info|prescriber-specialty" ] ; fhir:Questionnaire.item.text [ fhir:value "Specialty/Facility Name If applicable" ] ; fhir:Questionnaire.item.type [ fhir:value "string" ] ], [ fhir:index -1 ; fhir:Element.extension [ fhir:index -1 ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression" ] ; fhir:Extension.valueExpression [ fhir:Expression.language [ fhir:value "text/cql-identifier" ] ; fhir:Expression.expression [ fhir:value "Prescriber Email Address" ] ] ] ; fhir:Questionnaire.item.linkId [ fhir:value "completing-form|prescriber-info|prescriber-email" ] ; fhir:Questionnaire.item.text [ fhir:value "Email Address" ] ; fhir:Questionnaire.item.type [ fhir:value "string" ] ] ], [ fhir:index -1 ; fhir:Questionnaire.item.linkId [ fhir:value "completing-form|drug-benefit" ] ; fhir:Questionnaire.item.text [ fhir:value "Prior Authorization Request for Drug Benefit" ] ; fhir:Questionnaire.item.type [ fhir:value "group" ] ; fhir:Questionnaire.item.item [ fhir:index -1 ; fhir:Element.extension [ fhir:index -1 ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression" ] ; fhir:Extension.valueExpression [ fhir:Expression.language [ fhir:value "text/cql-identifier" ] ; fhir:Expression.expression [ fhir:value "Request Type" ] ] ] ; fhir:Questionnaire.item.linkId [ fhir:value "completing-form|drug-benefit|request-type" ] ; fhir:Questionnaire.item.text [ fhir:value "New Request" ] ; fhir:Questionnaire.item.type [ fhir:value "choice" ] ; fhir:Questionnaire.item.answerOption [ fhir:index -1 ; fhir:Questionnaire.item.answerOption.valueString [ fhir:value "New Request" ] ], [ fhir:index -1 ; fhir:Questionnaire.item.answerOption.valueString [ fhir:value "Reauthorization" ] ] ], [ fhir:index -1 ; fhir:Element.extension [ fhir:index -1 ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression" ] ; fhir:Extension.valueExpression [ fhir:Expression.language [ fhir:value "text/cql-identifier" ] ; fhir:Expression.expression [ fhir:value "ICD 10 Codes" ] ] ] ; fhir:Questionnaire.item.linkId [ fhir:value "completing-form|drug-benefit|diagnosis-codes" ] ; fhir:Questionnaire.item.text [ fhir:value "Patient ICD Diagnostic Codes" ] ; fhir:Questionnaire.item.type [ fhir:value "open-choice" ] ; fhir:Questionnaire.item.repeats [ fhir:value "true"^^xsd:boolean ] ; fhir:Questionnaire.item.answerValueSet [ fhir:value "http://hl7.org/fhir/ValueSet/icd-10" ; fhir:link <http://hl7.org/fhir/ValueSet/icd-10> ] ], [ fhir:index -1 ; fhir:Element.extension [ fhir:index -1 ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression" ] ; fhir:Extension.valueExpression [ fhir:Expression.language [ fhir:value "text/cql-identifier" ] ; fhir:Expression.expression [ fhir:value "Diagnosis Descriptions" ] ] ] ; fhir:Questionnaire.item.linkId [ fhir:value "completing-form|drug-benefit|diagnosis-descriptions" ] ; fhir:Questionnaire.item.text [ fhir:value "Patient Diagnosis" ] ; fhir:Questionnaire.item.type [ fhir:value "string" ] ; fhir:Questionnaire.item.repeats [ fhir:value "true"^^xsd:boolean ] ], [ fhir:index -1 ; fhir:Questionnaire.item.linkId [ fhir:value "completing-form|drug-benefit|drugs" ] ; fhir:Questionnaire.item.text [ fhir:value "Drugs Requested with J-Code; if applicable" ] ; fhir:Questionnaire.item.type [ fhir:value "string" ] ; fhir:Questionnaire.item.repeats [ fhir:value "true"^^xsd:boolean ] ], [ fhir:index -1 ; fhir:Questionnaire.item.linkId [ fhir:value "completing-form|drug-benefit|strength-route-frequency" ] ; fhir:Questionnaire.item.text [ fhir:value "Strength/Route/Frequency" ] ; fhir:Questionnaire.item.type [ fhir:value "string" ] ], [ fhir:index -1 ; fhir:Questionnaire.item.linkId [ fhir:value "completing-form|drug-benefit|unit-volume" ] ; fhir:Questionnaire.item.text [ fhir:value "Unit/Volume of Named Drugs" ] ; fhir:Questionnaire.item.type [ fhir:value "string" ] ], [ fhir:index -1 ; fhir:Element.extension [ fhir:index -1 ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression" ] ; fhir:Extension.valueExpression [ fhir:Expression.language [ fhir:value "text/cql-identifier" ] ; fhir:Expression.expression [ fhir:value "Start Date and Length" ] ] ] ; fhir:Questionnaire.item.linkId [ fhir:value "completing-form|drug-benefit|start-length" ] ; fhir:Questionnaire.item.text [ fhir:value "Start Date and Length of Therapy" ] ; fhir:Questionnaire.item.type [ fhir:value "string" ] ], [ fhir:index -1 ; fhir:Questionnaire.item.linkId [ fhir:value "completing-form|drug-benefit|location" ] ; fhir:Questionnaire.item.text [ fhir:value "Location of Treatment e.g. provider office; facility; home health; etc. including name; Type 2 NPI if applicable; address and tax ID:" ] ; fhir:Questionnaire.item.type [ fhir:value "string" ] ], [ fhir:index -1 ; fhir:Questionnaire.item.linkId [ fhir:value "completing-form|drug-benefit|criteria" ] ; fhir:Questionnaire.item.text [ fhir:value "Clinical Criteria for Approval; Including other Pertinent Information to Support the Request; other Medications Tried; Their Names; Duration; and Patient Response:" ] ; fhir:Questionnaire.item.type [ fhir:value "string" ] ], [ fhir:index -1 ; fhir:Questionnaire.item.linkId [ fhir:value "completing-form|drug-benefit|for-trial" ] ; fhir:Questionnaire.item.text [ fhir:value "For use in clinical trial?" ] ; fhir:Questionnaire.item.type [ fhir:value "boolean" ] ], [ fhir:index -1 ; fhir:Questionnaire.item.linkId [ fhir:value "completing-form|drug-benefit|for-trial|registration-number" ] ; fhir:Questionnaire.item.text [ fhir:value "Provide trial name and registration number" ] ; fhir:Questionnaire.item.type [ fhir:value "string" ] ; fhir:Questionnaire.item.enableWhen [ fhir:index -1 ; fhir:Questionnaire.item.enableWhen.question [ fhir:value "completing-form|drug-benefit|for-trial" ] ; fhir:Questionnaire.item.enableWhen.operator [ fhir:value "=" ] ; fhir:Questionnaire.item.enableWhen.answerBoolean [ fhir:value "true"^^xsd:boolean ] ] ], [ fhir:index -1 ; fhir:Questionnaire.item.linkId [ fhir:value "completing-form|drug-benefit|drug-name" ] ; fhir:Questionnaire.item.text [ fhir:value "Drug Name Brand Name and Scientific Name/Strength:" ] ; fhir:Questionnaire.item.type [ fhir:value "string" ] ], [ fhir:index -1 ; fhir:Questionnaire.item.linkId [ fhir:value "completing-form|drug-benefit|dose" ] ; fhir:Questionnaire.item.text [ fhir:value "Dose" ] ; fhir:Questionnaire.item.type [ fhir:value "string" ] ], [ fhir:index -1 ; fhir:Questionnaire.item.linkId [ fhir:value "completing-form|drug-benefit|route" ] ; fhir:Questionnaire.item.text [ fhir:value "Route" ] ; fhir:Questionnaire.item.type [ fhir:value "string" ] ], [ fhir:index -1 ; fhir:Questionnaire.item.linkId [ fhir:value "completing-form|drug-benefit|frequency" ] ; fhir:Questionnaire.item.text [ fhir:value "Frequency" ] ; fhir:Questionnaire.item.type [ fhir:value "string" ] ], [ fhir:index -1 ; fhir:Questionnaire.item.linkId [ fhir:value "completing-form|drug-benefit|quantity" ] ; fhir:Questionnaire.item.text [ fhir:value "Quantity" ] ; fhir:Questionnaire.item.type [ fhir:value "quantity" ] ], [ fhir:index -1 ; fhir:Questionnaire.item.linkId [ fhir:value "completing-form|drug-benefit|refills" ] ; fhir:Questionnaire.item.text [ fhir:value "Number of Refills" ] ; fhir:Questionnaire.item.type [ fhir:value "integer" ] ], [ fhir:index -1 ; fhir:Questionnaire.item.linkId [ fhir:value "completing-form|drug-benefit|delivery" ] ; fhir:Questionnaire.item.text [ fhir:value "Product will be delivered to:" ] ; fhir:Questionnaire.item.type [ fhir:value "choice" ] ; fhir:Questionnaire.item.answerOption [ fhir:index -1 ; fhir:Questionnaire.item.answerOption.valueString [ fhir:value "Patient's Home" ] ], [ fhir:index -1 ; fhir:Questionnaire.item.answerOption.valueString [ fhir:value "Physician Office" ] ], [ fhir:index -1 ; fhir:Questionnaire.item.answerOption.valueString [ fhir:value "Other" ] ] ], [ fhir:index -1 ; fhir:Questionnaire.item.linkId [ fhir:value "completing-form|drug-benefit|signature" ] ; fhir:Questionnaire.item.text [ fhir:value "Prescriber or Authorized Signature:" ] ; fhir:Questionnaire.item.type [ fhir:value "attachment" ] ], [ fhir:index -1 ; fhir:Questionnaire.item.linkId [ fhir:value "completing-form|drug-benefit|pharmacy" ] ; fhir:Questionnaire.item.text [ fhir:value "Dispensing Pharmacy Name and Phone Number:" ] ; fhir:Questionnaire.item.type [ fhir:value "string" ] ], [ fhir:index -1 ; fhir:Questionnaire.item.linkId [ fhir:value "completing-form|drug-benefit|date" ] ; fhir:Questionnaire.item.text [ fhir:value "Date" ] ; fhir:Questionnaire.item.type [ fhir:value "date" ] ] ] ] . # - ontology header ------------------------------------------------------------ <http://hl7.org/fhir/Questionnaire/UPPARFQuestionnaire.ttl> a owl:Ontology ; owl:imports fhir:fhir.ttl ; owl:versionIRI <http://build.fhir.org/Questionnaire/UPPARFQuestionnaire.ttl> .
IG © 2019+ HL7 International / Clinical Decision Support.
Package hl7.fhir.us.cql#2.0.0-cibuild based on FHIR 4.0.1.
Generated
2026-07-12
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