# CF1 Sample JSON Bundle - Member is not the Patient - NHDR Implementation Guide Release 1.0 v0.1.0

* [**Table of Contents**](toc.md)
* [**Claims Form 1**](CF1.md)
* **CF1 Sample JSON Bundle - Member is not the Patient**

## CF1 Sample JSON Bundle - Member is not the Patient

```
{
  "resourceType": "Bundle",
  "id": "ClaimsForm1-1",
  "type": "transaction",
  "identifier": {
    "system": "http://nhdr.gov.ph/fhir/ValueSet-form-type",
    "value": "CF1"
},
"entry": [
    {
      "fullUrl": "urn:uuid:CF1-RelatedPerson",
      "resource": {
        "resourceType": "RelatedPerson",
        "meta": {
          "profile": [
            "https://nhdr.gov.ph/fhir/StructureDefinition/PH-RelatedPerson"
          ]
        },
        "identifier": [
          {
            "type": {
              "coding": [
                {
                  "code": "NIIP"
                }
              ],
              "text": "PhilHealth Identification Number"
            },
            "value": "PH54321"
          }
        ],
        "patient": {
          "reference": "urn:uuid:CF1-Patient-2"
        },
        "name": [
          {
            "family": "Bautista",
            "given": [
              "Lorna Mae",
              "Santos"
            ],
            "suffix": [
              "Mrs."
            ]
          }
        ],
        "birthDate": "1971-02-11",
        "address": [
          {
            "line": [
              "Fordham Road"
            ],
            "extension": [
              {
                "url": "https://nhdr.gov.ph/fhir/StructureDefinition/Barangay",
                "valueCoding": {
                  "code": "0123456789",
                  "display": "Blue Ridge"
                }
              },
              {
                "url": "https://nhdr.gov.ph/fhir/StructureDefinition/CityMunicipality",
                "valueCoding": {
                  "code": "0123456",
                  "display": "Quezon City"
                }
              },
              {
                "url": "https://nhdr.gov.ph/fhir/StructureDefinition/Province",
                "valueCoding": {
                  "code": "01234",
                  "display": "Metro Manila"
                }
              }
            ],
            "country": "PH",
            "postalCode": "1110"
          }
        ],
        "extension": [
          {
            "url": "https://nhdr.gov.ph/fhir/StructureDefinition/Sex",
            "valueCode": "F"
          }
        ],
        "telecom": [
          {
            "system": "phone",
            "value": "912-00-00"
          },
          {
            "system": "phone",
            "value": "0927-000-0000"
          },
          {
            "system": "email",
            "value": "lmbautista@email.com"
          }
        ]
      },
      "request": {
        "method": "POST",
        "url": "RelatedPerson"
      }
    },
       {
      "fullUrl": "urn:uuid:CF1-Patient",
      "resource": {
        "resourceType": "Patient",
        "meta": {
          "profile": [
            "https://nhdr.gov.ph/fhir/StructureDefinition/PH-Patient"
          ]
        },
        "link": [
        {
            "other": {
                "reference": "urn:uuid:CF1-RelatedPerson"
            },
            "type": "refer"
        }
      ]
      },
      "request": {
        "method": "POST",
        "url": "Patient"
      }
    },
    {
      "fullUrl": "urn:uuid:CF1-Organization",
      "resource": {
        "resourceType": "Organization",
        "meta": {
          "profile": [
            "https://nhdr.gov.ph/fhir/StructureDefinition/PH-Organization"
          ]
        },
        "identifier": [
          {
            "type": {
              "coding": [
                {
                  "code": "EN"
                }
              ],
              "text": "PhilHealth Employer Number (PEN)"
            },
            "value": "EN15243"
          }
        ],
        "name": "PhilHealth",
        "telecom": [
          {
            "value": "080-00-00"
          }
        ]
      },
      "request": {
        "method": "POST",
        "url": "Organization"
      }
    },
    {
      "fullUrl": "urn:uuid:CF1-Provenance",
      "resource": {
        "resourceType": "Provenance",
        "meta": {
          "profile": [
            "https://nhdr.gov.ph/fhir/StructureDefinition/PH-Provenance"
          ]
        },
        "target": [
          {
            "reference": "urn:uuid:CF1-Claim"
          }
        ],
        "recorded": "2026-02-03T09:00:00+08:00",
        "agent": [
          {
            "who": {
              "reference": "urn:uuid:CF1-Organization"
            }
          }
        ],
        "signature": [
          {
            "type": [
              {
                "system": "urn:iso-astm:E1762-95:2013",
                "code": "1.2.840.10065.1.12.1.20",
                "display": "Electronic Signature"
              }
            ],
            "when": "2026-02-03T10:30:00+08:00",
            "who": {
              "reference": "urn:uuid:CF1-RelatedPerson"
            },
            "data": "QkFTRTY0X1NJR05BVFVSRV9QQVRJRU5U",
            "extension": [
              {
                "url": "https://nhdr.gov.ph/fhir/StructureDefinition/SignatureReason",
                "valueString": "Claim Approval"
              }
            ]
          },
          {
            "type": [
              {
                "system": "urn:iso-astm:E1762-95:2013",
                "code": "1.2.840.10065.1.12.1.20",
                "display": "Electronic Signature"
              }
            ],
            "when": "2026-02-03T10:30:00+08:00",
            "who": {
              "reference": "urn:uuid:CF1-Organization"
            },
            "data": "QkFTRTY0X1NJR05BVFVSRV9PUkdBTklaVElPTg=="
          }
        ]
      },
      "request": {
        "method": "POST",
        "url": "Provenance"
      }
    },
    {
      "fullUrl": "urn:uuid:CF1-Questionnaire",
      "resource": {
        "resourceType": "Questionnaire",
        "meta": {
          "profile": [
            "https://nhdr.gov.ph/fhir/StructureDefinition/PH-Questionnaire"
          ]
        },
        "status": "active",
        "item": [
          {
            "linkId": "CF1-Q1",
            "text": "Patient is the member?",
            "type": "boolean"
          }
        ]
      },
      "request": {
        "method": "POST",
        "url": "Questionnaire"
      }
    },
    {
      "fullUrl": "urn:uuid:CF1-QuestionnaireResponse",
      "resource": {
        "resourceType": "QuestionnaireResponse",
        "meta": {
          "profile": [
            "https://nhdr.gov.ph/fhir/StructureDefinition/PH-QuestionnaireResponse"
          ]
        },
        "status": "completed",
        "item": [
          {
            "linkId": "CF1-Q1",
            "answer": [
              {
                "valueBoolean": true
              }
            ]
          }
        ]
      },
      "request": {
        "method": "POST",
        "url": "QuestionnaireResponse"
      }
    },
    {
      "fullUrl": "urn:uuid:CF1-Coverage",
      "resource": {
        "resourceType": "Coverage",
        "meta": {
          "profile": [
            "https://nhdr.gov.ph/fhir/StructureDefinition/PH-Coverage"
          ]
        },
        "status": "active",
        "policyHolder": {
          "reference": "urn:uuid:CF1-Organization"
        },
        "beneficiary": {
          "reference": "urn:uuid:CF1-Patient-2"
        },
        "payor": [
          {
            "reference": "urn:uuid:CF1-Organization"
          }
        ]
      },
      "request": {
        "method": "POST",
        "url": "Coverage"
      }
    },
    {
      "fullUrl": "urn:uuid:CF1-Claim",
      "resource": {
        "resourceType": "Claim",
        "meta": {
          "profile": [
            "https://nhdr.gov.ph/fhir/StructureDefinition/PH-Claim"
          ]
        },
        "identifier": [
          {
            "system": "https://philhealth.gov.ph/claim",
            "value": "CF1-CLM-00001"
          }
        ],
        "status": "active",
        "type": {
          "coding": [
            {
              "system": "http://terminology.hl7.org/CodeSystem/claim-type",
              "code": "institutional",
              "display": "Institutional"
            }
          ]
        },
        "use": "claim",
        "created": "2026-02-03T08:00:00+08:00",
        "provider": {
          "reference": "urn:uuid:CF1-Organization"
        },
        "priority": {
          "coding": [
            {
              "system": "http://terminology.hl7.org/CodeSystem/processpriority",
              "code": "normal",
              "display": "Normal"
            }
          ]
        },
        "payee": {
          "type": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/payeetype",
                "code": "subscriber",
                "display": "Subscriber"
              }
            ]
          },
          "party": {
            "reference": "urn:uuid:CF1-RelatedPerson"
          }
        },
        "patient": {
          "reference": "urn:uuid:CF1-Patient-2"
        },
        "insurance": [
          {
            "sequence": 1,
            "focal": true,
            "coverage": {
              "reference": "urn:uuid:CF1-Coverage"
            }
          }
        ]
      },
      "request": {
        "method": "POST",
        "url": "Claim"
      }
    }
  ]
}

```

