# ClaimsForm2 - NHDR Implementation Guide Release 1.0 v0.1.0

* [**Table of Contents**](toc.md)
* [**Artifacts Summary**](artifacts.md)
* **ClaimsForm2**

## Example Bundle: ClaimsForm2



## Resource Content

```json
{
  "resourceType" : "Bundle",
  "id" : "ClaimsForm2",
  "identifier" : {
    "system" : "http://nhdr.gov.ph/fhir/ValueSet-form-type",
    "value" : "CF2"
  },
  "type" : "transaction",
  "entry" : [{
    "fullUrl" : "urn:uuid:patient",
    "resource" : {
      "resourceType" : "Patient",
      "id" : "CF2-Patient",
      "meta" : {
        "profile" : ["https://nhdr.gov.ph/fhir/StructureDefinition/PH-Patient"]
      },
      "text" : {
        "status" : "generated",
        "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Patient_CF2-Patient\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Patient CF2-Patient</b></p><a name=\"CF2-Patient\"> </a><a name=\"hcCF2-Patient\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\"/><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-PH-Patient.html\">PH Patient</a></p></div><p style=\"border: 1px #661aff solid; background-color: #e6e6ff; padding: 10px;\">John Harris Doe  (no stated gender), DoB Unknown</p><hr/></div>"
      },
      "name" : [{
        "family" : "Doe",
        "given" : ["John", "Harris"],
        "suffix" : ["Mr."]
      }]
    },
    "request" : {
      "method" : "POST",
      "url" : "Patient"
    }
  },
  {
    "fullUrl" : "urn:uuid:relatedperson",
    "resource" : {
      "resourceType" : "RelatedPerson",
      "id" : "CF2-RelatedPerson",
      "meta" : {
        "profile" : ["https://nhdr.gov.ph/fhir/StructureDefinition/PH-RelatedPerson",
        "https://nhdr.gov.ph/fhir/StructureDefinition/PH_RelatedPerson"]
      },
      "text" : {
        "status" : "generated",
        "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"RelatedPerson_CF2-RelatedPerson\"> </a><p class=\"res-header-id\"><b>Generated Narrative: RelatedPerson CF2-RelatedPerson</b></p><a name=\"CF2-RelatedPerson\"> </a><a name=\"hcCF2-RelatedPerson\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\"/><p style=\"margin-bottom: 0px\">Profiles: <a href=\"StructureDefinition-PH-RelatedPerson.html\">PH RelatedPerson</a>, <code>https://nhdr.gov.ph/fhir/StructureDefinition/PH_RelatedPerson</code></p></div><p><b>patient</b>: <a href=\"Bundle-ClaimsForm2.html#Patient_CF2-Patient\">Patient</a></p><p><b>relationship</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/v3-RoleCode MTH}\">mother</span></p><p><b>name</b>: Maria Dela Cruz </p></div>"
      },
      "patient" : {
        "reference" : "Patient/CF2-Patient",
        "display" : "Patient"
      },
      "relationship" : [{
        "coding" : [{
          "system" : "http://terminology.hl7.org/CodeSystem/v3-RoleCode",
          "code" : "MTH",
          "display" : "mother"
        }]
      }],
      "name" : [{
        "family" : "Dela Cruz",
        "given" : ["Maria"]
      }]
    },
    "request" : {
      "method" : "POST",
      "url" : "RelatedPerson"
    }
  },
  {
    "fullUrl" : "urn:uuid:organization",
    "resource" : {
      "resourceType" : "Organization",
      "id" : "CF2-Organization",
      "meta" : {
        "profile" : ["https://nhdr.gov.ph/fhir/StructureDefinition/PH-Organization"]
      },
      "text" : {
        "status" : "generated",
        "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Organization_CF2-Organization\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Organization CF2-Organization</b></p><a name=\"CF2-Organization\"> </a><a name=\"hcCF2-Organization\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\"/><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-PH-Organization.html\">PH Organization</a></p></div><p><b>identifier</b>: PhilHealth Accreditation Number (PAN)/AN199513893</p><p><b>name</b>: 6th General Hospital</p><p><b>address</b>: </p><ul><li>San Roque </li><li>Tarlac City </li><li>Tarlac </li></ul><h3>Contacts</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Name</b></td></tr><tr><td style=\"display: none\">*</td><td>Dr. Maria Santos</td></tr></table></div>"
      },
      "identifier" : [{
        "type" : {
          "coding" : [{
            "code" : "AN"
          }],
          "text" : "PhilHealth Accreditation Number (PAN)"
        },
        "value" : "AN199513893"
      }],
      "name" : "6th General Hospital",
      "address" : [{
        "line" : ["San Roque"]
      },
      {
        "line" : ["Tarlac City"]
      },
      {
        "extension" : [{
          "url" : "https://nhdr.gov.ph/fhir/StructureDefinition/Barangay",
          "valueCoding" : {
            "code" : "036916001",
            "display" : "San Roque"
          }
        },
        {
          "url" : "https://nhdr.gov.ph/fhir/StructureDefinition/CityMunicipality",
          "valueCoding" : {
            "code" : "036916000",
            "display" : "Tarlac City"
          }
        },
        {
          "url" : "https://nhdr.gov.ph/fhir/StructureDefinition/Province",
          "valueCoding" : {
            "code" : "036900000",
            "display" : "Tarlac"
          }
        }],
        "line" : ["Tarlac"]
      }],
      "contact" : [{
        "name" : {
          "text" : "Dr. Maria Santos"
        }
      }]
    },
    "request" : {
      "method" : "POST",
      "url" : "Organization"
    }
  },
  {
    "fullUrl" : "urn:uuid:encounter",
    "resource" : {
      "resourceType" : "Encounter",
      "id" : "CF2-Encounter",
      "meta" : {
        "profile" : ["https://nhdr.gov.ph/fhir/StructureDefinition/PH-Encounter"]
      },
      "text" : {
        "status" : "generated",
        "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Encounter_CF2-Encounter\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Encounter CF2-Encounter</b></p><a name=\"CF2-Encounter\"> </a><a name=\"hcCF2-Encounter\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\"/><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-PH-Encounter.html\">PH Encounter</a></p></div><p><b>status</b>: booked</p><p><b>class</b>: <a href=\"http://terminology.hl7.org/7.1.0/CodeSystem-v3-ActCode.html#v3-ActCode-AMB\">ActCode: AMB</a> (ambulatory)</p><p><b>period</b>: 2024-07-18 08:00:00+0800 --&gt; 2024-07-18 10:00:00+0800</p><h3>Hospitalizations</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>DischargeDisposition</b></td></tr><tr><td style=\"display: none\">*</td><td><span title=\"Codes:{http://terminology.hl7.org/CodeSystem/discharge-disposition home}\">Discharged to home</span></td></tr></table><p><b>serviceProvider</b>: <a href=\"Bundle-ClaimsForm2.html#Organization_CF2-Organization\">Organization</a></p></div>"
      },
      "status" : "booked",
      "class" : {
        "system" : "http://terminology.hl7.org/CodeSystem/v3-ActCode",
        "code" : "AMB"
      },
      "period" : {
        "start" : "2024-07-18T08:00:00+08:00",
        "end" : "2024-07-18T10:00:00+08:00"
      },
      "hospitalization" : {
        "dischargeDisposition" : {
          "coding" : [{
            "system" : "http://terminology.hl7.org/CodeSystem/discharge-disposition",
            "code" : "home",
            "display" : "Discharged to home"
          }]
        }
      },
      "serviceProvider" : {
        "reference" : "Organization/CF2-Organization",
        "display" : "Organization"
      }
    },
    "request" : {
      "method" : "POST",
      "url" : "Encounter"
    }
  },
  {
    "fullUrl" : "urn:uuid:procedure",
    "resource" : {
      "resourceType" : "Procedure",
      "id" : "CF2-Procedure",
      "meta" : {
        "profile" : ["https://nhdr.gov.ph/fhir/StructureDefinition/PH-Procedure"]
      },
      "text" : {
        "status" : "generated",
        "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Procedure_CF2-Procedure\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Procedure CF2-Procedure</b></p><a name=\"CF2-Procedure\"> </a><a name=\"hcCF2-Procedure\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\"/><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-PH-Procedure.html\">PH Procedure</a></p></div><p><b>status</b>: Completed</p><p><b>code</b>: <span title=\"Codes:{https://nhdr.gov.ph/fhir/ValueSet/ProcedureCodeVS 10060}\">INCISION AND DRAINAGE OF ABSCESS (E.G., CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA)</span></p><p><b>subject</b>: <a href=\"Bundle-ClaimsForm2.html#Patient_CF2-Patient\">Patient</a></p><p><b>bodySite</b>: <span title=\"Codes:{http://snomed.info/sct 66754008}\">Appendix structure</span></p></div>"
      },
      "status" : "completed",
      "code" : {
        "coding" : [{
          "system" : "https://nhdr.gov.ph/fhir/ValueSet/ProcedureCodeVS",
          "code" : "10060",
          "display" : "INCISION AND DRAINAGE OF ABSCESS (E.G., CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA)"
        }]
      },
      "subject" : {
        "reference" : "Patient/CF2-Patient",
        "display" : "Patient"
      },
      "bodySite" : [{
        "coding" : [{
          "system" : "http://snomed.info/sct",
          "code" : "66754008",
          "display" : "Appendix structure"
        }]
      }]
    },
    "request" : {
      "method" : "POST",
      "url" : "Procedure"
    }
  },
  {
    "fullUrl" : "urn:uuid:servicerequest",
    "resource" : {
      "resourceType" : "ServiceRequest",
      "id" : "CF2-ServiceRequest",
      "meta" : {
        "profile" : ["https://nhdr.gov.ph/fhir/StructureDefinition/PH-ServiceRequest"]
      },
      "text" : {
        "status" : "generated",
        "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"ServiceRequest_CF2-ServiceRequest\"> </a><p class=\"res-header-id\"><b>Generated Narrative: ServiceRequest CF2-ServiceRequest</b></p><a name=\"CF2-ServiceRequest\"> </a><a name=\"hcCF2-ServiceRequest\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\"/><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-PH-ServiceRequest.html\">PH ServiceRequest</a></p></div><p><b>status</b>: Completed</p><p><b>intent</b>: Order</p><p><b>subject</b>: <a href=\"Bundle-ClaimsForm2.html#Patient_CF2-Patient\">Patient</a></p><p><b>requester</b>: <a href=\"Bundle-ClaimsForm3.html#Organization_CF3-Organization\">Organization</a></p><p><b>performer</b>: <a href=\"Bundle-ClaimsForm2.html#Organization_CF2-Organization\">Organization</a></p><p><b>reasonReference</b>: <a href=\"Bundle-ClaimsForm2.html#Observation_CF2-Observation\">Observation</a></p></div>"
      },
      "status" : "completed",
      "intent" : "order",
      "subject" : {
        "reference" : "Patient/CF2-Patient",
        "display" : "Patient"
      },
      "requester" : {
        "reference" : "Organization/CF3-Organization",
        "display" : "Organization"
      },
      "performer" : [{
        "reference" : "Organization/CF2-Organization",
        "display" : "Organization"
      }],
      "reasonReference" : [{
        "reference" : "Observation/CF2-Observation",
        "display" : "Observation"
      }]
    },
    "request" : {
      "method" : "POST",
      "url" : "ServiceRequest"
    }
  },
  {
    "fullUrl" : "urn:uuid:observation",
    "resource" : {
      "resourceType" : "Observation",
      "id" : "CF2-Observation",
      "meta" : {
        "profile" : ["https://nhdr.gov.ph/fhir/StructureDefinition/PH-Observation"]
      },
      "text" : {
        "status" : "generated",
        "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Observation_CF2-Observation\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Observation CF2-Observation</b></p><a name=\"CF2-Observation\"> </a><a name=\"hcCF2-Observation\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\"/><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-PH-Observation.html\">PH Observation</a></p></div><p><b>status</b>: Final</p><p><b>code</b>: <span title=\"Codes:{http://loinc.org 81247-9}\">Preoperative assessment</span></p><p><b>subject</b>: <a href=\"Bundle-ClaimsForm2.html#Patient_CF2-Patient\">Patient</a></p><p><b>value</b>: <span title=\"Codes:\">Subject for Surgery</span></p></div>"
      },
      "status" : "final",
      "code" : {
        "coding" : [{
          "system" : "http://loinc.org",
          "code" : "81247-9",
          "display" : "Preoperative assessment"
        }]
      },
      "subject" : {
        "reference" : "Patient/CF2-Patient",
        "display" : "Patient"
      },
      "valueCodeableConcept" : {
        "text" : "Subject for Surgery"
      }
    },
    "request" : {
      "method" : "POST",
      "url" : "Observation"
    }
  },
  {
    "fullUrl" : "urn:uuid:practitioner",
    "resource" : {
      "resourceType" : "Practitioner",
      "id" : "CF2-Practitioner",
      "meta" : {
        "profile" : ["https://nhdr.gov.ph/fhir/StructureDefinition/PH-Practitioner"]
      },
      "text" : {
        "status" : "generated",
        "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Practitioner_CF2-Practitioner\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Practitioner CF2-Practitioner</b></p><a name=\"CF2-Practitioner\"> </a><a name=\"hcCF2-Practitioner\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\"/><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-PH-Practitioner.html\">PH Practitioner</a></p></div><p><b>identifier</b>: <code>https://prc.gov.ph</code>/1234567</p><p><b>name</b>: Maria Santos </p></div>"
      },
      "identifier" : [{
        "system" : "https://prc.gov.ph",
        "value" : "1234567"
      }],
      "name" : [{
        "family" : "Santos",
        "given" : ["Maria"],
        "suffix" : ["MD"]
      }]
    },
    "request" : {
      "method" : "POST",
      "url" : "Practitioner"
    }
  },
  {
    "fullUrl" : "urn:uuid:coverage",
    "resource" : {
      "resourceType" : "Coverage",
      "id" : "CF2-Coverage",
      "meta" : {
        "profile" : ["https://nhdr.gov.ph/fhir/StructureDefinition/PH-Coverage"]
      },
      "text" : {
        "status" : "generated",
        "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Coverage_CF2-Coverage\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Coverage CF2-Coverage</b></p><a name=\"CF2-Coverage\"> </a><a name=\"hcCF2-Coverage\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\"/><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-PH-Coverage.html\">PH Coverage</a></p></div><p><b>status</b>: Active</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/v3-ActCode EHCPOL}\">extended healthcare</span></p><p><b>beneficiary</b>: <a href=\"Bundle-ClaimsForm2.html#Patient_CF2-Patient\">Patient</a></p><p><b>payor</b>: <a href=\"Bundle-ClaimsForm2.html#Organization_CF2-Organization\">Organization</a></p><h3>CostToBeneficiaries</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Type</b></td><td><b>Value[x]</b></td></tr><tr><td style=\"display: none\">*</td><td><span title=\"Codes:{http://terminology.hl7.org/CodeSystem/coverage-copay-type copay}\">Copayment</span></td><td><span title=\"Philippine Peso\">₱500.00</span> (PHP)</td></tr></table></div>"
      },
      "status" : "active",
      "type" : {
        "coding" : [{
          "system" : "http://terminology.hl7.org/CodeSystem/v3-ActCode",
          "code" : "EHCPOL",
          "display" : "extended healthcare"
        }]
      },
      "beneficiary" : {
        "reference" : "Patient/CF2-Patient",
        "display" : "Patient"
      },
      "payor" : [{
        "reference" : "Organization/CF2-Organization",
        "display" : "Organization"
      }],
      "costToBeneficiary" : [{
        "type" : {
          "coding" : [{
            "system" : "http://terminology.hl7.org/CodeSystem/coverage-copay-type",
            "code" : "copay",
            "display" : "Copayment"
          }]
        },
        "valueMoney" : {
          "value" : 500,
          "currency" : "PHP"
        }
      }]
    },
    "request" : {
      "method" : "POST",
      "url" : "Coverage"
    }
  },
  {
    "fullUrl" : "urn:uuid:questionnaire",
    "resource" : {
      "resourceType" : "Questionnaire",
      "id" : "CF2-Questionnaire",
      "meta" : {
        "profile" : ["https://nhdr.gov.ph/fhir/StructureDefinition/PH-Questionnaire"]
      },
      "text" : {
        "status" : "generated",
        "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Questionnaire_CF2-Questionnaire\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Questionnaire CF2-Questionnaire</b></p><a name=\"CF2-Questionnaire\"> </a><a name=\"hcCF2-Questionnaire\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\"/><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-PH-Questionnaire.html\">PH Questionnaire</a></p></div><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 &amp; 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, \" 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\"/> </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\"></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\">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\"></td></tr>\r\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_bck00.png)\" id=\"item.CF2-Q1\" 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-boolean.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"boolean\" class=\"hierarchy\"/> CF2-Q1</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. Certification of Consumption of Benefits (Y/N)</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>\r\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, \" alt=\"doco\" style=\"background-color: inherit\"/> Documentation for this format</a></td></tr></table></div>"
      },
      "status" : "active",
      "item" : [{
        "linkId" : "CF2-Q1",
        "text" : "A. Certification of Consumption of Benefits (Y/N)",
        "type" : "boolean"
      }]
    },
    "request" : {
      "method" : "POST",
      "url" : "Questionnaire"
    }
  },
  {
    "fullUrl" : "urn:uuid:questionnaireResponse",
    "resource" : {
      "resourceType" : "QuestionnaireResponse",
      "id" : "CF2-QuestionnaireResponse",
      "meta" : {
        "profile" : ["https://nhdr.gov.ph/fhir/StructureDefinition/PH-QuestionnaireResponse"]
      },
      "text" : {
        "status" : "generated",
        "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"QuestionnaireResponse_CF2-QuestionnaireResponse\"> </a><p class=\"res-header-id\"><b>Generated Narrative: QuestionnaireResponse CF2-QuestionnaireResponse</b></p><a name=\"CF2-QuestionnaireResponse\"> </a><a name=\"hcCF2-QuestionnaireResponse\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\"/><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-PH-QuestionnaireResponse.html\">PH QuestionnaireResponse</a></p></div><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\">Definition</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\">Answer</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, \" 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=\"QuestionnaireResponseRoot\" class=\"hierarchy\"/> CF2-QuestionnaireResponse</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><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><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:None specified</td></tr>\r\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_bck00.png)\" 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-string.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"Item\" class=\"hierarchy\"/> CF2-Q1</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\"></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\"/><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\">true</td></tr>\r\n<tr><td colspan=\"4\" class=\"hierarchy\"><br/><a href=\"https://hl7.org/fhir/R4/formats.html#table\" title=\"Legend for this format\"><img src=\"data:image/png;base64, \" alt=\"doco\" style=\"background-color: inherit\"/> Documentation for this format</a></td></tr></table></div>"
      },
      "status" : "completed",
      "item" : [{
        "linkId" : "CF2-Q1",
        "answer" : [{
          "valueBoolean" : true
        }]
      }]
    },
    "request" : {
      "method" : "POST",
      "url" : "QuestionnaireResponse"
    }
  },
  {
    "fullUrl" : "urn:uuid:provenance",
    "resource" : {
      "resourceType" : "Provenance",
      "id" : "CF2-Provenance",
      "meta" : {
        "profile" : ["https://nhdr.gov.ph/fhir/StructureDefinition/PH-Provenance"]
      },
      "text" : {
        "status" : "generated",
        "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Provenance_CF2-Provenance\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Provenance CF2-Provenance</b></p><a name=\"CF2-Provenance\"> </a><a name=\"hcCF2-Provenance\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\"/><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-PH-Provenance.html\">PH Provenance</a></p></div><p>Provenance for <a href=\"Bundle-ClaimsForm2.html#Claim_CF2-Claim\">Claim</a></p><p>Summary</p><table class=\"grid\"><tr><td>Recorded</td><td>2026-02-03 09:00:00+0800</td></tr></table><p><b>Agents</b></p><table class=\"grid\"><tr><td><b>who</b></td></tr><tr><td><a href=\"Bundle-ClaimsForm2.html#Practitioner_CF2-Practitioner\">Practitioner</a></td></tr></table></div>"
      },
      "target" : [{
        "reference" : "Claim/CF2-Claim",
        "display" : "Claim"
      }],
      "recorded" : "2026-02-03T09:00:00+08:00",
      "agent" : [{
        "who" : {
          "reference" : "Practitioner/CF2-Practitioner",
          "display" : "Practitioner"
        }
      }],
      "signature" : [{
        "extension" : [{
          "url" : "https://nhdr.gov.ph/fhir/StructureDefinition/SignaturePosition",
          "valueString" : "Attending Physician"
        }],
        "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" : "Practitioner/CF2-Practitioner",
          "display" : "Practitioner"
        },
        "data" : "U1VCTUlUU0lPTl9QUkFDVElUSU9ORVJfU0lHTg=="
      },
      {
        "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" : "Patient/CF2-Patient",
          "display" : "Patient"
        },
        "data" : "U1VCTUlUU0lPTl9QQVRJRU5UX1NJR04="
      },
      {
        "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" : "RelatedPerson/CF2-RelatedPerson",
          "display" : "RelatedPerson"
        },
        "data" : "U1VCTUlUU0lPTl9SRUxBVEVEX1NJR04="
      }]
    },
    "request" : {
      "method" : "POST",
      "url" : "Provenance"
    }
  },
  {
    "fullUrl" : "urn:uuid:claim",
    "resource" : {
      "resourceType" : "Claim",
      "id" : "CF2-Claim",
      "meta" : {
        "profile" : ["https://nhdr.gov.ph/fhir/StructureDefinition/PH-Claim"]
      },
      "text" : {
        "status" : "extensions",
        "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Claim_CF2-Claim\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Claim CF2-Claim</b></p><a name=\"CF2-Claim\"> </a><a name=\"hcCF2-Claim\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\"/><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-PH-Claim.html\">PH Claim</a></p></div><p><b>Encounter (Extension)</b>: <a href=\"Bundle-ClaimsForm2.html#Encounter_CF2-Encounter\">Encounter</a></p><p><b>identifier</b>: <code>https://philhealth.gov.ph/claim</code>/CLM-2026-00001</p><p><b>status</b>: Active</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/claim-type institutional}\">Institutional</span></p><p><b>use</b>: Claim</p><p><b>patient</b>: <a href=\"Bundle-ClaimsForm2.html#Patient_CF2-Patient\">Patient</a></p><p><b>created</b>: 2026-02-03 08:00:00+0800</p><p><b>provider</b>: <a href=\"Bundle-ClaimsForm2.html#Organization_CF2-Organization\">Organization</a></p><p><b>priority</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/processpriority normal}\">Normal</span></p><p><b>referral</b>: <a href=\"Bundle-ClaimsForm2.html#ServiceRequest_CF2-ServiceRequest\">ServiceRequest</a></p><h3>SupportingInfos</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Sequence</b></td><td><b>Category</b></td><td><b>Value[x]</b></td></tr><tr><td style=\"display: none\">*</td><td>1</td><td><span title=\"Codes:{http://terminology.hl7.org/CodeSystem/claiminformationcategory information}\">Supporting Information</span></td><td><a href=\"Bundle-ClaimsForm2.html#Practitioner_CF2-Practitioner\">Practitioner</a></td></tr></table><h3>Diagnoses</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Sequence</b></td><td><b>Diagnosis[x]</b></td></tr><tr><td style=\"display: none\">*</td><td>1</td><td><span title=\"Codes:{http://hl7.org/fhir/sid/icd-10 I10}\">Essential (primary) hypertension</span></td></tr></table><h3>Procedures</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Sequence</b></td><td><b>Date</b></td><td><b>Procedure[x]</b></td></tr><tr><td style=\"display: none\">*</td><td>1</td><td>2026-02-03 09:00:00+0800</td><td><a href=\"Bundle-ClaimsForm2.html#Procedure_CF2-Procedure\">Procedure</a></td></tr></table><h3>Insurances</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Sequence</b></td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td style=\"display: none\">*</td><td>1</td><td>true</td><td><a href=\"Bundle-ClaimsForm2.html#Coverage_CF2-Coverage\">Coverage</a></td></tr></table><blockquote><p><b>item</b></p><p><b>sequence</b>: 1</p><p><b>productOrService</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/service-uscls 80146002}\">Appendectomy</span></p><p><b>serviced</b>: 2026-02-03</p><h3>Nets</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>15000</td><td>Philippine piso</td></tr></table><blockquote><p><b>detail</b></p><p><b>sequence</b>: 1</p><p><b>productOrService</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/service-uscls 80146002}\">Appendectomy Procedure Fee</span></p><h3>Nets</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>15000</td><td>Philippine piso</td></tr></table></blockquote></blockquote><h3>Totals</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>15000</td><td>Philippine piso</td></tr></table></div>"
      },
      "extension" : [{
        "url" : "https://nhdr.gov.ph/fhir/StructureDefinition/EncounterExtension",
        "valueReference" : {
          "reference" : "Encounter/CF2-Encounter",
          "display" : "Encounter"
        }
      }],
      "identifier" : [{
        "system" : "https://philhealth.gov.ph/claim",
        "value" : "CLM-2026-00001"
      }],
      "status" : "active",
      "type" : {
        "coding" : [{
          "system" : "http://terminology.hl7.org/CodeSystem/claim-type",
          "code" : "institutional",
          "display" : "Institutional"
        }]
      },
      "use" : "claim",
      "patient" : {
        "reference" : "Patient/CF2-Patient",
        "display" : "Patient"
      },
      "created" : "2026-02-03T08:00:00+08:00",
      "provider" : {
        "reference" : "Organization/CF2-Organization",
        "display" : "Organization"
      },
      "priority" : {
        "coding" : [{
          "system" : "http://terminology.hl7.org/CodeSystem/processpriority",
          "code" : "normal",
          "display" : "Normal"
        }]
      },
      "referral" : {
        "reference" : "ServiceRequest/CF2-ServiceRequest",
        "display" : "ServiceRequest"
      },
      "supportingInfo" : [{
        "sequence" : 1,
        "category" : {
          "coding" : [{
            "system" : "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
            "code" : "information",
            "display" : "Supporting Information"
          }]
        },
        "valueReference" : {
          "reference" : "Practitioner/CF2-Practitioner",
          "display" : "Practitioner"
        }
      }],
      "diagnosis" : [{
        "sequence" : 1,
        "diagnosisCodeableConcept" : {
          "coding" : [{
            "system" : "http://hl7.org/fhir/sid/icd-10",
            "code" : "I10",
            "display" : "Essential (primary) hypertension"
          }]
        }
      }],
      "procedure" : [{
        "sequence" : 1,
        "date" : "2026-02-03T09:00:00+08:00",
        "procedureReference" : {
          "reference" : "Procedure/CF2-Procedure",
          "display" : "Procedure"
        }
      }],
      "insurance" : [{
        "sequence" : 1,
        "focal" : true,
        "coverage" : {
          "reference" : "Coverage/CF2-Coverage",
          "display" : "Coverage"
        }
      }],
      "item" : [{
        "sequence" : 1,
        "productOrService" : {
          "coding" : [{
            "system" : "http://terminology.hl7.org/CodeSystem/service-uscls",
            "code" : "80146002",
            "display" : "Appendectomy"
          }]
        },
        "servicedDate" : "2026-02-03",
        "net" : {
          "value" : 15000,
          "currency" : "PHP"
        },
        "detail" : [{
          "sequence" : 1,
          "productOrService" : {
            "coding" : [{
              "system" : "http://terminology.hl7.org/CodeSystem/service-uscls",
              "code" : "80146002",
              "display" : "Appendectomy Procedure Fee"
            }]
          },
          "net" : {
            "value" : 15000,
            "currency" : "PHP"
          }
        }]
      }],
      "total" : {
        "value" : 15000,
        "currency" : "PHP"
      }
    },
    "request" : {
      "method" : "POST",
      "url" : "Claim"
    }
  }]
}

```
