# Mapping of Konsulta Request for Authorization Transaction Code Form to FHIR - NHDR Implementation Guide Release 1.0 v0.1.0

* [**Table of Contents**](toc.md)
* [**Konsulta Request for Authorization Transaction Code Form**](K2.md)
* **Mapping of Konsulta Request for Authorization Transaction Code Form to FHIR**

## Mapping of Konsulta Request for Authorization Transaction Code Form to FHIR

**View
Form**

<iframe src="K2.pdf" width="700" height="900"></iframe>

### Mapped Fields

| | | | | |
| :--- | :--- | :--- | :--- | :--- |
| **To be filled out by Beneficiary** |   |   |   |   |
| Date of Appointment | Appointment.created | dateTime | 0..1 |   |
| Membership Type | Appointment.participant.actor | Reference([PH_Patient](StructureDefinition-PH-Patient.md)) | 0..1 |   |
| ► | Patient.type | codeableConcept |   | ValueSet:[PatientType](ValueSet-PatientTypeVS.md) |
| PhilHealth Identification Number (PIN) | Appointment.participant.actor | Reference([PH_Patient](StructureDefinition-PH-Patient.md)) | 0..1 |   |
| ► | Patient.identifier | Identifier |   | PhilHealth ID |
| Date of Birth (MM-DD-YYYY) | Appointment.participant.actor | Reference([PH_Patient](StructureDefinition-PH-Patient.md)) | 0..1 |   |
| ► | Patient.birthDate | date |   |   |
| Name (Last Name) | Appointment.participant.actor | Reference([PH_Patient](StructureDefinition-PH-Patient.md)) | 0..1 |   |
| ► | Patient.name.family | string |   |   |
| Name (First Name) | Appointment.participant.actor | Reference([PH_Patient](StructureDefinition-PH-Patient.md)) | 0..1 |   |
| ► | Patient.name.given | string |   |   |
| Name (Middle Name) | Appointment.participant.actor | Reference([PH_Patient](StructureDefinition-PH-Patient.md)) | 0..1 |   |
| ► | Patient.name.given | string |   |   |
| Address (BRGY/Town) | Appointment.participant.actor | Reference([PH_Patient](StructureDefinition-PH-Patient.md)) | 0..1 |   |
| ► | Patient.address.barangay | coding |   | ValueSet:[BarangayCodes](ValueSet-BarangayVS.md) |
| Address (City/Municipality) | Appointment.participant.actor | Reference([PH_Patient](StructureDefinition-PH-Patient.md)) | 0..1 |   |
| ► | Patient.address.cityMunicipality | coding |   | ValueSet:[CityCodes](ValueSet-CityVS.md) |
| Address (Province) | Appointment.participant.actor | Reference([PH_Patient](StructureDefinition-PH-Patient.md)) | 0..1 |   |
| ► | Patient.address.province | coding |   | ValueSet:[ProvinceCodes](ValueSet-ProvinceVS.md) |
| **Signature**Over Printed Name | Provenance.signature.data | base64Binary | 0..1 |   |
| Signature Over**Printed Name** | Provenance.signature.who | Reference([PH_Patient](StructureDefinition-PH-Patient.md)) | 1..1 |   |
| ► | Patient.name | HumanName |   |   |
| **To be filled out by Philhealth Konsulta Personnel** |   |   |   |   |
| ATC | Appointment.identifier | identifier | 0..* | Then referenced in a later claim |
| **Signature**Over Printed Name of Authored PhilHealth Personnel | Provenance.signature.data | base64Binary | 0..1 |   |
| Signature Over**Printed Name**of Authored PhilHealth Personnel | Provenance.signature.who | Reference([PH_Organization](StructureDefinition-PH-Organization.md)) | 1..1 |   |
| ► | Organization.contact.name | HumanName |   |   |

### Mandatory Elements Not in the Form

| | | |
| :--- | :--- | :--- |
| Appointment.status | code |   |
| Appointment.participant.status | code |   |
| Provenance.target | Reference(Any) |   |
| Provenance.recorded | instant |   |
| Provenance.signature.type | coding |   |
| Provenance.agent.who | Reference([PH_Organization](StructureDefinition-PH-Organization.md)) |   |
| Organization.name | string |   |
| Provenance.signature.when | instant |   |

