| Package | hl7.fhir.us.cql |
| Resource Type | Questionnaire |
| Id | MBODAQuestionnaire |
| FHIR Version | R4 |
| Source | http://hl7.org/fhir/us/cql/https://build.fhir.org/ig/HL7/us-cql-ig/Questionnaire-MBODAQuestionnaire.html |
| URL | http://hl7.org/fhir/us/cql/Questionnaire/MBODAQuestionnaire |
| Version | 1.0.0-ballot |
| Status | active |
| Date | 2023-08-14T00:00:00+00:00 |
| Name | MBODAQuestionnaire |
| Title | Example Medical Benefit Outpatient Drug Authorization Questionnaire |
| Realm | us |
| Authority | hl7 |
| Description | This is an example of a prior authorization questionnaire developed based on an existing industry prior-authorization form. |
| Copyright | This content is is informed by the following source, used with permission: https://www.geisinger.org/-/media/OneGeisinger/Files/PDFs/Provider/NaviNet/Forms/medical-benefit-outpatient-drug-authorization-form-050819.pdf?sc_lang=en&hash=6EDE27E13FCCB5731E081FC49B85359D |
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Note: links and images are rebased to the (stated) source
Generated Narrative: Questionnaire MBODAQuestionnaire
Structure| LinkID | Text | Cardinality | Type | Description & Constraints |
|---|---|---|---|---|
  MBODAQuestionnaire | This is an example of a prior authorization questionnaire developed based on an existing industry prior-authorization form. | Questionnaire | http://hl7.org/fhir/us/cql/Questionnaire/MBODAQuestionnaire#1.0.0-ballot | |
  patient-info | Patient Information | 0..1 | group | |
  patient-info|drug-allergies | Drug allergies | 0..* | open-choice | |
 patient-info|height | Height | 0..1 | decimal | |
| patient-info|weight | Weight | 0..1 | decimal | |
 patient-info|bsa | BSA | 0..1 | decimal | |
| provider-info | Ordering Provider Information | 0..1 | group | |
 provider-info|name | Ordering provider name | 0..1 | string | |
| provider-info|npi | Ordering provider NPI # | 0..1 | string | |
| provider-info|address | Ordering provider address | 0..1 | string | |
| provider-info|city | City | 0..1 | string | |
| provider-info|state | State | 0..1 | string | |
| provider-info|zip-code | Zip | 0..1 | string | |
| person-submitting-request | Person submitting request | 0..1 | group | |
| person-submitting-request|name | Name | 0..1 | string | |
| person-submitting-request|phone-number | Phone | 0..1 | string | |
| person-submitting-request|fax | Fax | 0..1 | string | |
| office-contact | Office contact | 0..1 | group | |
 office-contact|name | Name | 0..1 | string | |
| office-contact|phone-number | Phone | 0..1 | string | |
| office-contact|fax | Fax | 0..1 | string | |
| servicing-provider-facility-info | Servicing Provider/Facility Information | 0..1 | group | |
| servicing-provider-facility-info|drug-admin | Who is administering the drug? | 0..1 | choice | Options: 3 options |
| select-one | Please select if the medication will be dispensed or administered | 0..1 | choice | Options: 2 options |
| if-buy-bill | If buy & bill, who will be billing for the drug? | 0..1 | choice | Enable When: select-one = Options: 3 options |
| provider-participating-ghp | Is the billing provider participating with GHP? | 0..1 | choice | Enable When: select-one = Options: 2 options |
| no-ghp | If No, is this a request for out-of-network services? | 0..1 | choice | Enable When: provider-participating-ghp = Options: 2 options |
| servicing-provider | Servicing provider | 0..1 | group | |
| servicing-provider|name | Provider name | 0..1 | string | |
| servicing-provider|npi | NPI # | 0..1 | string | |
| servicing-provider|address | Address | 0..1 | string | |
| servicing-provider|phone-number | Phone | 0..1 | string | |
| servicing-provider|fax | Fax | 0..1 | string | |
| servicing-provider|office-contact | Office contact | 0..1 | string | |
| facility-of-service | Facility/location of service | 0..1 | group | |
| facility-of-service|name | Facility/location name | 0..1 | string | |
| facility-of-service|npi | NPI # | 0..1 | string | |
| facility-of-service|address | Address | 0..1 | string | |
| facility-of-service|phone-number | Phone | 0..1 | string | |
| facility-of-service|fax | Fax | 0..1 | string | |
| facility-of-service|office-contact | Facility contact | 0..1 | string | |
| specialty-vendor | Specialty vendor (if applicable) | 0..1 | group | |
| specialty-vendor|name | Specialty pharmacy name | 0..1 | string | |
| specialty-vendor|npi | NPI # | 0..1 | string | |
| specialty-vendor|address | Address | 0..1 | string | |
| specialty-vendor|phone-number | Phone | 0..1 | string | |
| specialty-vendor|fax | Fax | 0..1 | string | |
| specialty-vendor|office-contact | Pharmacy contact | 0..1 | string | |
| diagnosis-info | Diagnosis Information | 0..1 | group | |
| diagnosis-info|diagnosis-code | Diagnosis/ICD-10 code(s) | 0..* | open-choice | |
| diagnosis-info|diagnosis-description | Diagnosis description | 0..* | string | |
| medication-info | Medication Information | 0..1 | group | |
| medication-info|name | Medication name | 0..1 | string | |
 medication-info|dose | Dose | 0..1 | quantity | |
| medication-info|route | Route | 0..* | open-choice | |
| medication-info|frequency | Frequency | 0..1 | quantity | |
| medication-info|therapy-leng | Expected length of therapy | 0..1 | quantity | |
 medication-info|num-visits | Quantity/number of requested visits | 0..1 | integer | |
 medication-info|service-date | Anticipated/actual date of service | 0..1 | date | |
| medication-info|new-med | New Medication or Continued Therapy | 0..1 | choice | Options: 2 options |
| medication-info|date-initiallized | Date therapy initially started | 0..1 | date | Enable When: medication-info|new-med = |
| medication-info|requested-drug-code | HCPCS/CPT code/J code/NDC code of requested drug | 0..1 | string | |
| medication-info|associated-procedure | Associated procedure codes requiring prior auth | 0..1 | string | |
| request-for-expedited-review | Request for Expedited Review | 0..1 | group | |
| request-for-expedited-review|para | When a request needs to be reviewed in an expedited manner because the standard review time frame may SERIOUSLY JEOPARDIZE THE LIFE OR HEALTH OF THE MEMBER OR THE MEMBER’S ABILITY TO REGAIN MAXIMUM FUNCTION, note this below by checking URGENT in the space provided, along with the reason the request is urgent. Requests will not be processed as urgent unless a rationale for urgency is provided. | 0..1 | group | |
| request-for-expedited-review|rationale | URGENT - rationale | 0..1 | string | |
| ordering-provider-signature | Ordering Provider Signature | 0..1 | group | |
 ordering-provider-signature|author-signature | Signature: | 0..1 | attachment | |
| Documentation for this format | ||||
Options Sets
Answer options for servicing-provider-facility-info|drug-admin
Answer options for select-one
Answer options for if-buy-bill
Answer options for provider-participating-ghp
Answer options for no-ghp
Answer options for medication-info|new-med
FHIR{
"resourceType": "Questionnaire",
"id": "MBODAQuestionnaire",
"text": {
"status": "extensions",
"div": "<!-- snip (see above) -->"
},
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/cqf-library",
"valueCanonical": "http://hl7.org/fhir/us/cql/Library/MBODAInitialExpressions"
},
{
"extension": [
{
"url": "name",
"valueCoding": {
"system": "http://hl7.org/fhir/uv/sdc/CodeSystem/launchContext",
"code": "patient",
"display": "Patient"
}
},
{
"url": "type",
"valueCode": "Patient"
},
{
"url": "description",
"valueString": "The patient that is to be used to pre-populate the form"
}
],
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-launchContext"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg",
"valueCode": "cds"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status",
"valueCode": "informative",
"_valueCode": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom",
"valueCanonical": "http://hl7.org/fhir/us/cql/ImplementationGuide/hl7.fhir.us.cql"
}
]
}
}
],
"url": "http://hl7.org/fhir/us/cql/Questionnaire/MBODAQuestionnaire",
"version": "1.0.0-ballot",
"name": "MBODAQuestionnaire",
"title": "Example Medical Benefit Outpatient Drug Authorization Questionnaire",
"status": "active",
"experimental": true,
"date": "2023-08-14T00:00:00+00:00",
"publisher": "HL7 International / Clinical Decision Support",
"contact": [
{
"telecom": [
{
"system": "url",
"value": "http://www.hl7.org/Special/committees/dss"
}
]
}
],
"description": "This is an example of a prior authorization questionnaire developed based on an existing industry prior-authorization form.",
"jurisdiction": [
{
"coding": [
{
"system": "urn:iso:std:iso:3166",
"code": "US",
"display": "United States of America"
}
]
}
],
"copyright": "This content is is informed by the following source, used with permission: https://www.geisinger.org/-/media/OneGeisinger/Files/PDFs/Provider/NaviNet/Forms/medical-benefit-outpatient-drug-authorization-form-050819.pdf?sc_lang=en&hash=6EDE27E13FCCB5731E081FC49B85359D",
"item": [
{
"linkId": "patient-info",
"text": "Patient Information",
"type": "group",
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Allergies"
}
}
],
"linkId": "patient-info|drug-allergies",
"text": "Drug allergies",
"type": "open-choice",
"repeats": true
},
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Height in [in_i]"
}
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-unit",
"valueCoding": {
"system": "http://unitsofmeasure.org",
"code": "[in_i]",
"display": "[in_i]"
}
}
],
"linkId": "patient-info|height",
"text": "Height",
"type": "decimal"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Weight in [lb_av]"
}
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-unit",
"valueCoding": {
"system": "http://unitsofmeasure.org",
"code": "[lb_av]",
"display": "[lb_av]"
}
}
],
"linkId": "patient-info|weight",
"text": "Weight",
"type": "decimal"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "BSA in m2"
}
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-unit",
"valueCoding": {
"system": "http://unitsofmeasure.org",
"code": "m2",
"display": "m2"
}
}
],
"linkId": "patient-info|bsa",
"text": "BSA",
"type": "decimal"
}
]
},
{
"linkId": "provider-info",
"text": "Ordering Provider Information",
"type": "group",
"item": [
{
"linkId": "provider-info|name",
"text": "Ordering provider name",
"type": "string"
},
{
"linkId": "provider-info|npi",
"text": "Ordering provider NPI #",
"type": "string"
},
{
"linkId": "provider-info|address",
"text": "Ordering provider address",
"type": "string"
},
{
"linkId": "provider-info|city",
"text": "City",
"type": "string"
},
{
"linkId": "provider-info|state",
"text": "State",
"type": "string"
},
{
"linkId": "provider-info|zip-code",
"text": "Zip",
"type": "string"
},
{
"linkId": "person-submitting-request",
"text": "Person submitting request",
"type": "group",
"item": [
{
"linkId": "person-submitting-request|name",
"text": "Name",
"type": "string"
},
{
"linkId": "person-submitting-request|phone-number",
"text": "Phone",
"type": "string"
},
{
"linkId": "person-submitting-request|fax",
"text": "Fax",
"type": "string"
}
]
},
{
"linkId": "office-contact",
"text": "Office contact",
"type": "group",
"item": [
{
"linkId": "office-contact|name",
"text": "Name",
"type": "string"
},
{
"linkId": "office-contact|phone-number",
"text": "Phone",
"type": "string"
},
{
"linkId": "office-contact|fax",
"text": "Fax",
"type": "string"
}
]
}
]
},
{
"linkId": "servicing-provider-facility-info",
"text": "Servicing Provider/Facility Information",
"type": "group",
"item": [
{
"linkId": "servicing-provider-facility-info|drug-admin",
"text": "Who is administering the drug?",
"type": "choice",
"answerOption": [
{
"valueCoding": {
"code": "OrderingProvider",
"display": "Ordering Provider"
}
},
{
"valueCoding": {
"code": "ServicingProvider",
"display": "Servicing Provider"
}
},
{
"valueCoding": {
"code": "HomeHealthAgency",
"display": "Home Health Agency - if yes, name of agency"
}
}
]
},
{
"linkId": "select-one",
"text": "Please select if the medication will be dispensed or administered",
"type": "choice",
"answerOption": [
{
"valueCoding": {
"code": "AdministeredFromProviderStock",
"display": "Medication will be administered from provider stock and billed by provider (buy & bill)"
}
},
{
"valueCoding": {
"code": "DispensedByPharmacy",
"display": "Medication will be dispensed by a specialty pharmacy and billed by the pharmacy"
}
}
],
"item": [
{
"linkId": "if-buy-bill",
"text": "If buy & bill, who will be billing for the drug?",
"type": "choice",
"enableWhen": [
{
"question": "select-one",
"operator": "=",
"answerCoding": {
"code": "AdministeredFromProviderStock"
}
}
],
"answerOption": [
{
"valueCoding": {
"code": "OrderingProvider",
"display": "Ordering Provider"
}
},
{
"valueCoding": {
"code": "ServicingProvider",
"display": "Servicing Provider"
}
},
{
"valueCoding": {
"code": "Facility",
"display": "Facility"
}
}
]
},
{
"linkId": "provider-participating-ghp",
"text": "Is the billing provider participating with GHP?",
"type": "choice",
"enableWhen": [
{
"question": "select-one",
"operator": "=",
"answerCoding": {
"code": "AdministeredFromProviderStock"
}
}
],
"answerOption": [
{
"valueCoding": {
"code": "Y",
"display": "Yes"
}
},
{
"valueCoding": {
"code": "N",
"display": "No"
}
}
],
"item": [
{
"linkId": "no-ghp",
"text": "If No, is this a request for out-of-network services?",
"type": "choice",
"enableWhen": [
{
"question": "provider-participating-ghp",
"operator": "=",
"answerCoding": {
"code": "N"
}
}
],
"answerOption": [
{
"valueCoding": {
"code": "Y",
"display": "Yes"
}
},
{
"valueCoding": {
"code": "N",
"display": "No"
}
}
]
}
]
}
]
}
]
},
{
"linkId": "servicing-provider",
"text": "Servicing provider",
"type": "group",
"item": [
{
"linkId": "servicing-provider|name",
"text": "Provider name",
"type": "string"
},
{
"linkId": "servicing-provider|npi",
"text": "NPI #",
"type": "string"
},
{
"linkId": "servicing-provider|address",
"text": "Address",
"type": "string"
},
{
"linkId": "servicing-provider|phone-number",
"text": "Phone",
"type": "string"
},
{
"linkId": "servicing-provider|fax",
"text": "Fax",
"type": "string"
},
{
"linkId": "servicing-provider|office-contact",
"text": "Office contact",
"type": "string"
}
]
},
{
"linkId": "facility-of-service",
"text": "Facility/location of service",
"type": "group",
"item": [
{
"linkId": "facility-of-service|name",
"text": "Facility/location name",
"type": "string"
},
{
"linkId": "facility-of-service|npi",
"text": "NPI #",
"type": "string"
},
{
"linkId": "facility-of-service|address",
"text": "Address",
"type": "string"
},
{
"linkId": "facility-of-service|phone-number",
"text": "Phone",
"type": "string"
},
{
"linkId": "facility-of-service|fax",
"text": "Fax",
"type": "string"
},
{
"linkId": "facility-of-service|office-contact",
"text": "Facility contact",
"type": "string"
}
]
},
{
"linkId": "specialty-vendor",
"text": "Specialty vendor (if applicable)",
"type": "group",
"item": [
{
"linkId": "specialty-vendor|name",
"text": "Specialty pharmacy name",
"type": "string"
},
{
"linkId": "specialty-vendor|npi",
"text": "NPI #",
"type": "string"
},
{
"linkId": "specialty-vendor|address",
"text": "Address",
"type": "string"
},
{
"linkId": "specialty-vendor|phone-number",
"text": "Phone",
"type": "string"
},
{
"linkId": "specialty-vendor|fax",
"text": "Fax",
"type": "string"
},
{
"linkId": "specialty-vendor|office-contact",
"text": "Pharmacy contact",
"type": "string"
}
]
},
{
"linkId": "diagnosis-info",
"text": "Diagnosis Information",
"type": "group",
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Diagnosis Codes"
}
}
],
"linkId": "diagnosis-info|diagnosis-code",
"text": "Diagnosis/ICD-10 code(s)",
"type": "open-choice",
"repeats": true
},
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Diagnosis Descriptions"
}
}
],
"linkId": "diagnosis-info|diagnosis-description",
"text": "Diagnosis description",
"type": "string",
"repeats": true
}
]
},
{
"linkId": "medication-info",
"text": "Medication Information",
"type": "group",
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Medication Name"
}
}
],
"linkId": "medication-info|name",
"text": "Medication name",
"type": "string"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-unitOption",
"valueCoding": {
"system": "http://unitsofmeasure.org",
"code": "ug",
"display": "ug"
}
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-unitOption",
"valueCoding": {
"system": "http://unitsofmeasure.org",
"code": "mg",
"display": "mg"
}
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-unitOption",
"valueCoding": {
"system": "http://unitsofmeasure.org",
"code": "g",
"display": "g"
}
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-unitOption",
"valueCoding": {
"system": "http://unitsofmeasure.org",
"code": "ml",
"display": "ml"
}
},
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Medication Dose"
}
}
],
"linkId": "medication-info|dose",
"text": "Dose",
"type": "quantity"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Medication Route"
}
}
],
"linkId": "medication-info|route",
"text": "Route",
"type": "open-choice",
"repeats": true
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-unitOption",
"valueCoding": {
"system": "http://unitsofmeasure.org",
"code": "h",
"display": "h"
}
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-unitOption",
"valueCoding": {
"system": "http://unitsofmeasure.org",
"code": "d",
"display": "d"
}
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-unitOption",
"valueCoding": {
"system": "http://unitsofmeasure.org",
"code": "wk",
"display": "wk"
}
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-unitOption",
"valueCoding": {
"system": "http://unitsofmeasure.org",
"code": "mo",
"display": "mo"
}
},
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Medication Frequency"
}
}
],
"linkId": "medication-info|frequency",
"text": "Frequency",
"type": "quantity"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-unitOption",
"valueCoding": {
"system": "http://unitsofmeasure.org",
"code": "h",
"display": "h"
}
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-unitOption",
"valueCoding": {
"system": "http://unitsofmeasure.org",
"code": "d",
"display": "d"
}
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-unitOption",
"valueCoding": {
"system": "http://unitsofmeasure.org",
"code": "wk",
"display": "wk"
}
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-unitOption",
"valueCoding": {
"system": "http://unitsofmeasure.org",
"code": "mo",
"display": "mo"
}
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-unitOption",
"valueCoding": {
"system": "http://unitsofmeasure.org",
"code": "a",
"display": "a"
}
},
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Expected Therapy Length"
}
}
],
"linkId": "medication-info|therapy-leng",
"text": "Expected length of therapy",
"type": "quantity"
},
{
"linkId": "medication-info|num-visits",
"text": "Quantity/number of requested visits",
"type": "integer"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Anticipated/actual date of service"
}
}
],
"linkId": "medication-info|service-date",
"text": "Anticipated/actual date of service",
"type": "date"
},
{
"linkId": "medication-info|new-med",
"text": "New Medication or Continued Therapy",
"type": "choice",
"answerOption": [
{
"valueCoding": {
"code": "NewMedication",
"display": "New Medication"
}
},
{
"valueCoding": {
"code": "ContinuedTherapy",
"display": "Continuation of therapy"
}
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Initial date of therapy"
}
}
],
"linkId": "medication-info|date-initiallized",
"text": "Date therapy initially started",
"type": "date",
"enableWhen": [
{
"question": "medication-info|new-med",
"operator": "=",
"answerCoding": {
"code": "ContinuedTherapy"
}
}
]
},
{
"linkId": "medication-info|requested-drug-code",
"text": "HCPCS/CPT code/J code/NDC code of requested drug",
"type": "string"
},
{
"linkId": "medication-info|associated-procedure",
"text": "Associated procedure codes requiring prior auth",
"type": "string"
}
]
},
{
"linkId": "request-for-expedited-review",
"text": "Request for Expedited Review",
"type": "group",
"item": [
{
"linkId": "request-for-expedited-review|para",
"text": "When a request needs to be reviewed in an expedited manner because the standard review time frame may SERIOUSLY JEOPARDIZE THE LIFE OR HEALTH OF THE MEMBER OR THE MEMBER’S ABILITY TO REGAIN MAXIMUM FUNCTION, note this below by checking URGENT in the space provided, along with the reason the request is urgent. Requests will not be processed as urgent unless a rationale for urgency is provided.",
"type": "group",
"item": [
{
"linkId": "request-for-expedited-review|rationale",
"text": "URGENT - rationale",
"type": "string"
}
]
}
]
},
{
"linkId": "ordering-provider-signature",
"text": "Ordering Provider Signature",
"type": "group",
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-signatureRequired",
"valueCodeableConcept": {
"coding": [
{
"system": "urn:iso-astm:E1762-95:2013",
"code": "1.2.840.10065.1.12.1.1",
"display": "Author's Signature"
}
]
}
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-usageMode",
"valueCode": "capture"
}
],
"linkId": "ordering-provider-signature|author-signature",
"text": "Signature:",
"type": "attachment"
}
]
}
]
}