# Example Uniform Pharmacy Prior Authorization Request Form - Common CQL Artifacts for FHIR (US-Based) v1.0.0

* [**Table of Contents**](toc.md)
* [**Artifacts Summary**](artifacts.md)
* **Example Uniform Pharmacy Prior Authorization Request Form**

## Questionnaire: Example Uniform Pharmacy Prior Authorization Request Form (Experimental) 

| | |
| :--- | :--- |
| *Official URL*:http://hl7.org/fhir/us/cql/Questionnaire/UPPARFQuestionnaire | *Version*:1.0.0 |
| *Standards status:*[Informative](http://hl7.org/fhir/R4/versions.html#std-process) | *Computable Name*:UPPARFQuestionnaire |
| **Copyright/Legal**: This content is informed by the following source, used with permission: https://docushare-web.apps.external.pioneer.humana.com/Marketing/docushare-app?file=4136509 | |

 
This is an example of a prior authorization questionnaire developed based on an existing industry prior-authorization form. 

**Structure**

* [LinkID](https://hl7.org/fhir/R4/formats.html#table): UPPARFQuestionnaire
  * [Text](https://hl7.org/fhir/R4/formats.html#table): This is an example of a prior authorization questionnaire developed based on an existing industry prior-authorization form.
  * [Cardinality](https://hl7.org/fhir/R4/formats.html#table): 
  * [Type](https://hl7.org/fhir/R4/formats.html#table): Questionnaire
  * [Description & Constraints](https://hl7.org/fhir/R4/formats.html#table)![](data:image/png;base64, ): http://hl7.org/fhir/us/cql/Questionnaire/UPPARFQuestionnaire#1.0.0
* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](icon-q-coding.png)urgency
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Urgency
  * [Cardinality](https://hl7.org/fhir/R4/formats.html#table): 0..1
  * [Type](https://hl7.org/fhir/R4/formats.html#table): [choice](https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-choice)
  * [Description & Constraints](https://hl7.org/fhir/R4/formats.html#table)![](data:image/png;base64, ): Options:[2 options](#opt-item.urgency)
* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](icon-q-group.png)drug-info
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Drug Information
  * [Cardinality](https://hl7.org/fhir/R4/formats.html#table): 0..1
  * [Type](https://hl7.org/fhir/R4/formats.html#table): [group](https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-group)
  * [Description & Constraints](https://hl7.org/fhir/R4/formats.html#table)![](data:image/png;base64, ): 
* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](icon-q-string.png)drug-info|drug-name
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Requested Drug Name
  * [Cardinality](https://hl7.org/fhir/R4/formats.html#table): 0..1
  * [Type](https://hl7.org/fhir/R4/formats.html#table): [string](https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string)
  * [Description & Constraints](https://hl7.org/fhir/R4/formats.html#table)![](data:image/png;base64, ): 
* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](icon-q-boolean.png)drug-info|drug-intention-opioid
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Is this drug intended to treat opioid dependence?
  * [Cardinality](https://hl7.org/fhir/R4/formats.html#table): 0..1
  * [Type](https://hl7.org/fhir/R4/formats.html#table): [boolean](https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-boolean)
  * [Description & Constraints](https://hl7.org/fhir/R4/formats.html#table)![](data:image/png;base64, ): 
* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](icon-q-boolean.png)drug-info|drug-intention-opioid|first-prior-authentication
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Is this a first request for prior authorization for this drug?
  * [Cardinality](https://hl7.org/fhir/R4/formats.html#table): 0..1
  * [Type](https://hl7.org/fhir/R4/formats.html#table): [boolean](https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-boolean)
  * [Description & Constraints](https://hl7.org/fhir/R4/formats.html#table)![](data:image/png;base64, ): Enable When:[drug-info|drug-intention-opioid](#item.drug-info|drug-intention-opioid)=
* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](icon-q-date.png)drug-info|drug-intention-opioid|date-first-request
  * [Text](https://hl7.org/fhir/R4/formats.html#table): What was the date of the first request?
  * [Cardinality](https://hl7.org/fhir/R4/formats.html#table): 0..1
  * [Type](https://hl7.org/fhir/R4/formats.html#table): [date](https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-date)
  * [Description & Constraints](https://hl7.org/fhir/R4/formats.html#table)![](data:image/png;base64, ): Enable When:[drug-info|drug-intention-opioid|first-prior-authentication](#item.drug-info|drug-intention-opioid|first-prior-authentication)=
* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](icon-q-boolean.png)drug-info|drug-intention-opioid|twelve-months-since-request
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Has the date of the first request been greater than twelve months ago?
  * [Cardinality](https://hl7.org/fhir/R4/formats.html#table): 0..1
  * [Type](https://hl7.org/fhir/R4/formats.html#table): [boolean](https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-boolean)
  * [Description & Constraints](https://hl7.org/fhir/R4/formats.html#table)![](data:image/png;base64, ): Enable When:[drug-info|drug-intention-opioid|first-prior-authentication](#item.drug-info|drug-intention-opioid|first-prior-authentication)=
* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](icon-q-group.png)completing-form
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Prior authentication is required and this form needs to be completed
  * [Cardinality](https://hl7.org/fhir/R4/formats.html#table): 0..1
  * [Type](https://hl7.org/fhir/R4/formats.html#table): [group](https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-group)
  * [Description & Constraints](https://hl7.org/fhir/R4/formats.html#table)![](data:image/png;base64, ): Enable When:* [drug-info|drug-intention-opioid](#item.drug-info|drug-intention-opioid) = 
* [drug-info|drug-intention-opioid|twelve-months-since-request](#item.drug-info|drug-intention-opioid|twelve-months-since-request) = 

* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](icon-q-group.png)completing-form|patient-info
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Patient Info
  * [Cardinality](https://hl7.org/fhir/R4/formats.html#table): 0..1
  * [Type](https://hl7.org/fhir/R4/formats.html#table): [group](https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-group)
  * [Description & Constraints](https://hl7.org/fhir/R4/formats.html#table)![](data:image/png;base64, ): 
* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](icon-q-string.png)completing-form|patient-info|prescription-date
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Prescription Date
  * [Cardinality](https://hl7.org/fhir/R4/formats.html#table): 0..1
  * [Type](https://hl7.org/fhir/R4/formats.html#table): [string](https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string)
  * [Description & Constraints](https://hl7.org/fhir/R4/formats.html#table)![](data:image/png;base64, ): 
* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](icon-q-group.png)completing-form|prescriber-info
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Prescriber Info
  * [Cardinality](https://hl7.org/fhir/R4/formats.html#table): 0..1
  * [Type](https://hl7.org/fhir/R4/formats.html#table): [group](https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-group)
  * [Description & Constraints](https://hl7.org/fhir/R4/formats.html#table)![](data:image/png;base64, ): 
* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](icon-q-string.png)completing-form|prescriber-info|prescriber-name
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Prescriber Name
  * [Cardinality](https://hl7.org/fhir/R4/formats.html#table): 0..1
  * [Type](https://hl7.org/fhir/R4/formats.html#table): [string](https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string)
  * [Description & Constraints](https://hl7.org/fhir/R4/formats.html#table)![](data:image/png;base64, ): 
* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](icon-q-string.png)completing-form|prescriber-info|prescriber-fax
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Prescriber Fax
  * [Cardinality](https://hl7.org/fhir/R4/formats.html#table): 0..1
  * [Type](https://hl7.org/fhir/R4/formats.html#table): [string](https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string)
  * [Description & Constraints](https://hl7.org/fhir/R4/formats.html#table)![](data:image/png;base64, ): 
* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](icon-q-string.png)completing-form|prescriber-info|prescriber-phone
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Prescriber Phone
  * [Cardinality](https://hl7.org/fhir/R4/formats.html#table): 0..1
  * [Type](https://hl7.org/fhir/R4/formats.html#table): [string](https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string)
  * [Description & Constraints](https://hl7.org/fhir/R4/formats.html#table)![](data:image/png;base64, ): 
* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](icon-q-string.png)completing-form|prescriber-info|prescriber-pager
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Prescriber Pager
  * [Cardinality](https://hl7.org/fhir/R4/formats.html#table): 0..1
  * [Type](https://hl7.org/fhir/R4/formats.html#table): [string](https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string)
  * [Description & Constraints](https://hl7.org/fhir/R4/formats.html#table)![](data:image/png;base64, ): 
* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](icon-q-string.png)completing-form|prescriber-info|prescriber-address
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Prescriber Address
  * [Cardinality](https://hl7.org/fhir/R4/formats.html#table): 0..1
  * [Type](https://hl7.org/fhir/R4/formats.html#table): [string](https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string)
  * [Description & Constraints](https://hl7.org/fhir/R4/formats.html#table)![](data:image/png;base64, ): 
* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](icon-q-string.png)completing-form|prescriber-info|prescriber-contact
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Prescriber Office Contact
  * [Cardinality](https://hl7.org/fhir/R4/formats.html#table): 0..1
  * [Type](https://hl7.org/fhir/R4/formats.html#table): [string](https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string)
  * [Description & Constraints](https://hl7.org/fhir/R4/formats.html#table)![](data:image/png;base64, ): 
* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](icon-q-string.png)completing-form|prescriber-info|prescriber-npi
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Prescriber NPI
  * [Cardinality](https://hl7.org/fhir/R4/formats.html#table): 0..1
  * [Type](https://hl7.org/fhir/R4/formats.html#table): [string](https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string)
  * [Description & Constraints](https://hl7.org/fhir/R4/formats.html#table)![](data:image/png;base64, ): 
* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](icon-q-string.png)completing-form|prescriber-info|prescriber-dea
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Prescriber DEA
  * [Cardinality](https://hl7.org/fhir/R4/formats.html#table): 0..1
  * [Type](https://hl7.org/fhir/R4/formats.html#table): [string](https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string)
  * [Description & Constraints](https://hl7.org/fhir/R4/formats.html#table)![](data:image/png;base64, ): 
* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](icon-q-string.png)completing-form|prescriber-info|prescriber-tax-id
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Prescriber Tax ID
  * [Cardinality](https://hl7.org/fhir/R4/formats.html#table): 0..1
  * [Type](https://hl7.org/fhir/R4/formats.html#table): [string](https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string)
  * [Description & Constraints](https://hl7.org/fhir/R4/formats.html#table)![](data:image/png;base64, ): 
* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](icon-q-string.png)completing-form|prescriber-info|prescriber-specialty
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Specialty/Facility Name If applicable
  * [Cardinality](https://hl7.org/fhir/R4/formats.html#table): 0..1
  * [Type](https://hl7.org/fhir/R4/formats.html#table): [string](https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string)
  * [Description & Constraints](https://hl7.org/fhir/R4/formats.html#table)![](data:image/png;base64, ): 
* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](icon-q-string.png)completing-form|prescriber-info|prescriber-email
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Email Address
  * [Cardinality](https://hl7.org/fhir/R4/formats.html#table): 0..1
  * [Type](https://hl7.org/fhir/R4/formats.html#table): [string](https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string)
  * [Description & Constraints](https://hl7.org/fhir/R4/formats.html#table)![](data:image/png;base64, ): 
* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](icon-q-group.png)completing-form|drug-benefit
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Prior Authorization Request for Drug Benefit
  * [Cardinality](https://hl7.org/fhir/R4/formats.html#table): 0..1
  * [Type](https://hl7.org/fhir/R4/formats.html#table): [group](https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-group)
  * [Description & Constraints](https://hl7.org/fhir/R4/formats.html#table)![](data:image/png;base64, ): 
* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](icon-q-coding.png)completing-form|drug-benefit|request-type
  * [Text](https://hl7.org/fhir/R4/formats.html#table): New Request
  * [Cardinality](https://hl7.org/fhir/R4/formats.html#table): 0..1
  * [Type](https://hl7.org/fhir/R4/formats.html#table): [choice](https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-choice)
  * [Description & Constraints](https://hl7.org/fhir/R4/formats.html#table)![](data:image/png;base64, ): Options:[2 options](#opt-item.completing-form|drug-benefit|request-type)
* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](icon-q-coding.png)completing-form|drug-benefit|diagnosis-codes
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Patient ICD Diagnostic Codes
  * [Cardinality](https://hl7.org/fhir/R4/formats.html#table): 0..*
  * [Type](https://hl7.org/fhir/R4/formats.html#table): [open-choice](https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-open-choice)
  * [Description & Constraints](https://hl7.org/fhir/R4/formats.html#table)![](data:image/png;base64, ): Value Set:[ICD-10 Codes](http://hl7.org/fhir/R4/valueset-icd-10.html)
* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](icon-q-string.png)completing-form|drug-benefit|diagnosis-descriptions
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Patient Diagnosis
  * [Cardinality](https://hl7.org/fhir/R4/formats.html#table): 0..*
  * [Type](https://hl7.org/fhir/R4/formats.html#table): [string](https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string)
  * [Description & Constraints](https://hl7.org/fhir/R4/formats.html#table)![](data:image/png;base64, ): 
* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](icon-q-string.png)completing-form|drug-benefit|drugs
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Drugs Requested with J-Code; if applicable
  * [Cardinality](https://hl7.org/fhir/R4/formats.html#table): 0..*
  * [Type](https://hl7.org/fhir/R4/formats.html#table): [string](https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string)
  * [Description & Constraints](https://hl7.org/fhir/R4/formats.html#table)![](data:image/png;base64, ): 
* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](icon-q-string.png)completing-form|drug-benefit|strength-route-frequency
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Strength/Route/Frequency
  * [Cardinality](https://hl7.org/fhir/R4/formats.html#table): 0..1
  * [Type](https://hl7.org/fhir/R4/formats.html#table): [string](https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string)
  * [Description & Constraints](https://hl7.org/fhir/R4/formats.html#table)![](data:image/png;base64, ): 
* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](icon-q-string.png)completing-form|drug-benefit|unit-volume
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Unit/Volume of Named Drugs
  * [Cardinality](https://hl7.org/fhir/R4/formats.html#table): 0..1
  * [Type](https://hl7.org/fhir/R4/formats.html#table): [string](https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string)
  * [Description & Constraints](https://hl7.org/fhir/R4/formats.html#table)![](data:image/png;base64, ): 
* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](icon-q-string.png)completing-form|drug-benefit|start-length
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Start Date and Length of Therapy
  * [Cardinality](https://hl7.org/fhir/R4/formats.html#table): 0..1
  * [Type](https://hl7.org/fhir/R4/formats.html#table): [string](https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string)
  * [Description & Constraints](https://hl7.org/fhir/R4/formats.html#table)![](data:image/png;base64, ): 
* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](icon-q-string.png)completing-form|drug-benefit|location
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Location of Treatment e.g. provider office; facility; home health; etc. including name; Type 2 NPI if applicable; address and tax ID:
  * [Cardinality](https://hl7.org/fhir/R4/formats.html#table): 0..1
  * [Type](https://hl7.org/fhir/R4/formats.html#table): [string](https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string)
  * [Description & Constraints](https://hl7.org/fhir/R4/formats.html#table)![](data:image/png;base64, ): 
* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](icon-q-string.png)completing-form|drug-benefit|criteria
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Clinical Criteria for Approval; Including other Pertinent Information to Support the Request; other Medications Tried; Their Names; Duration; and Patient Response:
  * [Cardinality](https://hl7.org/fhir/R4/formats.html#table): 0..1
  * [Type](https://hl7.org/fhir/R4/formats.html#table): [string](https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string)
  * [Description & Constraints](https://hl7.org/fhir/R4/formats.html#table)![](data:image/png;base64, ): 
* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](icon-q-boolean.png)completing-form|drug-benefit|for-trial
  * [Text](https://hl7.org/fhir/R4/formats.html#table): For use in clinical trial?
  * [Cardinality](https://hl7.org/fhir/R4/formats.html#table): 0..1
  * [Type](https://hl7.org/fhir/R4/formats.html#table): [boolean](https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-boolean)
  * [Description & Constraints](https://hl7.org/fhir/R4/formats.html#table)![](data:image/png;base64, ): 
* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](icon-q-string.png)completing-form|drug-benefit|for-trial|registration-number
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Provide trial name and registration number
  * [Cardinality](https://hl7.org/fhir/R4/formats.html#table): 0..1
  * [Type](https://hl7.org/fhir/R4/formats.html#table): [string](https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string)
  * [Description & Constraints](https://hl7.org/fhir/R4/formats.html#table)![](data:image/png;base64, ): Enable When:[completing-form|drug-benefit|for-trial](#item.completing-form|drug-benefit|for-trial)=
* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](icon-q-string.png)completing-form|drug-benefit|drug-name
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Drug Name Brand Name and Scientific Name/Strength:
  * [Cardinality](https://hl7.org/fhir/R4/formats.html#table): 0..1
  * [Type](https://hl7.org/fhir/R4/formats.html#table): [string](https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string)
  * [Description & Constraints](https://hl7.org/fhir/R4/formats.html#table)![](data:image/png;base64, ): 
* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](icon-q-string.png)completing-form|drug-benefit|dose
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Dose
  * [Cardinality](https://hl7.org/fhir/R4/formats.html#table): 0..1
  * [Type](https://hl7.org/fhir/R4/formats.html#table): [string](https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string)
  * [Description & Constraints](https://hl7.org/fhir/R4/formats.html#table)![](data:image/png;base64, ): 
* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](icon-q-string.png)completing-form|drug-benefit|route
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Route
  * [Cardinality](https://hl7.org/fhir/R4/formats.html#table): 0..1
  * [Type](https://hl7.org/fhir/R4/formats.html#table): [string](https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string)
  * [Description & Constraints](https://hl7.org/fhir/R4/formats.html#table)![](data:image/png;base64, ): 
* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](icon-q-string.png)completing-form|drug-benefit|frequency
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Frequency
  * [Cardinality](https://hl7.org/fhir/R4/formats.html#table): 0..1
  * [Type](https://hl7.org/fhir/R4/formats.html#table): [string](https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string)
  * [Description & Constraints](https://hl7.org/fhir/R4/formats.html#table)![](data:image/png;base64, ): 
* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](icon-q-quantity.png)completing-form|drug-benefit|quantity
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Quantity
  * [Cardinality](https://hl7.org/fhir/R4/formats.html#table): 0..1
  * [Type](https://hl7.org/fhir/R4/formats.html#table): [quantity](https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-quantity)
  * [Description & Constraints](https://hl7.org/fhir/R4/formats.html#table)![](data:image/png;base64, ): 
* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](icon-q-integer.png)completing-form|drug-benefit|refills
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Number of Refills
  * [Cardinality](https://hl7.org/fhir/R4/formats.html#table): 0..1
  * [Type](https://hl7.org/fhir/R4/formats.html#table): [integer](https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-integer)
  * [Description & Constraints](https://hl7.org/fhir/R4/formats.html#table)![](data:image/png;base64, ): 
* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](icon-q-coding.png)completing-form|drug-benefit|delivery
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Product will be delivered to:
  * [Cardinality](https://hl7.org/fhir/R4/formats.html#table): 0..1
  * [Type](https://hl7.org/fhir/R4/formats.html#table): [choice](https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-choice)
  * [Description & Constraints](https://hl7.org/fhir/R4/formats.html#table)![](data:image/png;base64, ): Options:[3 options](#opt-item.completing-form|drug-benefit|delivery)
* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](icon-q-attachment.png)completing-form|drug-benefit|signature
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Prescriber or Authorized Signature:
  * [Cardinality](https://hl7.org/fhir/R4/formats.html#table): 0..1
  * [Type](https://hl7.org/fhir/R4/formats.html#table): [attachment](https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-attachment)
  * [Description & Constraints](https://hl7.org/fhir/R4/formats.html#table)![](data:image/png;base64, ): 
* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](icon-q-string.png)completing-form|drug-benefit|pharmacy
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Dispensing Pharmacy Name and Phone Number:
  * [Cardinality](https://hl7.org/fhir/R4/formats.html#table): 0..1
  * [Type](https://hl7.org/fhir/R4/formats.html#table): [string](https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string)
  * [Description & Constraints](https://hl7.org/fhir/R4/formats.html#table)![](data:image/png;base64, ): 
* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](icon-q-date.png)completing-form|drug-benefit|date
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Date
  * [Cardinality](https://hl7.org/fhir/R4/formats.html#table): 0..1
  * [Type](https://hl7.org/fhir/R4/formats.html#table): [date](https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-date)
  * [Description & Constraints](https://hl7.org/fhir/R4/formats.html#table)![](data:image/png;base64, ): 
* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](data:image/png;base64, )Documentation for this format

-------

**Options Sets**

**Answer options for urgency**

* http://example.org/fhir/CodeSystem/UPPARFQuestionnaire-urgency#urgent ("Urgent")
* http://example.org/fhir/CodeSystem/UPPARFQuestionnaire-urgency#routine ("Non-Urgent")

**Answer options for completing-form|drug-benefit|request-type**

* New Request
* Reauthorization

**Answer options for completing-form|drug-benefit|delivery**

* Patient's Home
* Physician Office
* Other



## Resource Content

```json
{
  "resourceType" : "Questionnaire",
  "id" : "UPPARFQuestionnaire",
  "extension" : [
    {
      "url" : "http://hl7.org/fhir/StructureDefinition/cqf-library",
      "valueCanonical" : "http://hl7.org/fhir/us/cql/Library/UPPARFInitialExpressions"
    },
    {
      "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"
    },
    {
      "extension" : [
        {
          "url" : "name",
          "valueCoding" : {
            "system" : "http://example.org/fhir/CodeSystem/additionalLaunchContext",
            "code" : "MedicationRequest",
            "display" : "MedicationRequest"
          }
        },
        {
          "url" : "type",
          "valueCode" : "MedicationRequest"
        },
        {
          "url" : "description",
          "valueString" : "The MedicationRequest 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/UPPARFQuestionnaire",
  "version" : "1.0.0",
  "name" : "UPPARFQuestionnaire",
  "title" : "Example Uniform Pharmacy Prior Authorization Request Form",
  "status" : "active",
  "experimental" : true,
  "date" : "2023-10-19T00:00:00+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 informed by the following source, used with permission: https://docushare-web.apps.external.pioneer.humana.com/Marketing/docushare-app?file=4136509",
  "item" : [
    {
      "extension" : [
        {
          "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
          "valueExpression" : {
            "language" : "text/cql-identifier",
            "expression" : "Urgency"
          }
        }
      ],
      "linkId" : "urgency",
      "text" : "Urgency",
      "type" : "choice",
      "answerOption" : [
        {
          "valueCoding" : {
            "system" : "http://example.org/fhir/CodeSystem/UPPARFQuestionnaire-urgency",
            "code" : "urgent",
            "display" : "Urgent"
          }
        },
        {
          "valueCoding" : {
            "system" : "http://example.org/fhir/CodeSystem/UPPARFQuestionnaire-urgency",
            "code" : "routine",
            "display" : "Non-Urgent"
          }
        }
      ]
    },
    {
      "linkId" : "drug-info",
      "text" : "Drug Information",
      "type" : "group",
      "item" : [
        {
          "extension" : [
            {
              "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
              "valueExpression" : {
                "language" : "text/cql-identifier",
                "expression" : "Most Recent Medication Name"
              }
            }
          ],
          "linkId" : "drug-info|drug-name",
          "text" : "Requested Drug Name",
          "type" : "string"
        },
        {
          "extension" : [
            {
              "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
              "valueExpression" : {
                "language" : "text/cql-identifier",
                "expression" : "Is Opioid Treatment"
              }
            }
          ],
          "linkId" : "drug-info|drug-intention-opioid",
          "text" : "Is this drug intended to treat opioid dependence?",
          "type" : "boolean",
          "item" : [
            {
              "extension" : [
                {
                  "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
                  "valueExpression" : {
                    "language" : "text/cql-identifier",
                    "expression" : "Is First Prior Authentication"
                  }
                }
              ],
              "linkId" : "drug-info|drug-intention-opioid|first-prior-authentication",
              "text" : "Is this a first request for prior authorization for this drug?",
              "type" : "boolean",
              "enableWhen" : [
                {
                  "question" : "drug-info|drug-intention-opioid",
                  "operator" : "=",
                  "answerBoolean" : true
                }
              ]
            },
            {
              "extension" : [
                {
                  "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
                  "valueExpression" : {
                    "language" : "text/cql-identifier",
                    "expression" : "Initial Request Date"
                  }
                }
              ],
              "linkId" : "drug-info|drug-intention-opioid|date-first-request",
              "text" : "What was the date of the first request?",
              "type" : "date",
              "enableWhen" : [
                {
                  "question" : "drug-info|drug-intention-opioid|first-prior-authentication",
                  "operator" : "=",
                  "answerBoolean" : false
                }
              ]
            },
            {
              "extension" : [
                {
                  "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
                  "valueExpression" : {
                    "language" : "text/cql-identifier",
                    "expression" : "Is First Request > 12 Months"
                  }
                }
              ],
              "linkId" : "drug-info|drug-intention-opioid|twelve-months-since-request",
              "text" : "Has the date of the first request been greater than twelve months ago?",
              "type" : "boolean",
              "enableWhen" : [
                {
                  "question" : "drug-info|drug-intention-opioid|first-prior-authentication",
                  "operator" : "=",
                  "answerBoolean" : false
                }
              ]
            }
          ]
        }
      ]
    },
    {
      "linkId" : "completing-form",
      "text" : "Prior authentication is required and this form needs to be completed",
      "type" : "group",
      "enableWhen" : [
        {
          "question" : "drug-info|drug-intention-opioid",
          "operator" : "=",
          "answerBoolean" : false
        },
        {
          "question" : "drug-info|drug-intention-opioid|twelve-months-since-request",
          "operator" : "=",
          "answerBoolean" : false
        }
      ],
      "enableBehavior" : "any",
      "item" : [
        {
          "linkId" : "completing-form|patient-info",
          "text" : "Patient Info",
          "type" : "group",
          "item" : [
            {
              "extension" : [
                {
                  "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
                  "valueExpression" : {
                    "language" : "text/cql-identifier",
                    "expression" : "Prescription Date"
                  }
                }
              ],
              "linkId" : "completing-form|patient-info|prescription-date",
              "text" : "Prescription Date",
              "type" : "string"
            }
          ]
        },
        {
          "linkId" : "completing-form|prescriber-info",
          "text" : "Prescriber Info",
          "type" : "group",
          "item" : [
            {
              "extension" : [
                {
                  "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
                  "valueExpression" : {
                    "language" : "text/cql-identifier",
                    "expression" : "Prescriber Name"
                  }
                }
              ],
              "linkId" : "completing-form|prescriber-info|prescriber-name",
              "text" : "Prescriber Name",
              "type" : "string"
            },
            {
              "extension" : [
                {
                  "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
                  "valueExpression" : {
                    "language" : "text/cql-identifier",
                    "expression" : "Prescriber Fax"
                  }
                }
              ],
              "linkId" : "completing-form|prescriber-info|prescriber-fax",
              "text" : "Prescriber Fax",
              "type" : "string"
            },
            {
              "extension" : [
                {
                  "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
                  "valueExpression" : {
                    "language" : "text/cql-identifier",
                    "expression" : "Prescriber Phone"
                  }
                }
              ],
              "linkId" : "completing-form|prescriber-info|prescriber-phone",
              "text" : "Prescriber Phone",
              "type" : "string"
            },
            {
              "extension" : [
                {
                  "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
                  "valueExpression" : {
                    "language" : "text/cql-identifier",
                    "expression" : "Prescriber Pager"
                  }
                }
              ],
              "linkId" : "completing-form|prescriber-info|prescriber-pager",
              "text" : "Prescriber Pager",
              "type" : "string"
            },
            {
              "extension" : [
                {
                  "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
                  "valueExpression" : {
                    "language" : "text/cql-identifier",
                    "expression" : "Prescriber Address"
                  }
                }
              ],
              "linkId" : "completing-form|prescriber-info|prescriber-address",
              "text" : "Prescriber Address",
              "type" : "string"
            },
            {
              "extension" : [
                {
                  "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
                  "valueExpression" : {
                    "language" : "text/cql-identifier",
                    "expression" : "Prescriber Contact"
                  }
                }
              ],
              "linkId" : "completing-form|prescriber-info|prescriber-contact",
              "text" : "Prescriber Office Contact",
              "type" : "string"
            },
            {
              "extension" : [
                {
                  "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
                  "valueExpression" : {
                    "language" : "text/cql-identifier",
                    "expression" : "Prescriber NPI"
                  }
                }
              ],
              "linkId" : "completing-form|prescriber-info|prescriber-npi",
              "text" : "Prescriber NPI",
              "type" : "string"
            },
            {
              "extension" : [
                {
                  "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
                  "valueExpression" : {
                    "language" : "text/cql-identifier",
                    "expression" : "Prescriber DEA"
                  }
                }
              ],
              "linkId" : "completing-form|prescriber-info|prescriber-dea",
              "text" : "Prescriber DEA",
              "type" : "string"
            },
            {
              "extension" : [
                {
                  "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
                  "valueExpression" : {
                    "language" : "text/cql-identifier",
                    "expression" : "Prescriber Tax ID"
                  }
                }
              ],
              "linkId" : "completing-form|prescriber-info|prescriber-tax-id",
              "text" : "Prescriber Tax ID",
              "type" : "string"
            },
            {
              "extension" : [
                {
                  "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
                  "valueExpression" : {
                    "language" : "text/cql-identifier",
                    "expression" : "Prescriber Specialty"
                  }
                }
              ],
              "linkId" : "completing-form|prescriber-info|prescriber-specialty",
              "text" : "Specialty/Facility Name If applicable",
              "type" : "string"
            },
            {
              "extension" : [
                {
                  "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
                  "valueExpression" : {
                    "language" : "text/cql-identifier",
                    "expression" : "Prescriber Email Address"
                  }
                }
              ],
              "linkId" : "completing-form|prescriber-info|prescriber-email",
              "text" : "Email Address",
              "type" : "string"
            }
          ]
        },
        {
          "linkId" : "completing-form|drug-benefit",
          "text" : "Prior Authorization Request for Drug Benefit",
          "type" : "group",
          "item" : [
            {
              "extension" : [
                {
                  "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
                  "valueExpression" : {
                    "language" : "text/cql-identifier",
                    "expression" : "Request Type"
                  }
                }
              ],
              "linkId" : "completing-form|drug-benefit|request-type",
              "text" : "New Request",
              "type" : "choice",
              "answerOption" : [
                {
                  "valueString" : "New Request"
                },
                {
                  "valueString" : "Reauthorization"
                }
              ]
            },
            {
              "extension" : [
                {
                  "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
                  "valueExpression" : {
                    "language" : "text/cql-identifier",
                    "expression" : "ICD 10 Codes"
                  }
                }
              ],
              "linkId" : "completing-form|drug-benefit|diagnosis-codes",
              "text" : "Patient ICD Diagnostic Codes",
              "type" : "open-choice",
              "repeats" : true,
              "answerValueSet" : "http://hl7.org/fhir/ValueSet/icd-10"
            },
            {
              "extension" : [
                {
                  "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
                  "valueExpression" : {
                    "language" : "text/cql-identifier",
                    "expression" : "Diagnosis Descriptions"
                  }
                }
              ],
              "linkId" : "completing-form|drug-benefit|diagnosis-descriptions",
              "text" : "Patient Diagnosis",
              "type" : "string",
              "repeats" : true
            },
            {
              "linkId" : "completing-form|drug-benefit|drugs",
              "text" : "Drugs Requested with J-Code; if applicable",
              "type" : "string",
              "repeats" : true
            },
            {
              "linkId" : "completing-form|drug-benefit|strength-route-frequency",
              "text" : "Strength/Route/Frequency",
              "type" : "string"
            },
            {
              "linkId" : "completing-form|drug-benefit|unit-volume",
              "text" : "Unit/Volume of Named Drugs",
              "type" : "string"
            },
            {
              "extension" : [
                {
                  "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
                  "valueExpression" : {
                    "language" : "text/cql-identifier",
                    "expression" : "Start Date and Length"
                  }
                }
              ],
              "linkId" : "completing-form|drug-benefit|start-length",
              "text" : "Start Date and Length of Therapy",
              "type" : "string"
            },
            {
              "linkId" : "completing-form|drug-benefit|location",
              "text" : "Location of Treatment e.g. provider office; facility; home health; etc. including name; Type 2 NPI if applicable; address and tax ID:",
              "type" : "string"
            },
            {
              "linkId" : "completing-form|drug-benefit|criteria",
              "text" : "Clinical Criteria for Approval; Including other Pertinent Information to Support the Request; other Medications Tried; Their Names; Duration; and Patient Response:",
              "type" : "string"
            },
            {
              "linkId" : "completing-form|drug-benefit|for-trial",
              "text" : "For use in clinical trial?",
              "type" : "boolean"
            },
            {
              "linkId" : "completing-form|drug-benefit|for-trial|registration-number",
              "text" : "Provide trial name and registration number",
              "type" : "string",
              "enableWhen" : [
                {
                  "question" : "completing-form|drug-benefit|for-trial",
                  "operator" : "=",
                  "answerBoolean" : true
                }
              ]
            },
            {
              "linkId" : "completing-form|drug-benefit|drug-name",
              "text" : "Drug Name Brand Name and Scientific Name/Strength:",
              "type" : "string"
            },
            {
              "linkId" : "completing-form|drug-benefit|dose",
              "text" : "Dose",
              "type" : "string"
            },
            {
              "linkId" : "completing-form|drug-benefit|route",
              "text" : "Route",
              "type" : "string"
            },
            {
              "linkId" : "completing-form|drug-benefit|frequency",
              "text" : "Frequency",
              "type" : "string"
            },
            {
              "linkId" : "completing-form|drug-benefit|quantity",
              "text" : "Quantity",
              "type" : "quantity"
            },
            {
              "linkId" : "completing-form|drug-benefit|refills",
              "text" : "Number of Refills",
              "type" : "integer"
            },
            {
              "linkId" : "completing-form|drug-benefit|delivery",
              "text" : "Product will be delivered to:",
              "type" : "choice",
              "answerOption" : [
                {
                  "valueString" : "Patient's Home"
                },
                {
                  "valueString" : "Physician Office"
                },
                {
                  "valueString" : "Other"
                }
              ]
            },
            {
              "linkId" : "completing-form|drug-benefit|signature",
              "text" : "Prescriber or Authorized Signature:",
              "type" : "attachment"
            },
            {
              "linkId" : "completing-form|drug-benefit|pharmacy",
              "text" : "Dispensing Pharmacy Name and Phone Number:",
              "type" : "string"
            },
            {
              "linkId" : "completing-form|drug-benefit|date",
              "text" : "Date",
              "type" : "date"
            }
          ]
        }
      ]
    }
  ]
}

```
