# Example Patient and Coverage Questionnaire - Common CQL Artifacts for FHIR (US-Based) v1.0.0

* [**Table of Contents**](toc.md)
* [**Artifacts Summary**](artifacts.md)
* **Example Patient and Coverage Questionnaire**

## Questionnaire: Example Patient and Coverage Questionnaire (Experimental) 

| | |
| :--- | :--- |
| *Official URL*:http://hl7.org/fhir/us/cql/Questionnaire/ExamplePatientAndCoverageQuestionnaire | *Version*:1.0.0 |
| *Standards status:*[Informative](http://hl7.org/fhir/R4/versions.html#std-process) | *Computable Name*:ExamplePatientAndCoverageQuestionnaire |

 
For the Prior Authorization Questionnaire Use Case, this type of in-context information is expected to be known already so it wouldn't typically be in a Questionnaire. This example illustrates how to get this information if it is needed. 

* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ExamplePatientAndCoverageQuestionnaire
  * [Text](https://hl7.org/fhir/R4/formats.html#table): For the Prior Authorization Questionnaire Use Case, this type of in-context information is expected to be known already so it wouldn't typically be in a Questionnaire. This example illustrates how to get this information if it is needed.
  * [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/ExamplePatientAndCoverageQuestionnaire#1.0.0
* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](icon-q-group.png)patient-info
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Patient 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)patient-info|patient-name
  * [Text](https://hl7.org/fhir/R4/formats.html#table): 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-date.png)patient-info|date-of-birth
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Date of Birth
  * [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): ![](icon-q-coding.png)patient-info|birth-sex
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Birth Sex
  * [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, ): Value Set:[Birth Sex](https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1021.24/expansion)
* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](icon-q-string.png)patient-info|medical-record-number
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Medical Record 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-string.png)patient-info|phone-number
  * [Text](https://hl7.org/fhir/R4/formats.html#table): 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-string.png)patient-info|email-address
  * [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-string.png)patient-info|address
  * [Text](https://hl7.org/fhir/R4/formats.html#table): 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)patient-info|city
  * [Text](https://hl7.org/fhir/R4/formats.html#table): City
  * [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)patient-info|state
  * [Text](https://hl7.org/fhir/R4/formats.html#table): State
  * [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)patient-info|postal-code
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Postal Code
  * [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)coverage-info
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Coverage 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)coverage-info|member-id
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Member 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|patient-info|policy-number
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Policy 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-group.png)provider-info
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Requesting Provider 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)provider-info|name
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Requesting provider 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)provider-info|phone-number
  * [Text](https://hl7.org/fhir/R4/formats.html#table): 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)provider-info|address
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Ordering provider 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)provider-info|npi
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Ordering provider Tax ID/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)provider-info|fax
  * [Text](https://hl7.org/fhir/R4/formats.html#table): 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-group.png)servicing-provider
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Laboratory performing testing/Servicing Provider
  * [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)servicing-provider|name
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Servicing Provider 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)servicing-provider|phone-number
  * [Text](https://hl7.org/fhir/R4/formats.html#table): 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)servicing-provider|address
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Ordering provider 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)servicing-provider|npi
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Ordering provider Tax ID/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)servicing-provider|fax
  * [Text](https://hl7.org/fhir/R4/formats.html#table): 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): ![](data:image/png;base64, )Documentation for this format



## Resource Content

```json
{
  "resourceType" : "Questionnaire",
  "id" : "ExamplePatientAndCoverageQuestionnaire",
  "extension" : [
    {
      "url" : "http://hl7.org/fhir/StructureDefinition/cqf-library",
      "valueCanonical" : "http://hl7.org/fhir/us/cql/Library/ExamplePatientAndCoverageInitialExpressions"
    },
    {
      "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" : "Coverage",
            "display" : "Coverage"
          }
        },
        {
          "url" : "type",
          "valueCode" : "Coverage"
        },
        {
          "url" : "description",
          "valueString" : "The coverage 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" : "ServiceRequest",
            "display" : "ServiceRequest"
          }
        },
        {
          "url" : "type",
          "valueCode" : "ServiceRequest"
        },
        {
          "url" : "description",
          "valueString" : "The ServiceRequest 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/ExamplePatientAndCoverageQuestionnaire",
  "version" : "1.0.0",
  "name" : "ExamplePatientAndCoverageQuestionnaire",
  "title" : "Example Patient and Coverage Questionnaire",
  "status" : "active",
  "experimental" : true,
  "date" : "2024-09-16T00:00:00+00:00",
  "publisher" : "HL7 International / Clinical Decision Support",
  "contact" : [
    {
      "telecom" : [
        {
          "system" : "url",
          "value" : "http://www.hl7.org/Special/committees/dss"
        }
      ]
    }
  ],
  "description" : "For the Prior Authorization Questionnaire Use Case, this type of in-context information is expected to be known already so it wouldn't typically be in a Questionnaire. This example illustrates how to get this information if it is needed.",
  "jurisdiction" : [
    {
      "coding" : [
        {
          "system" : "urn:iso:std:iso:3166",
          "code" : "US",
          "display" : "United States of America"
        }
      ]
    }
  ],
  "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" : "Patient Name"
              }
            }
          ],
          "linkId" : "patient-info|patient-name",
          "text" : "Name",
          "type" : "string"
        },
        {
          "extension" : [
            {
              "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
              "valueExpression" : {
                "language" : "text/cql-identifier",
                "expression" : "Date of Birth"
              }
            }
          ],
          "linkId" : "patient-info|date-of-birth",
          "text" : "Date of Birth",
          "type" : "date"
        },
        {
          "extension" : [
            {
              "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
              "valueExpression" : {
                "language" : "text/cql-identifier",
                "expression" : "Birth Sex"
              }
            }
          ],
          "linkId" : "patient-info|birth-sex",
          "text" : "Birth Sex",
          "type" : "choice",
          "answerValueSet" : "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1021.24"
        },
        {
          "extension" : [
            {
              "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
              "valueExpression" : {
                "language" : "text/cql-identifier",
                "expression" : "Medical Record Number"
              }
            }
          ],
          "linkId" : "patient-info|medical-record-number",
          "text" : "Medical Record Number",
          "type" : "string"
        },
        {
          "extension" : [
            {
              "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
              "valueExpression" : {
                "language" : "text/cql-identifier",
                "expression" : "Phone Number"
              }
            }
          ],
          "linkId" : "patient-info|phone-number",
          "text" : "Phone Number",
          "type" : "string"
        },
        {
          "extension" : [
            {
              "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
              "valueExpression" : {
                "language" : "text/cql-identifier",
                "expression" : "Email Address"
              }
            }
          ],
          "linkId" : "patient-info|email-address",
          "text" : "Email Address",
          "type" : "string"
        },
        {
          "extension" : [
            {
              "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
              "valueExpression" : {
                "language" : "text/cql-identifier",
                "expression" : "Address"
              }
            }
          ],
          "linkId" : "patient-info|address",
          "text" : "Address",
          "type" : "string"
        },
        {
          "extension" : [
            {
              "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
              "valueExpression" : {
                "language" : "text/cql-identifier",
                "expression" : "City"
              }
            }
          ],
          "linkId" : "patient-info|city",
          "text" : "City",
          "type" : "string"
        },
        {
          "extension" : [
            {
              "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
              "valueExpression" : {
                "language" : "text/cql-identifier",
                "expression" : "State"
              }
            }
          ],
          "linkId" : "patient-info|state",
          "text" : "State",
          "type" : "string"
        },
        {
          "extension" : [
            {
              "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
              "valueExpression" : {
                "language" : "text/cql-identifier",
                "expression" : "Postal Code"
              }
            }
          ],
          "linkId" : "patient-info|postal-code",
          "text" : "Postal Code",
          "type" : "string"
        }
      ]
    },
    {
      "linkId" : "coverage-info",
      "text" : "Coverage Information",
      "type" : "group",
      "item" : [
        {
          "extension" : [
            {
              "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
              "valueExpression" : {
                "language" : "text/cql-identifier",
                "expression" : "Member ID"
              }
            }
          ],
          "linkId" : "coverage-info|member-id",
          "text" : "Member ID",
          "type" : "string"
        },
        {
          "extension" : [
            {
              "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
              "valueExpression" : {
                "language" : "text/cql-identifier",
                "expression" : "Policy Number"
              }
            }
          ],
          "linkId" : "completing-form|patient-info|policy-number",
          "text" : "Policy Number",
          "type" : "string"
        }
      ]
    },
    {
      "linkId" : "provider-info",
      "text" : "Requesting Provider Information",
      "type" : "group",
      "item" : [
        {
          "extension" : [
            {
              "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
              "valueExpression" : {
                "language" : "text/cql-identifier",
                "expression" : "Requesting Provider Name"
              }
            }
          ],
          "linkId" : "provider-info|name",
          "text" : "Requesting provider name",
          "type" : "string"
        },
        {
          "extension" : [
            {
              "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
              "valueExpression" : {
                "language" : "text/cql-identifier",
                "expression" : "Requesting Provider Phone"
              }
            }
          ],
          "linkId" : "provider-info|phone-number",
          "text" : "Phone",
          "type" : "string"
        },
        {
          "extension" : [
            {
              "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
              "valueExpression" : {
                "language" : "text/cql-identifier",
                "expression" : "Requesting Provider Address"
              }
            }
          ],
          "linkId" : "provider-info|address",
          "text" : "Ordering provider address",
          "type" : "string"
        },
        {
          "extension" : [
            {
              "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
              "valueExpression" : {
                "language" : "text/cql-identifier",
                "expression" : "Requesting Provider NPI"
              }
            }
          ],
          "linkId" : "provider-info|npi",
          "text" : "Ordering provider Tax ID/NPI #",
          "type" : "string"
        },
        {
          "extension" : [
            {
              "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
              "valueExpression" : {
                "language" : "text/cql-identifier",
                "expression" : "Requesting Provider Fax"
              }
            }
          ],
          "linkId" : "provider-info|fax",
          "text" : "Fax",
          "type" : "string"
        }
      ]
    },
    {
      "linkId" : "servicing-provider",
      "text" : "Laboratory performing testing/Servicing Provider",
      "type" : "group",
      "item" : [
        {
          "extension" : [
            {
              "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
              "valueExpression" : {
                "language" : "text/cql-identifier",
                "expression" : "Servicing Provider Name"
              }
            }
          ],
          "linkId" : "servicing-provider|name",
          "text" : "Servicing Provider name",
          "type" : "string"
        },
        {
          "extension" : [
            {
              "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
              "valueExpression" : {
                "language" : "text/cql-identifier",
                "expression" : "Servicing Provider Phone"
              }
            }
          ],
          "linkId" : "servicing-provider|phone-number",
          "text" : "Phone",
          "type" : "string"
        },
        {
          "extension" : [
            {
              "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
              "valueExpression" : {
                "language" : "text/cql-identifier",
                "expression" : "Servicing Provider Address"
              }
            }
          ],
          "linkId" : "servicing-provider|address",
          "text" : "Ordering provider address",
          "type" : "string"
        },
        {
          "extension" : [
            {
              "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
              "valueExpression" : {
                "language" : "text/cql-identifier",
                "expression" : "Servicing Provider NPI"
              }
            }
          ],
          "linkId" : "servicing-provider|npi",
          "text" : "Ordering provider Tax ID/NPI #",
          "type" : "string"
        },
        {
          "extension" : [
            {
              "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
              "valueExpression" : {
                "language" : "text/cql-identifier",
                "expression" : "Servicing Provider Fax"
              }
            }
          ],
          "linkId" : "servicing-provider|fax",
          "text" : "Fax",
          "type" : "string"
        }
      ]
    }
  ]
}

```
