Common CQL Artifacts for FHIR (US-Based)
2.0.0-ballot - Informative 2 Ballot

Common CQL Artifacts for FHIR (US-Based) - Downloaded Version null See the Directory of published versions

## : Example Uniform Pharmacy Prior Authorization Request Form

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    @prefix fhir: <http://hl7.org/fhir/> .
    @prefix owl: <http://www.w3.org/2002/07/owl#> .
    @prefix rdf: <http://www.w3.org/1999/02/22-rdf-syntax-ns#> .
    @prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
    @prefix xsd: <http://www.w3.org/2001/XMLSchema#> .

    # - resource -------------------------------------------------------------------

     a fhir:Questionnaire ;
      fhir:nodeRole fhir:treeRoot ;
      fhir:id [ fhir:v "UPPARFQuestionnaire"] ; #
      fhir:language [ fhir:v "en"] ; #
      fhir:text [
    fhir:status [ fhir:v "extensions" ] ;
    fhir:div [ fhir:v "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: Questionnaire UPPARFQuestionnaire</b></p><a name=\"UPPARFQuestionnaire\"> </a><a name=\"hcUPPARFQuestionnaire\"> </a><b>Structure</b><table border=\"1\" cellpadding=\"0\" cellspacing=\"0\" style=\"border: 1px #F0F0F0 solid; font-size: 11px; font-family: verdana; vertical-align: top;\"><tr style=\"border: 2px #F0F0F0 solid; font-size: 11px; font-family: verdana; vertical-align: top\"><th style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; padding-top: 3px; padding-bottom: 3px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/formats.html#table\" title=\"The linkID for the item\">LinkID</a></th><th style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; padding-top: 3px; padding-bottom: 3px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/formats.html#table\" title=\"Text for the item\">Text</a></th><th style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; padding-top: 3px; padding-bottom: 3px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/formats.html#table\" title=\"Minimum and Maximum # of times the item can appear in the instance\">Cardinality</a></th><th style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; padding-top: 3px; padding-bottom: 3px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/formats.html#table\" title=\"The type of the item\">Type</a></th><th style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; padding-top: 3px; padding-bottom: 3px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/formats.html#table\" title=\"Additional information about the item\">Description &amp; Constraints</a><span style=\"float: right\"><a href=\"https://hl7.org/fhir/R4/formats.html#table\" title=\"Legend for this format\"><img src=\"data:image/png;base64, \" alt=\"doco\" style=\"background-color: inherit\"/></a></span></th></tr><tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck1.png)\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon_q_root.gif\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"QuestionnaireRoot\" class=\"hierarchy\"/> UPPARFQuestionnaire</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">This is an example of a prior authorization questionnaire developed based on an existing industry prior-authorization form.</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Questionnaire</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">http://hl7.org/fhir/us/cql/Questionnaire/UPPARFQuestionnaire#2.0.0-ballot</td></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck10.png)\" id=\"item.urgency\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-coding.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"coding\" class=\"hierarchy\"/> urgency</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Urgency</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-choice\">choice</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Options: <a href=\"#opt-item.urgency\">2 options</a></td></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck11.png)\" id=\"item.drug-info\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-group.png\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"group\" class=\"hierarchy\"/> drug-info</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Drug Information</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-group\">group</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck110.png)\" id=\"item.drug-info|drug-name\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vline.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-string.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"string\" class=\"hierarchy\"/> drug-info|drug-name</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Requested Drug Name</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string\">string</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck101.png)\" id=\"item.drug-info|drug-intention-opioid\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vline.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin_end.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-boolean.png\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"boolean\" class=\"hierarchy\"/> drug-info|drug-intention-opioid</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Is this drug intended to treat opioid dependence?</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-boolean\">boolean</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck1010.png)\" id=\"item.drug-info|drug-intention-opioid|first-prior-authentication\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vline.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-boolean.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"boolean\" class=\"hierarchy\"/> drug-info|drug-intention-opioid|first-prior-authentication</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Is this a first request for prior authorization for this drug?</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-boolean\">boolean</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Enable When: <span><a href=\"#item.drug-info|drug-intention-opioid\">drug-info|drug-intention-opioid</a> = true</span></td></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck1010.png)\" id=\"item.drug-info|drug-intention-opioid|date-first-request\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vline.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-date.png\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"date\" class=\"hierarchy\"/> drug-info|drug-intention-opioid|date-first-request</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">What was the date of the first request?</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-date\">date</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Enable When: <span><a href=\"#item.drug-info|drug-intention-opioid|first-prior-authentication\">drug-info|drug-intention-opioid|first-prior-authentication</a> = false</span></td></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck1000.png)\" id=\"item.drug-info|drug-intention-opioid|twelve-months-since-request\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vline.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin_end.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-boolean.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"boolean\" class=\"hierarchy\"/> drug-info|drug-intention-opioid|twelve-months-since-request</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Has the date of the first request been greater than twelve months ago?</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-boolean\">boolean</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Enable When: <span><a href=\"#item.drug-info|drug-intention-opioid|first-prior-authentication\">drug-info|drug-intention-opioid|first-prior-authentication</a> = false</span></td></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck01.png)\" id=\"item.completing-form\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin_end.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-group.png\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"group\" class=\"hierarchy\"/> completing-form</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Prior authentication is required and this form needs to be completed</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-group\">group</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Enable When: <ul><li><a href=\"#item.drug-info|drug-intention-opioid\">drug-info|drug-intention-opioid</a> = false</li><li><a href=\"#item.drug-info|drug-intention-opioid|twelve-months-since-request\">drug-info|drug-intention-opioid|twelve-months-since-request</a> = false</li></ul></td></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck011.png)\" id=\"item.completing-form|patient-info\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-group.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"group\" class=\"hierarchy\"/> completing-form|patient-info</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Patient Info</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-group\">group</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck0100.png)\" id=\"item.completing-form|patient-info|prescription-date\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vline.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin_end.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-string.png\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"string\" class=\"hierarchy\"/> completing-form|patient-info|prescription-date</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Prescription Date</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string\">string</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck011.png)\" id=\"item.completing-form|prescriber-info\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-group.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"group\" class=\"hierarchy\"/> completing-form|prescriber-info</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Prescriber Info</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-group\">group</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck0110.png)\" id=\"item.completing-form|prescriber-info|prescriber-name\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vline.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-string.png\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"string\" class=\"hierarchy\"/> completing-form|prescriber-info|prescriber-name</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Prescriber Name</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string\">string</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck0110.png)\" id=\"item.completing-form|prescriber-info|prescriber-fax\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vline.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-string.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"string\" class=\"hierarchy\"/> completing-form|prescriber-info|prescriber-fax</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Prescriber Fax</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string\">string</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck0110.png)\" id=\"item.completing-form|prescriber-info|prescriber-phone\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vline.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-string.png\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"string\" class=\"hierarchy\"/> completing-form|prescriber-info|prescriber-phone</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Prescriber Phone</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string\">string</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck0110.png)\" id=\"item.completing-form|prescriber-info|prescriber-pager\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vline.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-string.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"string\" class=\"hierarchy\"/> completing-form|prescriber-info|prescriber-pager</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Prescriber Pager</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string\">string</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck0110.png)\" id=\"item.completing-form|prescriber-info|prescriber-address\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vline.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-string.png\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"string\" class=\"hierarchy\"/> completing-form|prescriber-info|prescriber-address</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Prescriber Address</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string\">string</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck0110.png)\" id=\"item.completing-form|prescriber-info|prescriber-contact\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vline.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-string.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"string\" class=\"hierarchy\"/> completing-form|prescriber-info|prescriber-contact</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Prescriber Office Contact</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string\">string</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck0110.png)\" id=\"item.completing-form|prescriber-info|prescriber-npi\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vline.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-string.png\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"string\" class=\"hierarchy\"/> completing-form|prescriber-info|prescriber-npi</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Prescriber NPI</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string\">string</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck0110.png)\" id=\"item.completing-form|prescriber-info|prescriber-dea\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vline.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-string.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"string\" class=\"hierarchy\"/> completing-form|prescriber-info|prescriber-dea</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Prescriber DEA</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string\">string</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck0110.png)\" id=\"item.completing-form|prescriber-info|prescriber-tax-id\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vline.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-string.png\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"string\" class=\"hierarchy\"/> completing-form|prescriber-info|prescriber-tax-id</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Prescriber Tax ID</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string\">string</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck0110.png)\" id=\"item.completing-form|prescriber-info|prescriber-specialty\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vline.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-string.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"string\" class=\"hierarchy\"/> completing-form|prescriber-info|prescriber-specialty</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Specialty/Facility Name If applicable</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string\">string</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck0100.png)\" id=\"item.completing-form|prescriber-info|prescriber-email\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vline.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin_end.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-string.png\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"string\" class=\"hierarchy\"/> completing-form|prescriber-info|prescriber-email</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Email Address</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string\">string</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck001.png)\" id=\"item.completing-form|drug-benefit\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin_end.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-group.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"group\" class=\"hierarchy\"/> completing-form|drug-benefit</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Prior Authorization Request for Drug Benefit</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-group\">group</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck0010.png)\" id=\"item.completing-form|drug-benefit|request-type\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-coding.png\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"coding\" class=\"hierarchy\"/> completing-form|drug-benefit|request-type</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">New Request</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-choice\">choice</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Options: <a href=\"#opt-item.completing-form|drug-benefit|request-type\">2 options</a></td></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck0010.png)\" id=\"item.completing-form|drug-benefit|diagnosis-codes\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-coding.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"coding\" class=\"hierarchy\"/> completing-form|drug-benefit|diagnosis-codes</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Patient ICD Diagnostic Codes</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..*</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-open-choice\">open-choice</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Value Set: <a href=\"http://hl7.org/fhir/R4/valueset-icd-10.html\">ICD-10 Codes</a></td></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck0010.png)\" id=\"item.completing-form|drug-benefit|diagnosis-descriptions\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-string.png\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"string\" class=\"hierarchy\"/> completing-form|drug-benefit|diagnosis-descriptions</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Patient Diagnosis</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..*</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string\">string</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck0010.png)\" id=\"item.completing-form|drug-benefit|drugs\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-string.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"string\" class=\"hierarchy\"/> completing-form|drug-benefit|drugs</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Drugs Requested with J-Code; if applicable</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..*</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string\">string</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck0010.png)\" id=\"item.completing-form|drug-benefit|strength-route-frequency\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-string.png\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"string\" class=\"hierarchy\"/> completing-form|drug-benefit|strength-route-frequency</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Strength/Route/Frequency</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string\">string</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck0010.png)\" id=\"item.completing-form|drug-benefit|unit-volume\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-string.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"string\" class=\"hierarchy\"/> completing-form|drug-benefit|unit-volume</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Unit/Volume of Named Drugs</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string\">string</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck0010.png)\" id=\"item.completing-form|drug-benefit|start-length\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-string.png\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"string\" class=\"hierarchy\"/> completing-form|drug-benefit|start-length</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Start Date and Length of Therapy</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string\">string</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck0010.png)\" id=\"item.completing-form|drug-benefit|location\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-string.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"string\" class=\"hierarchy\"/> completing-form|drug-benefit|location</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Location of Treatment e.g. provider office; facility; home health; etc. including name; Type 2 NPI if applicable; address and tax ID:</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string\">string</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck0010.png)\" id=\"item.completing-form|drug-benefit|criteria\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-string.png\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"string\" class=\"hierarchy\"/> completing-form|drug-benefit|criteria</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Clinical Criteria for Approval; Including other Pertinent Information to Support the Request; other Medications Tried; Their Names; Duration; and Patient Response:</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string\">string</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck0010.png)\" id=\"item.completing-form|drug-benefit|for-trial\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-boolean.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"boolean\" class=\"hierarchy\"/> completing-form|drug-benefit|for-trial</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">For use in clinical trial?</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-boolean\">boolean</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck0010.png)\" id=\"item.completing-form|drug-benefit|for-trial|registration-number\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-string.png\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"string\" class=\"hierarchy\"/> completing-form|drug-benefit|for-trial|registration-number</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Provide trial name and registration number</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string\">string</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Enable When: <span><a href=\"#item.completing-form|drug-benefit|for-trial\">completing-form|drug-benefit|for-trial</a> = true</span></td></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck0010.png)\" id=\"item.completing-form|drug-benefit|drug-name\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-string.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"string\" class=\"hierarchy\"/> completing-form|drug-benefit|drug-name</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Drug Name Brand Name and Scientific Name/Strength:</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string\">string</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck0010.png)\" id=\"item.completing-form|drug-benefit|dose\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-string.png\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"string\" class=\"hierarchy\"/> completing-form|drug-benefit|dose</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Dose</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string\">string</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck0010.png)\" id=\"item.completing-form|drug-benefit|route\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-string.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"string\" class=\"hierarchy\"/> completing-form|drug-benefit|route</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Route</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string\">string</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck0010.png)\" id=\"item.completing-form|drug-benefit|frequency\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-string.png\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"string\" class=\"hierarchy\"/> completing-form|drug-benefit|frequency</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Frequency</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string\">string</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck0010.png)\" id=\"item.completing-form|drug-benefit|quantity\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-quantity.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"quantity\" class=\"hierarchy\"/> completing-form|drug-benefit|quantity</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Quantity</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-quantity\">quantity</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck0010.png)\" id=\"item.completing-form|drug-benefit|refills\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-integer.png\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"integer\" class=\"hierarchy\"/> completing-form|drug-benefit|refills</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Number of Refills</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-integer\">integer</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck0010.png)\" id=\"item.completing-form|drug-benefit|delivery\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-coding.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"coding\" class=\"hierarchy\"/> completing-form|drug-benefit|delivery</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Product will be delivered to:</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-choice\">choice</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Options: <a href=\"#opt-item.completing-form|drug-benefit|delivery\">3 options</a></td></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck0010.png)\" id=\"item.completing-form|drug-benefit|signature\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-attachment.png\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"attachment\" class=\"hierarchy\"/> completing-form|drug-benefit|signature</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Prescriber or Authorized Signature:</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-attachment\">attachment</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck0010.png)\" id=\"item.completing-form|drug-benefit|pharmacy\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-string.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"string\" class=\"hierarchy\"/> completing-form|drug-benefit|pharmacy</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Dispensing Pharmacy Name and Phone Number:</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string\">string</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck0000.png)\" id=\"item.completing-form|drug-benefit|date\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin_end.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-date.png\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"date\" class=\"hierarchy\"/> completing-form|drug-benefit|date</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Date</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-date\">date</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr><td colspan=\"5\" class=\"hierarchy\"><br/><a href=\"https://hl7.org/fhir/R4/formats.html#table\" title=\"Legend for this format\"><img src=\"data:image/png;base64, \" alt=\"doco\" style=\"background-color: inherit\"/> Documentation for this format</a></td></tr></table><hr/><p><b>Options Sets</b></p><a name=\"opt-item.urgency\"> </a><p><b>Answer options for urgency </b></p><ul><li style=\"font-size: 11px\">http://example.org/fhir/CodeSystem/UPPARFQuestionnaire-urgency#urgent (\"Urgent\")</li><li style=\"font-size: 11px\">http://example.org/fhir/CodeSystem/UPPARFQuestionnaire-urgency#routine (\"Non-Urgent\")</li></ul><a name=\"opt-item.completing-form|drug-benefit|request-type\"> </a><p><b>Answer options for completing-form|drug-benefit|request-type </b></p><ul><li style=\"font-size: 11px\">New Request</li><li style=\"font-size: 11px\">Reauthorization</li></ul><a name=\"opt-item.completing-form|drug-benefit|delivery\"> </a><p><b>Answer options for completing-form|drug-benefit|delivery </b></p><ul><li style=\"font-size: 11px\">Patient's Home</li><li style=\"font-size: 11px\">Physician Office</li><li style=\"font-size: 11px\">Other</li></ul><h2>Contained Resources</h2><hr/>\n  <table class=\"narrative-table\">\n    <tbody>\n<tr>\n\n\n<th colspan=\"2\" scope=\"row\" class=\"row-header\">Metadata</th>\n\n\n</tr>\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n<tr>\n\n\n<th scope=\"row\" class=\"row-header\">Type</th>\n\n\n\n<td class=\"content-container\">\n    module-definition from <a href=\"http://terminology.hl7.org/7.1.0/CodeSystem-library-type.html\">http://terminology.hl7.org/CodeSystem/library-type</a> \n\n\n</td>\n\n\n</tr>\n\n\n\n<tr>\n  \n  \n  \n  \n  \n\n<th scope=\"row\" class=\"row-header\">Dependency</th>\n\n\n  \n  \n  <td class=\"content-container\">\n    \n    <em>Description</em>: USCore model information\n    \n    <br/>\n    \n    \n    \n    \n    \n    \n    <em>Resource</em>: <a href=\"Library-USCore-ModelInfo.html\">US Core Model Informationversion: null6.1.0-derived)</a>\n    <br/>\n    <em>Canonical URL</em>: <tt>http://hl7.org/fhir/us/cql/Library/USCore-ModelInfo|6.1.0-derived</tt>\n    \n    \n    \n  </td>\n</tr>\n\n<tr>\n  \n  \n  \n  \n  \n\n<th scope=\"row\" class=\"row-header\">Dependency</th>\n\n\n  \n  \n  <td class=\"content-container\">\n    \n    <em>Description</em>: FHIR model information\n    \n    <br/>\n    \n    \n    \n    \n    \n    \n    <em>Resource</em>: <a href=\"http://hl7.org/fhir/uv/cql/STU2/Library-FHIR-ModelInfo.html\">http://hl7.org/fhir/uv/cql/Library/FHIR-ModelInfo|4.0.1</a>\n    <br/>\n    <em>Canonical URL</em>: <tt>http://hl7.org/fhir/uv/cql/Library/FHIR-ModelInfo|4.0.1</tt>\n    \n    \n    \n  </td>\n</tr>\n\n<tr>\n  \n  \n  \n  \n  \n\n<th scope=\"row\" class=\"row-header\">Dependency</th>\n\n\n  \n  \n  <td class=\"content-container\">\n    \n    <em>Description</em>: Library FHIRHelpers\n    \n    <br/>\n    \n    \n    \n    \n    \n    \n    <em>Resource</em>: <a href=\"http://hl7.org/fhir/uv/cql/STU2/Library-FHIRHelpers.html\">http://hl7.org/fhir/uv/cql/Library/FHIRHelpers|4.0.1</a>\n    <br/>\n    <em>Canonical URL</em>: <tt>http://hl7.org/fhir/uv/cql/Library/FHIRHelpers|4.0.1</tt>\n    \n    \n    \n  </td>\n</tr>\n\n\n\n\n\n\n\n\n<tr>\n  <th scope=\"row\" class=\"row-header\">Data Requirement</th>\n  <td class=\"content-container\">\n    <em>Type</em>: MedicationRequest\n    <br/>\n  \n    <em>Profile(s)</em>: \n  \n    <a href=\"http://hl7.org/fhir/us/core/STU7/StructureDefinition-us-core-medicationrequest.html\">US Core MedicationRequest Profile</a>\n    <br/>        \n  \n   \n   \n    <em>Must Support Elements</em>: id\n    <br/>\n   \n   \n  </td>\n</tr>\n\n<tr>\n\n\n<th colspan=\"2\" scope=\"row\" class=\"row-header\"><a name=\"parameters\"> </a>Parameters</th>\n\n\n</tr>\n\n<tr>\n  \n\n<th scope=\"row\" class=\"row-header\"/>\n\n\n  <td class=\"content-container\">\n    <table>\n      <thead>\n        <tr>\n          <td><em>Name</em></td>\n          <td><em>Use</em></td>\n          <td><em>Card.</em></td>\n          <td><em>Type</em></td>\n          <td>Documentation</td>\n        </tr>\n      </thead>\n      <tbody>\n      \n        <tr>\n          <td>MedicationRequest</td>\n          <td>In</td>\n          <td>0..1</td>\n          <td>Resource</td>\n          <td/>\n        </tr>\n      \n        <tr>\n          <td>Urgency</td>\n          <td>Out</td>\n          <td>0..1</td>\n          <td>string</td>\n          <td/>\n        </tr>\n      \n      </tbody>\n    </table>\n  </td>\n</tr>\n\n\n\n\n\n<tr>\n  <th colspan=\"2\" scope=\"row\" class=\"row-header\">Generated using version 0.5.3-cibuild of the sample-content-ig Liquid templates</th>\n</tr>\n\n    </tbody>\n  </table>\n</div>"^^rdf:XMLLiteral ]
      ] ; #
      fhir:contained ( [
    a fhir:Library ;
    fhir:id [ fhir:v "effective-data-requirements" ] ;
        ( fhir:extension [
          ( fhir:extension [
    fhir:url [
    fhir:v "libraryName"^^xsd:anyURI ;
    fhir:l fhir:libraryName         ] ;
    fhir:value [
    a fhir:String ;
    fhir:v "UPPARFInitialExpressions"         ]       ] [
    fhir:url [
    fhir:v "name"^^xsd:anyURI ;
    fhir:l fhir:name         ] ;
    fhir:value [
    a fhir:String ;
    fhir:v "Retrieve Medication Request test parameter"         ]       ] [
    fhir:url [
    fhir:v "statement"^^xsd:anyURI ;
    fhir:l fhir:statement         ] ;
    fhir:value [
    a fhir:String ;
    fhir:v "define \"Retrieve Medication Request test parameter\":\n  // The VSCode extension doesn't support parameters\n  // When executing CQL with the VSCode extension retrieve the resource specific for the test case\n  //   the list of resource ids match the resources from the test case folders\n  singleton from ([USCore.MedicationRequestProfile] MR where MR.id in { \n    'reference-nizatidine',                 // from tests/library/UPPARFInitialExpressions/example/MedicationRequest-new-reference-nizatidine.json\n    'MedicationRequest-1-nizatidine',       // from tests/library/UPPARFInitialExpressions/Patient-example-UPPARF-1/MedicationRequest-1-nizatidine.json\n    'MedicationRequest-lisinopril-example'  // from tests/library/UPPARFInitialExpressions/Patient-example-UPPARF-2/MedicationRequest-lisinopril-example.json\n  })"         ]       ] [
    fhir:url [
    fhir:v "displaySequence"^^xsd:anyURI ;
    fhir:l fhir:displaySequence         ] ;
    fhir:value [
    a fhir:Integer ;
    fhir:v 0         ]       ] ) ;
    fhir:url [
    fhir:v "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition>       ]     ] [
          ( fhir:extension [
    fhir:url [
    fhir:v "libraryName"^^xsd:anyURI ;
    fhir:l fhir:libraryName         ] ;
    fhir:value [
    a fhir:String ;
    fhir:v "UPPARFInitialExpressions"         ]       ] [
    fhir:url [
    fhir:v "name"^^xsd:anyURI ;
    fhir:l fhir:name         ] ;
    fhir:value [
    a fhir:String ;
    fhir:v "Medication Request"         ]       ] [
    fhir:url [
    fhir:v "statement"^^xsd:anyURI ;
    fhir:l fhir:statement         ] ;
    fhir:value [
    a fhir:String ;
    fhir:v "define \"Medication Request\":\n  Coalesce(\n    MedicationRequest,\n    \"Retrieve Medication Request test parameter\"\n  )"         ]       ] [
    fhir:url [
    fhir:v "displaySequence"^^xsd:anyURI ;
    fhir:l fhir:displaySequence         ] ;
    fhir:value [
    a fhir:Integer ;
    fhir:v 1         ]       ] ) ;
    fhir:url [
    fhir:v "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition>       ]     ] [
          ( fhir:extension [
    fhir:url [
    fhir:v "libraryName"^^xsd:anyURI ;
    fhir:l fhir:libraryName         ] ;
    fhir:value [
    a fhir:String ;
    fhir:v "UPPARFInitialExpressions"         ]       ] [
    fhir:url [
    fhir:v "name"^^xsd:anyURI ;
    fhir:l fhir:name         ] ;
    fhir:value [
    a fhir:String ;
    fhir:v "Most Recent Medication Request"         ]       ] [
    fhir:url [
    fhir:v "statement"^^xsd:anyURI ;
    fhir:l fhir:statement         ] ;
    fhir:value [
    a fhir:String ;
    fhir:v "define \"Most Recent Medication Request\":\n  \"Medication Request\""         ]       ] [
    fhir:url [
    fhir:v "displaySequence"^^xsd:anyURI ;
    fhir:l fhir:displaySequence         ] ;
    fhir:value [
    a fhir:Integer ;
    fhir:v 2         ]       ] ) ;
    fhir:url [
    fhir:v "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition>       ]     ] [
          ( fhir:extension [
    fhir:url [
    fhir:v "libraryName"^^xsd:anyURI ;
    fhir:l fhir:libraryName         ] ;
    fhir:value [
    a fhir:String ;
    fhir:v "UPPARFInitialExpressions"         ]       ] [
    fhir:url [
    fhir:v "name"^^xsd:anyURI ;
    fhir:l fhir:name         ] ;
    fhir:value [
    a fhir:String ;
    fhir:v "Urgency"         ]       ] [
    fhir:url [
    fhir:v "statement"^^xsd:anyURI ;
    fhir:l fhir:statement         ] ;
    fhir:value [
    a fhir:String ;
    fhir:v "define \"Urgency\":\n\"Most Recent Medication Request\".priority P\n  return (\n    if P != 'routine' then 'Urgent'\n    else  'Not Urgent'\n  )"         ]       ] [
    fhir:url [
    fhir:v "displaySequence"^^xsd:anyURI ;
    fhir:l fhir:displaySequence         ] ;
    fhir:value [
    a fhir:Integer ;
    fhir:v 3         ]       ] ) ;
    fhir:url [
    fhir:v "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition>       ]     ] [
          ( fhir:extension [
    fhir:url [
    fhir:v "libraryName"^^xsd:anyURI ;
    fhir:l fhir:libraryName         ] ;
    fhir:value [
    a fhir:String ;
    fhir:v "FHIRHelpers"         ]       ] [
    fhir:url [
    fhir:v "name"^^xsd:anyURI ;
    fhir:l fhir:name         ] ;
    fhir:value [
    a fhir:String ;
    fhir:v "ToString"         ]       ] [
    fhir:url [
    fhir:v "statement"^^xsd:anyURI ;
    fhir:l fhir:statement         ] ;
    fhir:value [
    a fhir:String ;
    fhir:v "define function ToString(value string): value.value"         ]       ] [
    fhir:url [
    fhir:v "displaySequence"^^xsd:anyURI ;
    fhir:l fhir:displaySequence         ] ;
    fhir:value [
    a fhir:Integer ;
    fhir:v 4         ]       ] ) ;
    fhir:url [
    fhir:v "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition>       ]     ] [
          ( fhir:extension [
    fhir:url [
    fhir:v "libraryName"^^xsd:anyURI ;
    fhir:l fhir:libraryName         ] ;
    fhir:value [
    a fhir:String ;
    fhir:v "FHIRHelpers"         ]       ] [
    fhir:url [
    fhir:v "name"^^xsd:anyURI ;
    fhir:l fhir:name         ] ;
    fhir:value [
    a fhir:String ;
    fhir:v "ToString"         ]       ] [
    fhir:url [
    fhir:v "statement"^^xsd:anyURI ;
    fhir:l fhir:statement         ] ;
    fhir:value [
    a fhir:String ;
    fhir:v "define function ToString(value MedicationRequestPriority): value.value"         ]       ] [
    fhir:url [
    fhir:v "displaySequence"^^xsd:anyURI ;
    fhir:l fhir:displaySequence         ] ;
    fhir:value [
    a fhir:Integer ;
    fhir:v 5         ]       ] ) ;
    fhir:url [
    fhir:v "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition>       ]     ] ) ;
    fhir:name [ fhir:v "EffectiveDataRequirements" ] ;
    fhir:status [ fhir:v "active" ] ;
    fhir:type [
          ( fhir:coding [
    fhir:system [
    fhir:v "http://terminology.hl7.org/CodeSystem/library-type"^^xsd:anyURI ;
    fhir:l <http://terminology.hl7.org/CodeSystem/library-type>         ] ;
    fhir:code [ fhir:v "module-definition" ]       ] )     ] ;
        ( fhir:relatedArtifact [
    fhir:type [ fhir:v "depends-on" ] ;
    fhir:display [ fhir:v "USCore model information" ] ;
    fhir:resource [
    fhir:v "http://hl7.org/fhir/us/cql/Library/USCore-ModelInfo|6.1.0-derived"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/us/cql/Library/USCore-ModelInfo?version=6.1.0-derived>       ]     ] [
    fhir:type [ fhir:v "depends-on" ] ;
    fhir:display [ fhir:v "FHIR model information" ] ;
    fhir:resource [
    fhir:v "http://hl7.org/fhir/uv/cql/Library/FHIR-ModelInfo|4.0.1"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/uv/cql/Library/FHIR-ModelInfo?version=4.0.1>       ]     ] [
    fhir:type [ fhir:v "depends-on" ] ;
    fhir:display [ fhir:v "Library FHIRHelpers" ] ;
    fhir:resource [
    fhir:v "http://hl7.org/fhir/uv/cql/Library/FHIRHelpers|4.0.1"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/uv/cql/Library/FHIRHelpers?version=4.0.1>       ]     ] ) ;
        ( fhir:parameter [
    fhir:name [ fhir:v "MedicationRequest" ] ;
    fhir:use [ fhir:v "in" ] ;
    fhir:min [ fhir:v 0 ] ;
    fhir:max [ fhir:v "1" ] ;
    fhir:type [ fhir:v "Resource" ]     ] [
    fhir:name [ fhir:v "Urgency" ] ;
    fhir:use [ fhir:v "out" ] ;
    fhir:min [ fhir:v 0 ] ;
    fhir:max [ fhir:v "1" ] ;
    fhir:type [ fhir:v "string" ]     ] ) ;
        ( fhir:dataRequirement [
    fhir:type [ fhir:v "MedicationRequest" ] ;
          ( fhir:profile [
    fhir:v "http://hl7.org/fhir/us/core/StructureDefinition/us-core-medicationrequest"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/us/core/StructureDefinition/us-core-medicationrequest>       ] ) ;
          ( fhir:mustSupport [ fhir:v "id" ] )     ] [
    fhir:type [ fhir:v "MedicationRequest" ] ;
          ( fhir:profile [
    fhir:v "http://hl7.org/fhir/us/core/StructureDefinition/us-core-medicationrequest"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/us/core/StructureDefinition/us-core-medicationrequest>       ] ) ;
          ( fhir:mustSupport [ fhir:v "id" ] )     ] )
      ] ) ; #
      fhir:extension ( [
    fhir:url [
    fhir:v "http://hl7.org/fhir/StructureDefinition/cqf-library"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/StructureDefinition/cqf-library>     ] ;
    fhir:value [
    a fhir:Canonical ;
    fhir:v "http://hl7.org/fhir/us/cql/Library/UPPARFInitialExpressions"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/us/cql/Library/UPPARFInitialExpressions>     ]
      ] [
        ( fhir:extension [
    fhir:url [
    fhir:v "name"^^xsd:anyURI ;
    fhir:l fhir:name       ] ;
    fhir:value [
    a fhir:Coding ;
    fhir:system [
    fhir:v "http://hl7.org/fhir/uv/sdc/CodeSystem/launchContext"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/uv/sdc/CodeSystem/launchContext>         ] ;
    fhir:code [ fhir:v "patient" ] ;
    fhir:display [ fhir:v "Patient" ]       ]     ] [
    fhir:url [
    fhir:v "type"^^xsd:anyURI ;
    fhir:l fhir:type       ] ;
    fhir:value [
    a fhir:Code ;
    fhir:v "Patient"       ]     ] [
    fhir:url [
    fhir:v "description"^^xsd:anyURI ;
    fhir:l fhir:description       ] ;
    fhir:value [
    a fhir:String ;
    fhir:v "The patient that is to be used to pre-populate the form"       ]     ] ) ;
    fhir:url [
    fhir:v "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-launchContext"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-launchContext>     ]
      ] [
        ( fhir:extension [
    fhir:url [
    fhir:v "name"^^xsd:anyURI ;
    fhir:l fhir:name       ] ;
    fhir:value [
    a fhir:Coding ;
    fhir:system [
    fhir:v "http://example.org/fhir/CodeSystem/additionalLaunchContext"^^xsd:anyURI ;
    fhir:l <http://example.org/fhir/CodeSystem/additionalLaunchContext>         ] ;
    fhir:code [ fhir:v "MedicationRequest" ] ;
    fhir:display [ fhir:v "MedicationRequest" ]       ]     ] [
    fhir:url [
    fhir:v "type"^^xsd:anyURI ;
    fhir:l fhir:type       ] ;
    fhir:value [
    a fhir:Code ;
    fhir:v "MedicationRequest"       ]     ] [
    fhir:url [
    fhir:v "description"^^xsd:anyURI ;
    fhir:l fhir:description       ] ;
    fhir:value [
    a fhir:String ;
    fhir:v "The MedicationRequest that is to be used to pre-populate the form"       ]     ] ) ;
    fhir:url [
    fhir:v "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-launchContext"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-launchContext>     ]
      ] [
    fhir:url [
    fhir:v "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/StructureDefinition/structuredefinition-wg>     ] ;
    fhir:value [
    a fhir:Code ;
    fhir:v "cds"     ]
      ] [
    fhir:url [
    fhir:v "http://hl7.org/fhir/uv/crmi/StructureDefinition/crmi-effectiveDataRequirements"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/uv/crmi/StructureDefinition/crmi-effectiveDataRequirements>     ] ;
    fhir:value [
    a fhir:Canonical ;
    fhir:v "#effective-data-requirements"^^xsd:anyURI ;
    fhir:l <#effective-data-requirements>     ]
      ] [
    fhir:url [
    fhir:v "http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status>     ] ;
    fhir:value [
    a fhir:Code ;
    fhir:v "informative" ;
          ( fhir:extension [
    fhir:url [
    fhir:v "http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom>         ] ;
    fhir:value [
    a fhir:Canonical ;
    fhir:v "http://hl7.org/fhir/us/cql/ImplementationGuide/hl7.fhir.us.cql"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/us/cql/ImplementationGuide/hl7.fhir.us.cql>         ]       ] )     ]
      ] ) ; #
      fhir:url [
    fhir:v "http://hl7.org/fhir/us/cql/Questionnaire/UPPARFQuestionnaire"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/us/cql/Questionnaire/UPPARFQuestionnaire>
      ] ; #
      fhir:version [ fhir:v "2.0.0-ballot"] ; #
      fhir:name [ fhir:v "UPPARFQuestionnaire"] ; #
      fhir:title [ fhir:v "Example Uniform Pharmacy Prior Authorization Request Form"] ; #
      fhir:status [ fhir:v "active"] ; #
      fhir:experimental [ fhir:v true] ; #
      fhir:date [ fhir:v "2023-10-19T00:00:00+00:00"^^xsd:dateTime] ; #
      fhir:publisher [ fhir:v "HL7 International / Clinical Decision Support"] ; #
      fhir:contact ( [
        ( fhir:telecom [
    fhir:system [ fhir:v "url" ] ;
    fhir:value [ fhir:v "http://www.hl7.org/Special/committees/dss" ]     ] )
      ] ) ; #
      fhir:description [ fhir:v "This is an example of a prior authorization questionnaire developed based on an existing industry prior-authorization form."] ; #
      fhir:jurisdiction ( [
        ( fhir:coding [
    fhir:system [
    fhir:v "urn:iso:std:iso:3166"^^xsd:anyURI ;
    fhir:l <urn:iso:std:iso:3166>       ] ;
    fhir:code [ fhir:v "US" ] ;
    fhir:display [ fhir:v "United States of America" ]     ] )
      ] ) ; #
      fhir:copyright [ fhir:v "This content is informed by the following source, used with permission: https://docushare-web.apps.external.pioneer.humana.com/Marketing/docushare-app?file=4136509"] ; #
      fhir:item ( [
        ( fhir:extension [
    fhir:url [
    fhir:v "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression>       ] ;
    fhir:value [
    a fhir:Expression ;
    fhir:language [ fhir:v "text/cql-identifier" ] ;
    fhir:expression [ fhir:v "Urgency" ]       ]     ] ) ;
    fhir:linkId [ fhir:v "urgency" ] ;
    fhir:text [ fhir:v "Urgency" ] ;
    fhir:type [ fhir:v "choice" ] ;
        ( fhir:answerOption [
    fhir:value [
    a fhir:Coding ;
    fhir:system [
    fhir:v "http://example.org/fhir/CodeSystem/UPPARFQuestionnaire-urgency"^^xsd:anyURI ;
    fhir:l <http://example.org/fhir/CodeSystem/UPPARFQuestionnaire-urgency>         ] ;
    fhir:code [ fhir:v "urgent" ] ;
    fhir:display [ fhir:v "Urgent" ]       ]     ] [
    fhir:value [
    a fhir:Coding ;
    fhir:system [
    fhir:v "http://example.org/fhir/CodeSystem/UPPARFQuestionnaire-urgency"^^xsd:anyURI ;
    fhir:l <http://example.org/fhir/CodeSystem/UPPARFQuestionnaire-urgency>         ] ;
    fhir:code [ fhir:v "routine" ] ;
    fhir:display [ fhir:v "Non-Urgent" ]       ]     ] )
      ] [
    fhir:linkId [ fhir:v "drug-info" ] ;
    fhir:text [ fhir:v "Drug Information" ] ;
    fhir:type [ fhir:v "group" ] ;
        ( fhir:item [
          ( fhir:extension [
    fhir:url [
    fhir:v "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression>         ] ;
    fhir:value [
    a fhir:Expression ;
    fhir:language [ fhir:v "text/cql-identifier" ] ;
    fhir:expression [ fhir:v "Most Recent Medication Name" ]         ]       ] ) ;
    fhir:linkId [ fhir:v "drug-info|drug-name" ] ;
    fhir:text [ fhir:v "Requested Drug Name" ] ;
    fhir:type [ fhir:v "string" ]     ] [
          ( fhir:extension [
    fhir:url [
    fhir:v "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression>         ] ;
    fhir:value [
    a fhir:Expression ;
    fhir:language [ fhir:v "text/cql-identifier" ] ;
    fhir:expression [ fhir:v "Is Opioid Treatment" ]         ]       ] ) ;
    fhir:linkId [ fhir:v "drug-info|drug-intention-opioid" ] ;
    fhir:text [ fhir:v "Is this drug intended to treat opioid dependence?" ] ;
    fhir:type [ fhir:v "boolean" ] ;
          ( fhir:item [
            ( fhir:extension [
    fhir:url [
    fhir:v "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression>           ] ;
    fhir:value [
    a fhir:Expression ;
    fhir:language [ fhir:v "text/cql-identifier" ] ;
    fhir:expression [ fhir:v "Is First Prior Authentication" ]           ]         ] ) ;
    fhir:linkId [ fhir:v "drug-info|drug-intention-opioid|first-prior-authentication" ] ;
    fhir:text [ fhir:v "Is this a first request for prior authorization for this drug?" ] ;
    fhir:type [ fhir:v "boolean" ] ;
            ( fhir:enableWhen [
    fhir:question [ fhir:v "drug-info|drug-intention-opioid" ] ;
    fhir:operator [ fhir:v "=" ] ;
    fhir:answer [
    a fhir:Boolean ;
    fhir:v true           ]         ] )       ] [
            ( fhir:extension [
    fhir:url [
    fhir:v "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression>           ] ;
    fhir:value [
    a fhir:Expression ;
    fhir:language [ fhir:v "text/cql-identifier" ] ;
    fhir:expression [ fhir:v "Initial Request Date" ]           ]         ] ) ;
    fhir:linkId [ fhir:v "drug-info|drug-intention-opioid|date-first-request" ] ;
    fhir:text [ fhir:v "What was the date of the first request?" ] ;
    fhir:type [ fhir:v "date" ] ;
            ( fhir:enableWhen [
    fhir:question [ fhir:v "drug-info|drug-intention-opioid|first-prior-authentication" ] ;
    fhir:operator [ fhir:v "=" ] ;
    fhir:answer [
    a fhir:Boolean ;
    fhir:v false           ]         ] )       ] [
            ( fhir:extension [
    fhir:url [
    fhir:v "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression>           ] ;
    fhir:value [
    a fhir:Expression ;
    fhir:language [ fhir:v "text/cql-identifier" ] ;
    fhir:expression [ fhir:v "Is First Request > 12 Months" ]           ]         ] ) ;
    fhir:linkId [ fhir:v "drug-info|drug-intention-opioid|twelve-months-since-request" ] ;
    fhir:text [ fhir:v "Has the date of the first request been greater than twelve months ago?" ] ;
    fhir:type [ fhir:v "boolean" ] ;
            ( fhir:enableWhen [
    fhir:question [ fhir:v "drug-info|drug-intention-opioid|first-prior-authentication" ] ;
    fhir:operator [ fhir:v "=" ] ;
    fhir:answer [
    a fhir:Boolean ;
    fhir:v false           ]         ] )       ] )     ] )
      ] [
    fhir:linkId [ fhir:v "completing-form" ] ;
    fhir:text [ fhir:v "Prior authentication is required and this form needs to be completed" ] ;
    fhir:type [ fhir:v "group" ] ;
        ( fhir:enableWhen [
    fhir:question [ fhir:v "drug-info|drug-intention-opioid" ] ;
    fhir:operator [ fhir:v "=" ] ;
    fhir:answer [
    a fhir:Boolean ;
    fhir:v false       ]     ] [
    fhir:question [ fhir:v "drug-info|drug-intention-opioid|twelve-months-since-request" ] ;
    fhir:operator [ fhir:v "=" ] ;
    fhir:answer [
    a fhir:Boolean ;
    fhir:v false       ]     ] ) ;
    fhir:enableBehavior [ fhir:v "any" ] ;
        ( fhir:item [
    fhir:linkId [ fhir:v "completing-form|patient-info" ] ;
    fhir:text [ fhir:v "Patient Info" ] ;
    fhir:type [ fhir:v "group" ] ;
          ( fhir:item [
            ( fhir:extension [
    fhir:url [
    fhir:v "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression>           ] ;
    fhir:value [
    a fhir:Expression ;
    fhir:language [ fhir:v "text/cql-identifier" ] ;
    fhir:expression [ fhir:v "Prescription Date" ]           ]         ] ) ;
    fhir:linkId [ fhir:v "completing-form|patient-info|prescription-date" ] ;
    fhir:text [ fhir:v "Prescription Date" ] ;
    fhir:type [ fhir:v "string" ]       ] )     ] [
    fhir:linkId [ fhir:v "completing-form|prescriber-info" ] ;
    fhir:text [ fhir:v "Prescriber Info" ] ;
    fhir:type [ fhir:v "group" ] ;
          ( fhir:item [
            ( fhir:extension [
    fhir:url [
    fhir:v "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression>           ] ;
    fhir:value [
    a fhir:Expression ;
    fhir:language [ fhir:v "text/cql-identifier" ] ;
    fhir:expression [ fhir:v "Prescriber Name" ]           ]         ] ) ;
    fhir:linkId [ fhir:v "completing-form|prescriber-info|prescriber-name" ] ;
    fhir:text [ fhir:v "Prescriber Name" ] ;
    fhir:type [ fhir:v "string" ]       ] [
            ( fhir:extension [
    fhir:url [
    fhir:v "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression>           ] ;
    fhir:value [
    a fhir:Expression ;
    fhir:language [ fhir:v "text/cql-identifier" ] ;
    fhir:expression [ fhir:v "Prescriber Fax" ]           ]         ] ) ;
    fhir:linkId [ fhir:v "completing-form|prescriber-info|prescriber-fax" ] ;
    fhir:text [ fhir:v "Prescriber Fax" ] ;
    fhir:type [ fhir:v "string" ]       ] [
            ( fhir:extension [
    fhir:url [
    fhir:v "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression>           ] ;
    fhir:value [
    a fhir:Expression ;
    fhir:language [ fhir:v "text/cql-identifier" ] ;
    fhir:expression [ fhir:v "Prescriber Phone" ]           ]         ] ) ;
    fhir:linkId [ fhir:v "completing-form|prescriber-info|prescriber-phone" ] ;
    fhir:text [ fhir:v "Prescriber Phone" ] ;
    fhir:type [ fhir:v "string" ]       ] [
            ( fhir:extension [
    fhir:url [
    fhir:v "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression>           ] ;
    fhir:value [
    a fhir:Expression ;
    fhir:language [ fhir:v "text/cql-identifier" ] ;
    fhir:expression [ fhir:v "Prescriber Pager" ]           ]         ] ) ;
    fhir:linkId [ fhir:v "completing-form|prescriber-info|prescriber-pager" ] ;
    fhir:text [ fhir:v "Prescriber Pager" ] ;
    fhir:type [ fhir:v "string" ]       ] [
            ( fhir:extension [
    fhir:url [
    fhir:v "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression>           ] ;
    fhir:value [
    a fhir:Expression ;
    fhir:language [ fhir:v "text/cql-identifier" ] ;
    fhir:expression [ fhir:v "Prescriber Address" ]           ]         ] ) ;
    fhir:linkId [ fhir:v "completing-form|prescriber-info|prescriber-address" ] ;
    fhir:text [ fhir:v "Prescriber Address" ] ;
    fhir:type [ fhir:v "string" ]       ] [
            ( fhir:extension [
    fhir:url [
    fhir:v "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression>           ] ;
    fhir:value [
    a fhir:Expression ;
    fhir:language [ fhir:v "text/cql-identifier" ] ;
    fhir:expression [ fhir:v "Prescriber Contact" ]           ]         ] ) ;
    fhir:linkId [ fhir:v "completing-form|prescriber-info|prescriber-contact" ] ;
    fhir:text [ fhir:v "Prescriber Office Contact" ] ;
    fhir:type [ fhir:v "string" ]       ] [
            ( fhir:extension [
    fhir:url [
    fhir:v "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression>           ] ;
    fhir:value [
    a fhir:Expression ;
    fhir:language [ fhir:v "text/cql-identifier" ] ;
    fhir:expression [ fhir:v "Prescriber NPI" ]           ]         ] ) ;
    fhir:linkId [ fhir:v "completing-form|prescriber-info|prescriber-npi" ] ;
    fhir:text [ fhir:v "Prescriber NPI" ] ;
    fhir:type [ fhir:v "string" ]       ] [
            ( fhir:extension [
    fhir:url [
    fhir:v "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression>           ] ;
    fhir:value [
    a fhir:Expression ;
    fhir:language [ fhir:v "text/cql-identifier" ] ;
    fhir:expression [ fhir:v "Prescriber DEA" ]           ]         ] ) ;
    fhir:linkId [ fhir:v "completing-form|prescriber-info|prescriber-dea" ] ;
    fhir:text [ fhir:v "Prescriber DEA" ] ;
    fhir:type [ fhir:v "string" ]       ] [
            ( fhir:extension [
    fhir:url [
    fhir:v "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression>           ] ;
    fhir:value [
    a fhir:Expression ;
    fhir:language [ fhir:v "text/cql-identifier" ] ;
    fhir:expression [ fhir:v "Prescriber Tax ID" ]           ]         ] ) ;
    fhir:linkId [ fhir:v "completing-form|prescriber-info|prescriber-tax-id" ] ;
    fhir:text [ fhir:v "Prescriber Tax ID" ] ;
    fhir:type [ fhir:v "string" ]       ] [
            ( fhir:extension [
    fhir:url [
    fhir:v "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression>           ] ;
    fhir:value [
    a fhir:Expression ;
    fhir:language [ fhir:v "text/cql-identifier" ] ;
    fhir:expression [ fhir:v "Prescriber Specialty" ]           ]         ] ) ;
    fhir:linkId [ fhir:v "completing-form|prescriber-info|prescriber-specialty" ] ;
    fhir:text [ fhir:v "Specialty/Facility Name If applicable" ] ;
    fhir:type [ fhir:v "string" ]       ] [
            ( fhir:extension [
    fhir:url [
    fhir:v "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression>           ] ;
    fhir:value [
    a fhir:Expression ;
    fhir:language [ fhir:v "text/cql-identifier" ] ;
    fhir:expression [ fhir:v "Prescriber Email Address" ]           ]         ] ) ;
    fhir:linkId [ fhir:v "completing-form|prescriber-info|prescriber-email" ] ;
    fhir:text [ fhir:v "Email Address" ] ;
    fhir:type [ fhir:v "string" ]       ] )     ] [
    fhir:linkId [ fhir:v "completing-form|drug-benefit" ] ;
    fhir:text [ fhir:v "Prior Authorization Request for Drug Benefit" ] ;
    fhir:type [ fhir:v "group" ] ;
          ( fhir:item [
            ( fhir:extension [
    fhir:url [
    fhir:v "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression>           ] ;
    fhir:value [
    a fhir:Expression ;
    fhir:language [ fhir:v "text/cql-identifier" ] ;
    fhir:expression [ fhir:v "Request Type" ]           ]         ] ) ;
    fhir:linkId [ fhir:v "completing-form|drug-benefit|request-type" ] ;
    fhir:text [ fhir:v "New Request" ] ;
    fhir:type [ fhir:v "choice" ] ;
            ( fhir:answerOption [
    fhir:value [
    a fhir:String ;
    fhir:v "New Request"           ]         ] [
    fhir:value [
    a fhir:String ;
    fhir:v "Reauthorization"           ]         ] )       ] [
            ( fhir:extension [
    fhir:url [
    fhir:v "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression>           ] ;
    fhir:value [
    a fhir:Expression ;
    fhir:language [ fhir:v "text/cql-identifier" ] ;
    fhir:expression [ fhir:v "ICD 10 Codes" ]           ]         ] ) ;
    fhir:linkId [ fhir:v "completing-form|drug-benefit|diagnosis-codes" ] ;
    fhir:text [ fhir:v "Patient ICD Diagnostic Codes" ] ;
    fhir:type [ fhir:v "open-choice" ] ;
    fhir:repeats [ fhir:v true ] ;
    fhir:answerValueSet [
    fhir:v "http://hl7.org/fhir/ValueSet/icd-10"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/ValueSet/icd-10>         ]       ] [
            ( fhir:extension [
    fhir:url [
    fhir:v "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression>           ] ;
    fhir:value [
    a fhir:Expression ;
    fhir:language [ fhir:v "text/cql-identifier" ] ;
    fhir:expression [ fhir:v "Diagnosis Descriptions" ]           ]         ] ) ;
    fhir:linkId [ fhir:v "completing-form|drug-benefit|diagnosis-descriptions" ] ;
    fhir:text [ fhir:v "Patient Diagnosis" ] ;
    fhir:type [ fhir:v "string" ] ;
    fhir:repeats [ fhir:v true ]       ] [
    fhir:linkId [ fhir:v "completing-form|drug-benefit|drugs" ] ;
    fhir:text [ fhir:v "Drugs Requested with J-Code; if applicable" ] ;
    fhir:type [ fhir:v "string" ] ;
    fhir:repeats [ fhir:v true ]       ] [
    fhir:linkId [ fhir:v "completing-form|drug-benefit|strength-route-frequency" ] ;
    fhir:text [ fhir:v "Strength/Route/Frequency" ] ;
    fhir:type [ fhir:v "string" ]       ] [
    fhir:linkId [ fhir:v "completing-form|drug-benefit|unit-volume" ] ;
    fhir:text [ fhir:v "Unit/Volume of Named Drugs" ] ;
    fhir:type [ fhir:v "string" ]       ] [
            ( fhir:extension [
    fhir:url [
    fhir:v "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression>           ] ;
    fhir:value [
    a fhir:Expression ;
    fhir:language [ fhir:v "text/cql-identifier" ] ;
    fhir:expression [ fhir:v "Start Date and Length" ]           ]         ] ) ;
    fhir:linkId [ fhir:v "completing-form|drug-benefit|start-length" ] ;
    fhir:text [ fhir:v "Start Date and Length of Therapy" ] ;
    fhir:type [ fhir:v "string" ]       ] [
    fhir:linkId [ fhir:v "completing-form|drug-benefit|location" ] ;
    fhir:text [ fhir:v "Location of Treatment e.g. provider office; facility; home health; etc. including name; Type 2 NPI if applicable; address and tax ID:" ] ;
    fhir:type [ fhir:v "string" ]       ] [
    fhir:linkId [ fhir:v "completing-form|drug-benefit|criteria" ] ;
    fhir:text [ fhir:v "Clinical Criteria for Approval; Including other Pertinent Information to Support the Request; other Medications Tried; Their Names; Duration; and Patient Response:" ] ;
    fhir:type [ fhir:v "string" ]       ] [
    fhir:linkId [ fhir:v "completing-form|drug-benefit|for-trial" ] ;
    fhir:text [ fhir:v "For use in clinical trial?" ] ;
    fhir:type [ fhir:v "boolean" ]       ] [
    fhir:linkId [ fhir:v "completing-form|drug-benefit|for-trial|registration-number" ] ;
    fhir:text [ fhir:v "Provide trial name and registration number" ] ;
    fhir:type [ fhir:v "string" ] ;
            ( fhir:enableWhen [
    fhir:question [ fhir:v "completing-form|drug-benefit|for-trial" ] ;
    fhir:operator [ fhir:v "=" ] ;
    fhir:answer [
    a fhir:Boolean ;
    fhir:v true           ]         ] )       ] [
    fhir:linkId [ fhir:v "completing-form|drug-benefit|drug-name" ] ;
    fhir:text [ fhir:v "Drug Name Brand Name and Scientific Name/Strength:" ] ;
    fhir:type [ fhir:v "string" ]       ] [
    fhir:linkId [ fhir:v "completing-form|drug-benefit|dose" ] ;
    fhir:text [ fhir:v "Dose" ] ;
    fhir:type [ fhir:v "string" ]       ] [
    fhir:linkId [ fhir:v "completing-form|drug-benefit|route" ] ;
    fhir:text [ fhir:v "Route" ] ;
    fhir:type [ fhir:v "string" ]       ] [
    fhir:linkId [ fhir:v "completing-form|drug-benefit|frequency" ] ;
    fhir:text [ fhir:v "Frequency" ] ;
    fhir:type [ fhir:v "string" ]       ] [
    fhir:linkId [ fhir:v "completing-form|drug-benefit|quantity" ] ;
    fhir:text [ fhir:v "Quantity" ] ;
    fhir:type [ fhir:v "quantity" ]       ] [
    fhir:linkId [ fhir:v "completing-form|drug-benefit|refills" ] ;
    fhir:text [ fhir:v "Number of Refills" ] ;
    fhir:type [ fhir:v "integer" ]       ] [
    fhir:linkId [ fhir:v "completing-form|drug-benefit|delivery" ] ;
    fhir:text [ fhir:v "Product will be delivered to:" ] ;
    fhir:type [ fhir:v "choice" ] ;
            ( fhir:answerOption [
    fhir:value [
    a fhir:String ;
    fhir:v "Patient's Home"           ]         ] [
    fhir:value [
    a fhir:String ;
    fhir:v "Physician Office"           ]         ] [
    fhir:value [
    a fhir:String ;
    fhir:v "Other"           ]         ] )       ] [
    fhir:linkId [ fhir:v "completing-form|drug-benefit|signature" ] ;
    fhir:text [ fhir:v "Prescriber or Authorized Signature:" ] ;
    fhir:type [ fhir:v "attachment" ]       ] [
    fhir:linkId [ fhir:v "completing-form|drug-benefit|pharmacy" ] ;
    fhir:text [ fhir:v "Dispensing Pharmacy Name and Phone Number:" ] ;
    fhir:type [ fhir:v "string" ]       ] [
    fhir:linkId [ fhir:v "completing-form|drug-benefit|date" ] ;
    fhir:text [ fhir:v "Date" ] ;
    fhir:type [ fhir:v "date" ]       ] )     ] )
      ] ) . #