External - Cotellic Questionnaire - XML Representation - Universal API Implementation Guide v1.1.19

Universal API Implementation Guide - Local Development build (v1.1.19). See the Directory of published versions
: External - Cotellic Questionnaire - XML Representation

Active as of 2024-02-19


<Questionnaire xmlns="http://hl7.org/fhir">
  <id value="questionnaireCotellic"/>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><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 : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a href="http://build.fhir.org/formats.html#table" title="The linkId for the item">LinkId</a></th><th style="vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a href="http://build.fhir.org/formats.html#table" title="Text for the item">Text</a></th><th style="vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a href="http://build.fhir.org/formats.html#table" title="Minimum and Maximum # of times the the itemcan appear in the instance">Cardinality</a></th><th style="vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a href="http://build.fhir.org/formats.html#table" title="The type of the item">Type</a></th><th style="vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a href="http://build.fhir.org/formats.html#table" title="Additional information about the item">Description &amp; Constraints</a><span style="float: right"><a href="http://build.fhir.org/formats.html#table" title="Legend for this format"><img src="http://build.fhir.org/help16.png" 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 : 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"/> Cotellic</td><td style="vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Example of questionnaire to be filled out when submitting enrollment bundle for product Cotellic.</td><td style="vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"></td><td style="vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Questionnaire</td><td style="vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">https://fhir.developer.gene.com/Questionnaire/questionnaireCotellic#1.1.19</td></tr>
<tr style="border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7"><td style="vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck10.png)" id="item.applied-for-bipa" 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-boolean.png" alt="." style="background-color: #F7F7F7; background-color: inherit" title="Boolean" class="hierarchy"/> applied-for-bipa</td><td style="vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">BIPA Service Request Applied?</td><td style="vertical-align: top; text-align : 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 : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a href="http://build.fhir.org/codesystem-item-type.html#item-type-boolean">boolean</a></td><td style="vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/></tr>
<tr style="border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white"><td style="vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck10.png)" id="item.applied-for-starter" 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-boolean.png" alt="." style="background-color: white; background-color: inherit" title="Boolean" class="hierarchy"/> applied-for-starter</td><td style="vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Starter Service Request Applied?</td><td style="vertical-align: top; text-align : 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 : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a href="http://build.fhir.org/codesystem-item-type.html#item-type-boolean">boolean</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/></tr>
<tr style="border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7"><td style="vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck10.png)" id="item.applied-for-copay" 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-boolean.png" alt="." style="background-color: #F7F7F7; background-color: inherit" title="Boolean" class="hierarchy"/> applied-for-copay</td><td style="vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Copay Service Request Applied?</td><td style="vertical-align: top; text-align : 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 : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a href="http://build.fhir.org/codesystem-item-type.html#item-type-boolean">boolean</a></td><td style="vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/></tr>
<tr style="border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white"><td style="vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck10.png)" id="item.applied-for-appeals" 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-boolean.png" alt="." style="background-color: white; background-color: inherit" title="Boolean" class="hierarchy"/> applied-for-appeals</td><td style="vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Appeals Service Request Applied?</td><td style="vertical-align: top; text-align : 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 : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a href="http://build.fhir.org/codesystem-item-type.html#item-type-boolean">boolean</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/></tr>
<tr style="border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7"><td style="vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck10.png)" id="item.applied-for-pf" 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-boolean.png" alt="." style="background-color: #F7F7F7; background-color: inherit" title="Boolean" class="hierarchy"/> applied-for-pf</td><td style="vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Patient Foundation Service Request Applied?</td><td style="vertical-align: top; text-align : 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 : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a href="http://build.fhir.org/codesystem-item-type.html#item-type-boolean">boolean</a></td><td style="vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/></tr>
<tr style="border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white"><td style="vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck10.png)" id="item.cotellic-unresectablemetastatic-melanoma" 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: white; background-color: inherit" title="Coding" class="hierarchy"/> cotellic-unresectablemetastatic-melanoma</td><td style="vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Does the patient have unresectable/metastatic melanoma? </td><td style="vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">1..1</td><td style="vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a href="http://build.fhir.org/codesystem-item-type.html#item-type-choice">choice</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Enable When: <span><a href="#item.applied-for-copay">applied-for-copay</a> = true</span></td></tr>
<tr style="border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7"><td style="vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck10.png)" id="item.contact-patient" 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-boolean.png" alt="." style="background-color: #F7F7F7; background-color: inherit" title="Boolean" class="hierarchy"/> contact-patient</td><td style="vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Do not contact patient</td><td style="vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">1..1</td><td style="vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a href="http://build.fhir.org/codesystem-item-type.html#item-type-boolean">boolean</a></td><td style="vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/></tr>
<tr style="border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white"><td style="vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck10.png)" id="item.cotellic-cotellic-in-combination-with-zelboraf-vemurafenib" 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: white; background-color: inherit" title="Coding" class="hierarchy"/> cotellic-cotellic-in-combination-with-zelboraf-vemurafenib</td><td style="vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Is Cotellic going to be used in combination with ZELBORAF® (vemurafenib)? </td><td style="vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">1..1</td><td style="vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a href="http://build.fhir.org/codesystem-item-type.html#item-type-choice">choice</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Enable When: <span><a href="#item.applied-for-copay">applied-for-copay</a> = true</span></td></tr>
<tr style="border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7"><td style="vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck10.png)" id="item.prescription-plan" 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-boolean.png" alt="." style="background-color: #F7F7F7; background-color: inherit" title="Boolean" class="hierarchy"/> prescription-plan</td><td style="vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Is this a Prescription plan?</td><td style="vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">1..1</td><td style="vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a href="http://build.fhir.org/codesystem-item-type.html#item-type-boolean">boolean</a></td><td style="vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/></tr>
<tr style="border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white"><td style="vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck10.png)" id="item.treatment-started" 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-boolean.png" alt="." style="background-color: white; background-color: inherit" title="Boolean" class="hierarchy"/> treatment-started</td><td style="vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Has treatment started?</td><td style="vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">1..1</td><td style="vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a href="http://build.fhir.org/codesystem-item-type.html#item-type-boolean">boolean</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Enable When: <span><a href="#item.applied-for-copay">applied-for-copay</a> = true</span></td></tr>
<tr style="border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7"><td style="vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck10.png)" id="item.prior-auth" 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-boolean.png" alt="." style="background-color: #F7F7F7; background-color: inherit" title="Boolean" class="hierarchy"/> prior-auth</td><td style="vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Is prior authorization in place?</td><td style="vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">1..1</td><td style="vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a href="http://build.fhir.org/codesystem-item-type.html#item-type-boolean">boolean</a></td><td style="vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Enable When: <span><a href="#item.applied-for-bipa">applied-for-bipa</a> = true</span></td></tr>
<tr style="border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white"><td style="vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck10.png)" id="item.auth" 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-boolean.png" alt="." style="background-color: white; background-color: inherit" title="Boolean" class="hierarchy"/> auth</td><td style="vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Authorization #</td><td style="vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">1..1</td><td style="vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a href="http://build.fhir.org/codesystem-item-type.html#item-type-boolean">boolean</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Enable When: <span><a href="#item.prior-auth">prior-auth</a> = true</span></td></tr>
<tr style="border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7"><td style="vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck10.png)" id="item.cotellic-drug-allergies" 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-string.png" alt="." style="background-color: #F7F7F7; background-color: inherit" title="String" class="hierarchy"/> cotellic-drug-allergies</td><td style="vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Drug Allergies?</td><td style="vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">1..1</td><td style="vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a href="http://build.fhir.org/codesystem-item-type.html#item-type-string">string</a></td><td style="vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Enable When: <span><a href="#item.applied-for-pf">applied-for-pf</a> = true</span></td></tr>
<tr style="border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white"><td style="vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck10.png)" id="item.cotellic-other-drug-allergies" 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-string.png" alt="." style="background-color: white; background-color: inherit" title="String" class="hierarchy"/> cotellic-other-drug-allergies</td><td style="vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Other Drug Allergies?</td><td style="vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">1..1</td><td style="vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a href="http://build.fhir.org/codesystem-item-type.html#item-type-string">string</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Enable When: <span><a href="#item.cotellic-drug-allergies">cotellic-drug-allergies</a> = Other</span></td></tr>
<tr style="border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7"><td style="vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck10.png)" id="item.cotellic-other-prescription" 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-string.png" alt="." style="background-color: #F7F7F7; background-color: inherit" title="String" class="hierarchy"/> cotellic-other-prescription</td><td style="vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Other Medicines Prescribed</td><td style="vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">1..1</td><td style="vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a href="http://build.fhir.org/codesystem-item-type.html#item-type-string">string</a></td><td style="vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Enable When: <span><a href="#item.applied-for-pf">applied-for-pf</a> = true</span></td></tr>
<tr style="border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white"><td style="vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck10.png)" id="item.shipment-options" 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-string.png" alt="." style="background-color: white; background-color: inherit" title="String" class="hierarchy"/> shipment-options</td><td style="vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Shipment Options</td><td style="vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">1..1</td><td style="vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a href="http://build.fhir.org/codesystem-item-type.html#item-type-string">string</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Enable When: <span><a href="#item.applied-for-pf">applied-for-pf</a> = true</span></td></tr>
<tr style="border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7"><td style="vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck10.png)" id="item.ship-to" 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-string.png" alt="." style="background-color: #F7F7F7; background-color: inherit" title="String" class="hierarchy"/> ship-to</td><td style="vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Ship To</td><td style="vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">1..1</td><td style="vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a href="http://build.fhir.org/codesystem-item-type.html#item-type-string">string</a></td><td style="vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Enable When: <ul><li><a href="#item.applied-for-pf">applied-for-pf</a> = true</li><li><a href="#item.applied-for-starter">applied-for-starter</a> = true</li></ul></td></tr>
<tr style="border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white"><td style="vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck10.png)" id="item.cotellic-positive-braf-v600e" 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: white; background-color: inherit" title="Coding" class="hierarchy"/> cotellic-positive-braf-v600e</td><td style="vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Has the patient been confirmed positive for BRAF V600E?</td><td style="vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">1..1</td><td style="vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a href="http://build.fhir.org/codesystem-item-type.html#item-type-choice">choice</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Enable When: <span><a href="#item.applied-for-copay">applied-for-copay</a> = true</span></td></tr>
<tr style="border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7"><td style="vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck10.png)" id="item.cotellic-positive-braf-v600k" 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"/> cotellic-positive-braf-v600k</td><td style="vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Has the patient been confirmed positive for BRAF V600K?</td><td style="vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">1..1</td><td style="vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a href="http://build.fhir.org/codesystem-item-type.html#item-type-choice">choice</a></td><td style="vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Enable When: <span><a href="#item.applied-for-copay">applied-for-copay</a> = true</span></td></tr>
<tr style="border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white"><td style="vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck10.png)" id="item.re-verify-benefits" 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: white; background-color: inherit" title="Coding" class="hierarchy"/> re-verify-benefits</td><td style="vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Re-verify benefits at PA expiration</td><td style="vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">1..1</td><td style="vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a href="http://build.fhir.org/codesystem-item-type.html#item-type-choice">choice</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Enable When: <span><a href="#item.applied-for-bipa">applied-for-bipa</a> = true</span></td></tr>
<tr style="border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7"><td style="vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck10.png)" id="item.specialty-pharmacy" 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"/> specialty-pharmacy</td><td style="vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Specialty Pharmacy?</td><td style="vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">1..1</td><td style="vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a href="http://build.fhir.org/codesystem-item-type.html#item-type-choice">choice</a></td><td style="vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Enable When: <span><a href="#item.applied-for-bipa">applied-for-bipa</a> = true</span></td></tr>
<tr style="border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white"><td style="vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck10.png)" id="item.preferred-sp" 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-string.png" alt="." style="background-color: white; background-color: inherit" title="String" class="hierarchy"/> preferred-sp</td><td style="vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Preferred Specialty Pharmacy (Optional)</td><td style="vertical-align: top; text-align : 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 : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a href="http://build.fhir.org/codesystem-item-type.html#item-type-string">string</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Enable When: <span><a href="#item.specialty-pharmacy">specialty-pharmacy</a> = true</span></td></tr>
<tr style="border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7"><td style="vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck10.png)" id="item.onsite-pharmacy" 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"/> onsite-pharmacy</td><td style="vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Onsite Pharmacy? </td><td style="vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">1..1</td><td style="vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a href="http://build.fhir.org/codesystem-item-type.html#item-type-choice">choice</a></td><td style="vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Enable When: <span><a href="#item.applied-for-bipa">applied-for-bipa</a> = true</span></td></tr>
<tr style="border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white"><td style="vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck10.png)" id="item.onsite-pharmacy-name" 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-string.png" alt="." style="background-color: white; background-color: inherit" title="String" class="hierarchy"/> onsite-pharmacy-name</td><td style="vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Onsite Pharmacy Name (Optional)</td><td style="vertical-align: top; text-align : 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 : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a href="http://build.fhir.org/codesystem-item-type.html#item-type-string">string</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Enable When: <span><a href="#item.onsite-pharmacy">onsite-pharmacy</a> = true</span></td></tr>
<tr style="border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7"><td style="vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck10.png)" id="item.line-of-therapy" 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"/> line-of-therapy</td><td style="vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Line of therapy?</td><td style="vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">1..1</td><td style="vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a href="http://build.fhir.org/codesystem-item-type.html#item-type-choice">choice</a></td><td style="vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Enable When: <span><a href="#item.applied-for-copay">applied-for-copay</a> = true</span></td></tr>
<tr style="border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white"><td style="vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck00.png)" id="item.line-of-therapy-other" 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-string.png" alt="." style="background-color: white; background-color: inherit" title="String" class="hierarchy"/> line-of-therapy-other</td><td style="vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Line of therapy-other?</td><td style="vertical-align: top; text-align : 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 : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a href="http://build.fhir.org/codesystem-item-type.html#item-type-string">string</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Enable When: <span><a href="#item.line-of-therapy">line-of-therapy</a> = other</span></td></tr>
<tr><td colspan="5" class="hierarchy"><br/><a href="http://build.fhir.org/formats.html#table" title="Legend for this format"><img src="http://build.fhir.org/help16.png" alt="doco" style="background-color: inherit"/> Documentation for this format</a></td></tr></table></div>
  </text>
  <url
       value="https://fhir.developer.gene.com/Questionnaire/questionnaireCotellic"/>
  <version value="1.1.19"/>
  <name value="Cotellic"/>
  <title value="Cotellic"/>
  <status value="active"/>
  <date value="2024-02-19T15:49:59-08:00"/>
  <contact>
    <name value="Krzysztof Wilczek"/>
    <telecom>
      <system value="email"/>
      <value value="mailto:wilczekk@gene.com"/>
    </telecom>
  </contact>
  <description
               value="Example of questionnaire to be filled out when submitting enrollment bundle for product Cotellic."/>
  <item>
    <linkId value="applied-for-bipa"/>
    <text value="BIPA Service Request Applied?"/>
    <type value="boolean"/>
    <required value="false"/>
  </item>
  <item>
    <linkId value="applied-for-starter"/>
    <text value="Starter Service Request Applied?"/>
    <type value="boolean"/>
    <required value="false"/>
  </item>
  <item>
    <linkId value="applied-for-copay"/>
    <text value="Copay Service Request Applied?"/>
    <type value="boolean"/>
    <required value="false"/>
  </item>
  <item>
    <linkId value="applied-for-appeals"/>
    <text value="Appeals Service Request Applied?"/>
    <type value="boolean"/>
    <required value="false"/>
  </item>
  <item>
    <linkId value="applied-for-pf"/>
    <text value="Patient Foundation Service Request Applied?"/>
    <type value="boolean"/>
    <required value="false"/>
  </item>
  <item>
    <linkId value="cotellic-unresectablemetastatic-melanoma"/>
    <text value="Does the patient have unresectable/metastatic melanoma? "/>
    <type value="choice"/>
    <enableWhen>
      <question value="applied-for-copay"/>
      <operator value="="/>
      <answerBoolean value="true"/>
    </enableWhen>
    <required value="true"/>
  </item>
  <item>
    <linkId value="contact-patient"/>
    <text value="Do not contact patient"/>
    <type value="boolean"/>
    <required value="true"/>
  </item>
  <item>
    <linkId
            value="cotellic-cotellic-in-combination-with-zelboraf-vemurafenib"/>
    <text
          value="Is Cotellic going to be used in combination with ZELBORAF® (vemurafenib)? "/>
    <type value="choice"/>
    <enableWhen>
      <question value="applied-for-copay"/>
      <operator value="="/>
      <answerBoolean value="true"/>
    </enableWhen>
    <required value="true"/>
  </item>
  <item>
    <linkId value="prescription-plan"/>
    <text value="Is this a Prescription plan?"/>
    <type value="boolean"/>
    <required value="true"/>
  </item>
  <item>
    <linkId value="treatment-started"/>
    <text value="Has treatment started?"/>
    <type value="boolean"/>
    <enableWhen>
      <question value="applied-for-copay"/>
      <operator value="="/>
      <answerBoolean value="true"/>
    </enableWhen>
    <required value="true"/>
  </item>
  <item>
    <linkId value="prior-auth"/>
    <text value="Is prior authorization in place?"/>
    <type value="boolean"/>
    <enableWhen>
      <question value="applied-for-bipa"/>
      <operator value="="/>
      <answerBoolean value="true"/>
    </enableWhen>
    <required value="true"/>
  </item>
  <item>
    <linkId value="auth"/>
    <text value="Authorization #"/>
    <type value="boolean"/>
    <enableWhen>
      <question value="prior-auth"/>
      <operator value="="/>
      <answerBoolean value="true"/>
    </enableWhen>
    <required value="true"/>
  </item>
  <item>
    <linkId value="cotellic-drug-allergies"/>
    <text value="Drug Allergies?"/>
    <type value="string"/>
    <enableWhen>
      <question value="applied-for-pf"/>
      <operator value="="/>
      <answerBoolean value="true"/>
    </enableWhen>
    <required value="true"/>
  </item>
  <item>
    <linkId value="cotellic-other-drug-allergies"/>
    <text value="Other Drug Allergies?"/>
    <type value="string"/>
    <enableWhen>
      <question value="cotellic-drug-allergies"/>
      <operator value="="/>
      <answerString value="Other"/>
    </enableWhen>
    <required value="true"/>
  </item>
  <item>
    <linkId value="cotellic-other-prescription"/>
    <text value="Other Medicines Prescribed"/>
    <type value="string"/>
    <enableWhen>
      <question value="applied-for-pf"/>
      <operator value="="/>
      <answerBoolean value="true"/>
    </enableWhen>
    <required value="true"/>
  </item>
  <item>
    <linkId value="shipment-options"/>
    <text value="Shipment Options"/>
    <type value="string"/>
    <enableWhen>
      <question value="applied-for-pf"/>
      <operator value="="/>
      <answerBoolean value="true"/>
    </enableWhen>
    <required value="true"/>
  </item>
  <item>
    <linkId value="ship-to"/>
    <text value="Ship To"/>
    <type value="string"/>
    <enableWhen>
      <question value="applied-for-pf"/>
      <operator value="="/>
      <answerBoolean value="true"/>
    </enableWhen>
    <enableWhen>
      <question value="applied-for-starter"/>
      <operator value="="/>
      <answerBoolean value="true"/>
    </enableWhen>
    <enableBehavior value="any"/>
    <required value="true"/>
  </item>
  <item>
    <linkId value="cotellic-positive-braf-v600e"/>
    <text value="Has the patient been confirmed positive for BRAF V600E?"/>
    <type value="choice"/>
    <enableWhen>
      <question value="applied-for-copay"/>
      <operator value="="/>
      <answerBoolean value="true"/>
    </enableWhen>
    <required value="true"/>
  </item>
  <item>
    <linkId value="cotellic-positive-braf-v600k"/>
    <text value="Has the patient been confirmed positive for BRAF V600K?"/>
    <type value="choice"/>
    <enableWhen>
      <question value="applied-for-copay"/>
      <operator value="="/>
      <answerBoolean value="true"/>
    </enableWhen>
    <required value="true"/>
  </item>
  <item>
    <linkId value="re-verify-benefits"/>
    <text value="Re-verify benefits at PA expiration"/>
    <type value="choice"/>
    <enableWhen>
      <question value="applied-for-bipa"/>
      <operator value="="/>
      <answerBoolean value="true"/>
    </enableWhen>
    <required value="true"/>
  </item>
  <item>
    <linkId value="specialty-pharmacy"/>
    <text value="Specialty Pharmacy?"/>
    <type value="choice"/>
    <enableWhen>
      <question value="applied-for-bipa"/>
      <operator value="="/>
      <answerBoolean value="true"/>
    </enableWhen>
    <required value="true"/>
  </item>
  <item>
    <linkId value="preferred-sp"/>
    <text value="Preferred Specialty Pharmacy (Optional)"/>
    <type value="string"/>
    <enableWhen>
      <question value="specialty-pharmacy"/>
      <operator value="="/>
      <answerBoolean value="true"/>
    </enableWhen>
    <required value="false"/>
  </item>
  <item>
    <linkId value="onsite-pharmacy"/>
    <text value="Onsite Pharmacy? "/>
    <type value="choice"/>
    <enableWhen>
      <question value="applied-for-bipa"/>
      <operator value="="/>
      <answerBoolean value="true"/>
    </enableWhen>
    <required value="true"/>
  </item>
  <item>
    <linkId value="onsite-pharmacy-name"/>
    <text value="Onsite Pharmacy Name (Optional)"/>
    <type value="string"/>
    <enableWhen>
      <question value="onsite-pharmacy"/>
      <operator value="="/>
      <answerBoolean value="true"/>
    </enableWhen>
    <required value="false"/>
  </item>
  <item>
    <linkId value="line-of-therapy"/>
    <text value="Line of therapy?"/>
    <type value="choice"/>
    <enableWhen>
      <question value="applied-for-copay"/>
      <operator value="="/>
      <answerBoolean value="true"/>
    </enableWhen>
    <required value="true"/>
  </item>
  <item>
    <linkId value="line-of-therapy-other"/>
    <text value="Line of therapy-other?"/>
    <type value="string"/>
    <enableWhen>
      <question value="line-of-therapy"/>
      <operator value="="/>
      <answerString value="other"/>
    </enableWhen>
    <required value="false"/>
  </item>
</Questionnaire>