Universal API Implementation Guide
1.1.19 - ci-build

Universal API Implementation Guide - Local Development build (v1.1.19). See the Directory of published versions

Questionnaire: External - Lucentis Questionnaire

Official URL: https://fhir.developer.gene.com/Questionnaire/questionnaireLucentis Version: 1.1.19
Active as of 2024-02-19 Computable Name: Lucentis

Example of questionnaire to be filled out when submitting enrollment bundle for product Lucentis.

LinkIdTextCardinalityTypeDescription & Constraintsdoco
.. LucentisExample of questionnaire to be filled out when submitting enrollment bundle for product Lucentis.Questionnairehttps://fhir.developer.gene.com/Questionnaire/questionnaireLucentis#1.1.19
... applied-for-bipaBIPA Service Request Applied?0..1boolean
... applied-for-starterStarter Service Request Applied?0..1boolean
... applied-for-copayCopay Service Request Applied?0..1boolean
... applied-for-appealsAppeals Service Request Applied?0..1boolean
... applied-for-pfPatient Foundation Service Request Applied?0..1boolean
... lucentis-s-p-neededSpecialty Pharmacy Needed for Dispensing?1..1stringEnable When: applied-for-bipa = true
... contact-patientDo not contact patient1..1boolean
... prescription-planIs this a Prescription plan?1..1boolean
... treatment-startedHas treatment started?1..1booleanEnable When: applied-for-copay = true
... adotAnticipated Date of Treatment (Optional)0..1booleanEnable When:
... posPlace of Service1..1booleanEnable When:
... eligibility-reasonEligibility Reason1..1booleanEnable When: applied-for-pf = true
... lucentis-drug-allergiesDrug Allergies?1..1stringEnable When: applied-for-pf = true
... lucentis-other-drug-allergiesOther Drug Allergies?1..1stringEnable When: lucentis-drug-allergies = Other
... lucentis-other-prescriptionOther Medicines Prescribed1..1stringEnable When: applied-for-pf = true
... shipment-optionsShipment Options1..1stringEnable When: applied-for-pf = true
... ship-toShip To1..1stringEnable When: applied-for-pf = true

doco Documentation for this format