diff --git a/.gitignore b/.gitignore new file mode 100644 index 00000000..cfb0ace8 --- /dev/null +++ b/.gitignore @@ -0,0 +1,60 @@ +# Environment variables +.env + +# Python +__pycache__/ +*.py[cod] +*$py.class +*.so +.Python +build/ +develop-eggs/ +dist/ +downloads/ +eggs/ +.eggs/ +lib/ +lib64/ +parts/ +sdist/ +var/ +wheels/ +*.egg-info/ +.installed.cfg +*.egg + +# Virtual Environment +venv/ +env/ +ENV/ +.venv/ +.env/ + +# IDE specific files +.idea/ +.vscode/ +*.swp +*.swo +.DS_Store + +# Jupyter Notebook +.ipynb_checkpoints + +# Testing +.coverage +htmlcov/ +.pytest_cache/ +.tox/ +.nox/ +coverage.xml +*.cover +.hypothesis/ + +# Distribution / packaging +.Python +*.manifest +*.spec + +# Logs +*.log +logs/ \ No newline at end of file diff --git a/Input Data/Adbulla/PA.pdf b/Input Data/Abdulla/PA.pdf similarity index 100% rename from Input Data/Adbulla/PA.pdf rename to Input Data/Abdulla/PA.pdf diff --git a/Input Data/Adbulla/referral_package.pdf b/Input Data/Abdulla/referral_package.pdf similarity index 100% rename from Input Data/Adbulla/referral_package.pdf rename to Input Data/Abdulla/referral_package.pdf diff --git a/Output Data/Abdulla/Completed_Form_Fields.json b/Output Data/Abdulla/Completed_Form_Fields.json new file mode 100644 index 00000000..50ccf7f3 --- /dev/null +++ b/Output Data/Abdulla/Completed_Form_Fields.json @@ -0,0 +1,2684 @@ +{ + "answers": [ + { + "name": "CB1", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "Start of treatment", + "context": "Subheading: Start of treatment. Indicates if this is the start of a new treatment cycle for the patient.", + "answer": "True" + }, + { + "name": "T2", + "page": 2, + "field_type_string": "Text", + "field_label": "Start date: (MM)", + "context": "Subheading: Start of treatment. Requires the month of the start date for a new treatment.", + "answer": "05" + }, + { + "name": "T3", + "page": 2, + "field_type_string": "Text", + "field_label": "Start date: (DD)", + "context": "Subheading: Start of treatment. Requires the day of the start date for a new treatment.", + "answer": "23" + }, + { + "name": "T4", + "page": 2, + "field_type_string": "Text", + "field_label": "Start date: (YYYY)", + "context": "Subheading: Start of treatment. Requires the year of the start date for a new treatment.", + "answer": "2024" + }, + { + "name": "CB5", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "Continuation of therapy", + "context": "Subheading: Continuation of therapy. Indicates if this request is for continuing an existing therapy.", + "answer": "False" + }, + { + "name": "T6", + "page": 2, + "field_type_string": "Text", + "field_label": "Date of last treatment: (MM)", + "context": "Subheading: Continuation of therapy. Requires the month of the last treatment date for continuing therapy.", + "answer": "null" + }, + { + "name": "T7", + "page": 2, + "field_type_string": "Text", + "field_label": "Date of last treatment: (DD)", + "context": "Subheading: Continuation of therapy. Requires the day of the last treatment date for continuing therapy.", + "answer": "null" + }, + { + "name": "T8", + "page": 2, + "field_type_string": "Text", + "field_label": "Date of last treatment: (YYYY)", + "context": "Subheading: Continuation of therapy. Requires the year of the last treatment date for continuing therapy.", + "answer": "null" + }, + { + "name": "T9", + "page": 2, + "field_type_string": "Text", + "field_label": "Precertification Requested By:", + "context": "Subheading: Precertification Requested By. Name of the person or entity requesting precertification.", + "answer": "Erfan Rostami, BSN, RN" + }, + { + "name": "T10", + "page": 2, + "field_type_string": "Text", + "field_label": "Phone:", + "context": "Subheading: Precertification Requested By. Phone number of the person or entity requesting precertification.", + "answer": "615-343-1176" + }, + { + "name": "T11", + "page": 2, + "field_type_string": "Text", + "field_label": "Fax:", + "context": "Subheading: Precertification Requested By. Fax number of the person or entity requesting precertification.", + "answer": "615-343-1219" + }, + { + "name": "T12", + "page": 2, + "field_type_string": "Text", + "field_label": "Patient First Name", + "context": "Subheading: A. PATIENT INFORMATION. The first name of the patient.", + "answer": "Shakh" + }, + { + "name": "T13", + "page": 2, + "field_type_string": "Text", + "field_label": "Patient Last Name", + "context": "Subheading: A. PATIENT INFORMATION. The last name of the patient.", + "answer": "Abdulla" + }, + { + "name": "T14", + "page": 2, + "field_type_string": "Text", + "field_label": "Patient DOB (MM/DD/YYYY)", + "context": "Subheading: A. PATIENT INFORMATION. The date of birth of the patient.", + "answer": "04/01/2001" + }, + { + "name": "T15", + "page": 2, + "field_type_string": "Text", + "field_label": "Address:", + "context": "Subheading: A. PATIENT INFORMATION. The street address of the patient.", + "answer": "425 Sherman Ave" + }, + { + "name": "T16", + "page": 2, + "field_type_string": "Text", + "field_label": "City:", + "context": "Subheading: A. PATIENT INFORMATION. The city of the patient's address.", + "answer": "Nashville" + }, + { + "name": "T17", + "page": 2, + "field_type_string": "Text", + "field_label": "State:", + "context": "Subheading: A. PATIENT INFORMATION. The state of the patient's address.", + "answer": "TN" + }, + { + "name": "T18", + "page": 2, + "field_type_string": "Text", + "field_label": "ZIP:", + "context": "Subheading: A. PATIENT INFORMATION. The ZIP code of the patient's address.", + "answer": "37995" + }, + { + "name": "T19", + "page": 2, + "field_type_string": "Text", + "field_label": "Patient Phone", + "context": "Subheading: A. PATIENT INFORMATION. The primary phone number for the patient.", + "answer": "865-395-3958" + }, + { + "name": "T20", + "page": 2, + "field_type_string": "Text", + "field_label": "Work Phone:", + "context": "Subheading: A. PATIENT INFORMATION. The work phone number for the patient.", + "answer": "null" + }, + { + "name": "T21", + "page": 2, + "field_type_string": "Text", + "field_label": "Cell Phone:", + "context": "Subheading: A. PATIENT INFORMATION. The cell phone number for the patient.", + "answer": "865-395-0481" + }, + { + "name": "T22", + "page": 2, + "field_type_string": "Text", + "field_label": "E-mail:", + "context": "Subheading: A. PATIENT INFORMATION. The email address for the patient.", + "answer": "null" + }, + { + "name": "T24", + "page": 2, + "field_type_string": "Text", + "field_label": "lbs", + "context": "Subheading: A. PATIENT INFORMATION. Input field for current weight in pounds.", + "answer": "null" + }, + { + "name": "T25", + "page": 2, + "field_type_string": "Text", + "field_label": "kgs", + "context": "Subheading: A. PATIENT INFORMATION. Input field for current weight in kilograms.", + "answer": "null" + }, + { + "name": "T26", + "page": 2, + "field_type_string": "Text", + "field_label": "inches", + "context": "Subheading: A. PATIENT INFORMATION. Input field for height in inches.", + "answer": "null" + }, + { + "name": "T27", + "page": 2, + "field_type_string": "Text", + "field_label": "cms", + "context": "Subheading: A. PATIENT INFORMATION. Input field for height in centimeters.", + "answer": "null" + }, + { + "name": "T23", + "page": 2, + "field_type_string": "Text", + "field_label": "Allergies:", + "context": "Subheading: A. PATIENT INFORMATION. Field to list any known allergies for the patient.", + "answer": "No Known Allergies" + }, + { + "name": "T28", + "page": 2, + "field_type_string": "Text", + "field_label": "Member ID #:", + "context": "Subheading: B. INSURANCE INFORMATION. The patient's insurance member identification number.", + "answer": "LAJM14345116" + }, + { + "name": "T29", + "page": 2, + "field_type_string": "Text", + "field_label": "Group #:", + "context": "Subheading: B. INSURANCE INFORMATION. The patient's insurance group number.", + "answer": "435000" + }, + { + "name": "T30", + "page": 2, + "field_type_string": "Text", + "field_label": "Insured:", + "context": "Subheading: B. INSURANCE INFORMATION. The name of the insured individual (if different from patient).", + "answer": "Abdulla, Shakh" + }, + { + "name": "CB31", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: B. INSURANCE INFORMATION. Relates to 'Does patient have other coverage?' field. Indicates 'Yes'.", + "answer": "False" + }, + { + "name": "CB32", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: B. INSURANCE INFORMATION. Relates to 'Does patient have other coverage?' field. Indicates 'No'.", + "answer": "True" + }, + { + "name": "T33", + "page": 2, + "field_type_string": "Text", + "field_label": "If yes, provide ID#:", + "context": "Subheading: B. INSURANCE INFORMATION. Requires the ID number if the patient has other coverage.", + "answer": "null" + }, + { + "name": "T34", + "page": 2, + "field_type_string": "Text", + "field_label": "Carrier Name:", + "context": "Subheading: B. INSURANCE INFORMATION. The name of the insurance carrier.", + "answer": "BC TENNCARE" + }, + { + "name": "T35", + "page": 2, + "field_type_string": "Text", + "field_label": "Insured:", + "context": "Subheading: B. INSURANCE INFORMATION. The name of the insured (if different from patient).", + "answer": "null" + }, + { + "name": "T42", + "page": 2, + "field_type_string": "Text", + "field_label": "First Name:", + "context": "Subheading: C. PRESCRIBER INFORMATION. The first name of the prescribing healthcare provider.", + "answer": "Hao" + }, + { + "name": "T43", + "page": 2, + "field_type_string": "Text", + "field_label": "Last Name:", + "context": "Subheading: C. PRESCRIBER INFORMATION. The last name of the prescribing healthcare provider.", + "answer": "Gu" + }, + { + "name": "CB44", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "M.D.", + "context": "Subheading: C. PRESCRIBER INFORMATION. Checkbox to indicate the prescriber is an M.D.", + "answer": "True" + }, + { + "name": "CB45", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "D.O.", + "context": "Subheading: C. PRESCRIBER INFORMATION. Checkbox to indicate the prescriber is a D.O.", + "answer": "False" + }, + { + "name": "CB46", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "N.P.", + "context": "Subheading: C. PRESCRIBER INFORMATION. Checkbox to indicate the prescriber is a Nurse Practitioner (N.P.).", + "answer": "False" + }, + { + "name": "CB47", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "P.A.", + "context": "Subheading: C. PRESCRIBER INFORMATION. Checkbox to indicate the prescriber is a Physician Assistant (P.A.).", + "answer": "False" + }, + { + "name": "T48", + "page": 2, + "field_type_string": "Text", + "field_label": "Address:", + "context": "Subheading: C. PRESCRIBER INFORMATION. The street address of the prescribing healthcare provider.", + "answer": "3320 Montgomery Dr" + }, + { + "name": "T49", + "page": 2, + "field_type_string": "Text", + "field_label": "City:", + "context": "Subheading: C. PRESCRIBER INFORMATION. The city of the prescribing healthcare provider's address.", + "answer": "NASHVILLE" + }, + { + "name": "T50", + "page": 2, + "field_type_string": "Text", + "field_label": "State:", + "context": "Subheading: C. PRESCRIBER INFORMATION. The state of the prescribing healthcare provider's address.", + "answer": "TN" + }, + { + "name": "T51", + "page": 2, + "field_type_string": "Text", + "field_label": "ZIP:", + "context": "Subheading: C. PRESCRIBER INFORMATION. The ZIP code of the prescribing healthcare provider's address.", + "answer": "37361" + }, + { + "name": "T52", + "page": 2, + "field_type_string": "Text", + "field_label": "Phone:", + "context": "Subheading: C. PRESCRIBER INFORMATION. The phone number of the prescribing healthcare provider.", + "answer": "614-936-0065" + }, + { + "name": "T53", + "page": 2, + "field_type_string": "Text", + "field_label": "Fax:", + "context": "Subheading: C. PRESCRIBER INFORMATION. The fax number of the prescribing healthcare provider.", + "answer": "null" + }, + { + "name": "T54", + "page": 2, + "field_type_string": "Text", + "field_label": "St Lic #:", + "context": "Subheading: C. PRESCRIBER INFORMATION. The state license number of the prescribing healthcare provider.", + "answer": "null" + }, + { + "name": "T55", + "page": 2, + "field_type_string": "Text", + "field_label": "NPI #:", + "context": "Subheading: C. PRESCRIBER INFORMATION. The National Provider Identifier (NPI) of the prescribing healthcare provider.", + "answer": "1154611523" + }, + { + "name": "T56", + "page": 2, + "field_type_string": "Text", + "field_label": "DEA #:", + "context": "Subheading: C. PRESCRIBER INFORMATION. The Drug Enforcement Administration (DEA) number of the prescribing healthcare provider.", + "answer": "null" + }, + { + "name": "T57", + "page": 2, + "field_type_string": "Text", + "field_label": "UPIN:", + "context": "Subheading: C. PRESCRIBER INFORMATION. The Unique Physician Identification Number (UPIN) of the prescribing healthcare provider.", + "answer": "null" + }, + { + "name": "T58.0", + "page": 2, + "field_type_string": "Text", + "field_label": "Provider Email:", + "context": "Subheading: C. PRESCRIBER INFORMATION. The email address of the prescribing healthcare provider.", + "answer": "null" + }, + { + "name": "T58.1", + "page": 2, + "field_type_string": "Text", + "field_label": "Office Contact Name:", + "context": "Subheading: C. PRESCRIBER INFORMATION. The name of the contact person in the prescriber's office.", + "answer": "null" + }, + { + "name": "T59", + "page": 2, + "field_type_string": "Text", + "field_label": "Phone:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. Phone number for the dispensing provider/pharmacy.", + "answer": "614-895-7655" + }, + { + "name": "Provider Admin CB.1", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "Self-administered", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. Place of Administration. Indicates if the medication is self-administered by the patient.", + "answer": "False" + }, + { + "name": "Provider Admin CB.2", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "Physician\u2019s Office", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. Place of Administration. Indicates if the medication is administered in a physician's office.", + "answer": "False" + }, + { + "name": "Provider Admin CB.3", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "Home", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. Place of Administration. Indicates if the medication is administered at home.", + "answer": "False" + }, + { + "name": "Provider Admin CB.4", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "Outpatient Infusion Center", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. Place of Administration. Indicates if the medication is administered at an outpatient infusion center.", + "answer": "True" + }, + { + "name": "Provider Admin T.5", + "page": 2, + "field_type_string": "Text", + "field_label": "Name:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. Name of the Outpatient Infusion Center.", + "answer": "Golden Gate Infusion Center" + }, + { + "name": "Provider Admin CB.7", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "Home Infusion Center", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. Place of Administration. Indicates if the medication is administered at a home infusion center.", + "answer": "False" + }, + { + "name": "Provider Admin T.6", + "page": 2, + "field_type_string": "Text", + "field_label": "Phone:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. Phone number for the Home Infusion Center.", + "answer": "null" + }, + { + "name": "Provider Admin T.8", + "page": 2, + "field_type_string": "Text", + "field_label": "Agency Name:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. Name of the agency providing home infusion services.", + "answer": "null" + }, + { + "name": "Provider Admin CB.10", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "Administration code(s)", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. Checkbox to indicate that administration codes (CPT) are provided.", + "answer": "False" + }, + { + "name": "Provider Admin T.9", + "page": 2, + "field_type_string": "Text", + "field_label": "CPT:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. Current Procedural Terminology (CPT) code for administration.", + "answer": "null" + }, + { + "name": "Provider Admin T.11A", + "page": 2, + "field_type_string": "Text", + "field_label": "Address:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. Street address of the dispensing provider/pharmacy.", + "answer": "null" + }, + { + "name": "Provider Admin T.13", + "page": 2, + "field_type_string": "Text", + "field_label": "City:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. City of the dispensing provider/pharmacy.", + "answer": "null" + }, + { + "name": "Provider Admin T.14", + "page": 2, + "field_type_string": "Text", + "field_label": "State:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. State of the dispensing provider/pharmacy.", + "answer": "null" + }, + { + "name": "Provider Admin T.15", + "page": 2, + "field_type_string": "Text", + "field_label": "ZIP:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. ZIP code of the dispensing provider/pharmacy.", + "answer": "null" + }, + { + "name": "Provider Admin T.16", + "page": 2, + "field_type_string": "Text", + "field_label": "Phone:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. Phone number of the dispensing provider/pharmacy.", + "answer": "614-895-7655" + }, + { + "name": "Provider Admin T.17A", + "page": 2, + "field_type_string": "Text", + "field_label": "Fax:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. Fax number of the dispensing provider/pharmacy.", + "answer": "614-278-3355" + }, + { + "name": "Provider Admin T.18", + "page": 2, + "field_type_string": "Text", + "field_label": "TIN:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. Taxpayer Identification Number (TIN) of the dispensing provider/pharmacy.", + "answer": "null" + }, + { + "name": "Provider Admin T.19", + "page": 2, + "field_type_string": "Text", + "field_label": "PIN:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. Pharmacy Identification Number (PIN) of the dispensing provider/pharmacy.", + "answer": "null" + }, + { + "name": "Provider Admin T.20", + "page": 2, + "field_type_string": "Text", + "field_label": "NPI:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. National Provider Identifier (NPI) of the dispensing provider/pharmacy.", + "answer": "null" + }, + { + "name": "Provider Admin CB.21", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "Outpatient Dialysis Center", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. Dispensing Provider/Pharmacy. Indicates if the dispensing provider is an Outpatient Dialysis Center.", + "answer": "False" + }, + { + "name": "Provider Admin CB.22", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "Physician\u2019s Office", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. Dispensing Provider/Pharmacy. Indicates if the dispensing provider is a Physician's Office.", + "answer": "False" + }, + { + "name": "Provider Admin CB.23.0.0", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "Retail Pharmacy", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. Dispensing Provider/Pharmacy. Indicates if the dispensing provider is a Retail Pharmacy.", + "answer": "False" + }, + { + "name": "Provider Admin CB.24.0.0", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "Specialty Pharmacy", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. Dispensing Provider/Pharmacy. Indicates if the dispensing provider is a Specialty Pharmacy.", + "answer": "False" + }, + { + "name": "Provider Admin CB.25", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "Mail Order", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. Dispensing Provider/Pharmacy. Indicates if the dispensing provider is a Mail Order Pharmacy.", + "answer": "False" + }, + { + "name": "Provider Admin CB.26", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "Other:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. Dispensing Provider/Pharmacy. Checkbox for 'Other' type of dispensing provider.", + "answer": "False" + }, + { + "name": "Provider Admin T.27", + "page": 2, + "field_type_string": "Text", + "field_label": "Other:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. Dispensing Provider/Pharmacy. Text field to specify 'Other' dispensing provider type.", + "answer": "null" + }, + { + "name": "Provider Admin T.28", + "page": 2, + "field_type_string": "Text", + "field_label": "Name:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. Name of the dispensing provider/pharmacy.", + "answer": "Golden Gate Infusion Center" + }, + { + "name": "Provider Admin T.29a", + "page": 2, + "field_type_string": "Text", + "field_label": "Address:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. Street address of the dispensing provider/pharmacy.", + "answer": "null" + }, + { + "name": "Provider Admin T.30a", + "page": 2, + "field_type_string": "Text", + "field_label": "City:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. City of the dispensing provider/pharmacy.", + "answer": "null" + }, + { + "name": "Provider Admin T.31", + "page": 2, + "field_type_string": "Text", + "field_label": "State:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. State of the dispensing provider/pharmacy.", + "answer": "null" + }, + { + "name": "Provider Admin T.32", + "page": 2, + "field_type_string": "Text", + "field_label": "ZIP:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. ZIP code of the dispensing provider/pharmacy.", + "answer": "null" + }, + { + "name": "Provider Admin T.33", + "page": 2, + "field_type_string": "Text", + "field_label": "Phone:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. Phone number of the dispensing provider/pharmacy.", + "answer": "614-895-7655" + }, + { + "name": "Provider Admin T.34", + "page": 2, + "field_type_string": "Text", + "field_label": "Fax:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. Fax number of the dispensing provider/pharmacy.", + "answer": "614-278-3355" + }, + { + "name": "Provider Admin T.35", + "page": 2, + "field_type_string": "Text", + "field_label": "TIN:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. Taxpayer Identification Number (TIN) of the dispensing provider/pharmacy.", + "answer": "null" + }, + { + "name": "Provider Admin T.36", + "page": 2, + "field_type_string": "Text", + "field_label": "PIN:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. Pharmacy Identification Number (PIN) of the dispensing provider/pharmacy.", + "answer": "null" + }, + { + "name": "Provider Admin T.37", + "page": 2, + "field_type_string": "Text", + "field_label": "NPI:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. National Provider Identifier (NPI) of the dispensing provider/pharmacy.", + "answer": "null" + }, + { + "name": "CB60", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "Riabni (rituximab-arrx)", + "context": "Subheading: E. PRODUCT INFORMATION. Checkbox to select Riabni (rituximab-arrx) as the requested product.", + "answer": "False" + }, + { + "name": "CB61", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "Rituxan (rituximab)", + "context": "Subheading: E. PRODUCT INFORMATION. Checkbox to select Rituxan (rituximab) as the requested product.", + "answer": "False" + }, + { + "name": "CB62", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "Ruxience (rituximab-pvvr)", + "context": "Subheading: E. PRODUCT INFORMATION. Checkbox to select Ruxience (rituximab-pvvr) as the requested product.", + "answer": "False" + }, + { + "name": "CB63", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "Truxima (rituximab-abbs)", + "context": "Subheading: E. PRODUCT INFORMATION. Checkbox to select Truxima (rituximab-abbs) as the requested product.", + "answer": "True" + }, + { + "name": "T64", + "page": 2, + "field_type_string": "Text", + "field_label": "Dose:", + "context": "Subheading: E. PRODUCT INFORMATION. The dosage of the requested product.", + "answer": "694 mg" + }, + { + "name": "T65", + "page": 2, + "field_type_string": "Text", + "field_label": "Directions for Use:", + "context": "Subheading: E. PRODUCT INFORMATION. Instructions for how the product should be used.", + "answer": "Initial: intraVENOUS, Once, Every 2 weeks, Starting 30 minutes after treatment start time. Maintenance: intraVENOUS, Once, Starting when released, Every 24 weeks." + }, + { + "name": "T66", + "page": 2, + "field_type_string": "Text", + "field_label": "HCPCS Code:", + "context": "Subheading: E. PRODUCT INFORMATION. Healthcare Common Procedure Coding System (HCPCS) code for the product.", + "answer": "null" + }, + { + "name": "T67", + "page": 2, + "field_type_string": "Text", + "field_label": "Primary ICD Code:", + "context": "Subheading: F. DIAGNOSIS INFORMATION. The primary International Classification of Diseases (ICD) code for the patient's diagnosis.", + "answer": "G35" + }, + { + "name": "CB68", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "Other ICD Code:", + "context": "Subheading: F. DIAGNOSIS INFORMATION. Checkbox to indicate that an Other ICD Code is provided.", + "answer": "False" + }, + { + "name": "T69", + "page": 2, + "field_type_string": "Text", + "field_label": "Other ICD Code:", + "context": "Subheading: F. DIAGNOSIS INFORMATION. Field to provide an additional International Classification of Diseases (ICD) code.", + "answer": "null" + }, + { + "name": "CB70", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION. Relates to 'Has the patient had prior therapy with the requested product within the last 365 days?' field. Indicates 'Yes'.", + "answer": "False" + }, + { + "name": "CB71", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION. Relates to 'Has the patient had prior therapy with the requested product within the last 365 days?' field. Indicates 'No'.", + "answer": "True" + }, + { + "name": "CB72", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION. Relates to 'Has the patient had a trial and failure of any of the following rituximab biosimilars?' field. Indicates 'No'.", + "answer": "True" + }, + { + "name": "CB73", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "Ruxience (rituximab-pvvr)", + "context": "Subheading: G. CLINICAL INFORMATION. Part of the question 'Has the patient had a trial and failure of any of the following rituximab biosimilars?' Allows selection of Ruxience.", + "answer": "False" + }, + { + "name": "CB74", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "Truxima (rituximab-abbs)", + "context": "Subheading: G. CLINICAL INFORMATION. Part of the question 'Has the patient had a trial and failure of any of the following rituximab biosimilars?' Allows selection of Truxima.", + "answer": "False" + }, + { + "name": "T75", + "page": 2, + "field_type_string": "Text", + "field_label": "When was the member\u2019s trial and failure of the preferred drug?", + "context": "Subheading: G. CLINICAL INFORMATION. Requires the date of trial and failure of the preferred drug.", + "answer": "null" + }, + { + "name": "T76", + "page": 2, + "field_type_string": "Text", + "field_label": "Please describe the nature of the failure of the preferred drug", + "context": "Subheading: G. CLINICAL INFORMATION. Requires a description of the failure of the preferred drug.", + "answer": "null" + }, + { + "name": "CB77", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION. Relates to 'Has the patient had an adverse reaction to any of the following rituximab biosimilars?' field. Indicates 'No'.", + "answer": "True" + }, + { + "name": "CB78", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "Ruxience (rituximab-pvvr)", + "context": "Subheading: G. CLINICAL INFORMATION. Part of the question 'Has the patient had an adverse reaction to any of the following rituximab biosimilars?' Allows selection of Ruxience.", + "answer": "False" + }, + { + "name": "CB79", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "Truxima (rituximab-abbs)", + "context": "Subheading: G. CLINICAL INFORMATION. Part of the question 'Has the patient had an adverse reaction to any of the following rituximab biosimilars?' Allows selection of Truxima.", + "answer": "False" + }, + { + "name": "T80", + "page": 2, + "field_type_string": "Text", + "field_label": "When was the member\u2019s adverse reaction to the preferred drug?", + "context": "Subheading: G. CLINICAL INFORMATION. Requires the date of the adverse reaction to the preferred drug.", + "answer": "null" + }, + { + "name": "T81", + "page": 2, + "field_type_string": "Text", + "field_label": "Please describe the nature of the adverse reaction to the preferred drug", + "context": "Subheading: G. CLINICAL INFORMATION. Requires a description of the adverse reaction to the preferred drug.", + "answer": "null" + }, + { + "name": "T84", + "page": 2, + "field_type_string": "Text", + "field_label": "Please explain if there are any contraindications or other medical reason(s) that the patient cannot use any of the following preferred biosimilar products when indicated for the patient\u2019s diagnosis?", + "context": "Subheading: G. CLINICAL INFORMATION. Requires an explanation of contraindications or reasons the patient cannot use preferred biosimilars.", + "answer": "null" + }, + { + "name": "CB82", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "Ruxience (rituximab-pvvr)", + "context": "Subheading: G. CLINICAL INFORMATION. Part of the question regarding contraindications to preferred biosimilars. Allows selection of Ruxience.", + "answer": "False" + }, + { + "name": "CB83", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "Truxima (rituximab-abbs)", + "context": "Subheading: G. CLINICAL INFORMATION. Part of the question regarding contraindications to preferred biosimilars. Allows selection of Truxima.", + "answer": "False" + }, + { + "name": "T12", + "page": 3, + "field_type_string": "Text", + "field_label": "Patient First Name", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). The first name of the patient.", + "answer": "Shakh" + }, + { + "name": "T13", + "page": 3, + "field_type_string": "Text", + "field_label": "Patient Last Name", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). The last name of the patient.", + "answer": "Abdulla" + }, + { + "name": "T19", + "page": 3, + "field_type_string": "Text", + "field_label": "Patient Phone", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). The phone number of the patient.", + "answer": "865-395-3958" + }, + { + "name": "T14", + "page": 3, + "field_type_string": "Text", + "field_label": "Patient DOB (MM/DD/YYYY)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). The date of birth of the patient.", + "answer": "04/01/2001" + }, + { + "name": "CB86", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Inflectra (infliximab-dyyb)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of the question 'Has the patient had a trial and failure of any of the following?' Allows selection of Inflectra.", + "answer": "False" + }, + { + "name": "CB87", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Renflexis (infliximab-abda)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of the question 'Has the patient had a trial and failure of any of the following?' Allows selection of Renflexis.", + "answer": "False" + }, + { + "name": "CB88", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Simponi Aria (golimumab)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of the question 'Has the patient had a trial and failure of any of the following?' Allows selection of Simponi Aria.", + "answer": "False" + }, + { + "name": "T89", + "page": 3, + "field_type_string": "Text", + "field_label": "When was the member\u2019s trial and failure of the preferred drug?", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Requires the date of trial and failure of the preferred drug. Dependent on the preceding 'Yes' to trial and failure question.", + "answer": "null" + }, + { + "name": "T90", + "page": 3, + "field_type_string": "Text", + "field_label": "Please describe the nature of the failure of the preferred drug", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Requires a description of the failure of the preferred drug. Dependent on the preceding 'Yes' to trial and failure question.", + "answer": "null" + }, + { + "name": "CB85", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Has the patient had a trial and failure of any of the following?' field. Indicates 'No'.", + "answer": "True" + }, + { + "name": "CB92", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Inflectra (infliximab-dyyb)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of the question 'Has the patient had an adverse reaction to any of the following?' Allows selection of Inflectra.", + "answer": "False" + }, + { + "name": "CB93", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Renflexis (infliximab-abda)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of the question 'Has the patient had an adverse reaction to any of the following?' Allows selection of Renflexis.", + "answer": "False" + }, + { + "name": "CB94", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Simponi Aria (golimumab)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of the question 'Has the patient had an adverse reaction to any of the following?' Allows selection of Simponi Aria.", + "answer": "False" + }, + { + "name": "T95", + "page": 3, + "field_type_string": "Text", + "field_label": "When was the member\u2019s adverse reaction to the preferred drug?", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Requires the date of the adverse reaction to the preferred drug. Dependent on the preceding 'Yes' to adverse reaction question.", + "answer": "null" + }, + { + "name": "T96a", + "page": 3, + "field_type_string": "Text", + "field_label": "Please describe the nature of the adverse reaction to the preferred drug", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Requires a description of the adverse reaction to the preferred drug. Dependent on the preceding 'Yes' to adverse reaction question.", + "answer": "null" + }, + { + "name": "CB91", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Has the patient had an adverse reaction to any of the following?' field. Indicates 'No'.", + "answer": "True" + }, + { + "name": "CB98a", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Enbrel (etanercept)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of the question 'Has the patient had a trial and failure of any of the following?' Allows selection of Enbrel.", + "answer": "False" + }, + { + "name": "CB99a", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Humira (adalimumab)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of the question 'Has the patient had a trial and failure of any of the following?' Allows selection of Humira.", + "answer": "False" + }, + { + "name": "CB100a", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Idacio (adalimumab-aacf)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of the question 'Has the patient had a trial and failure of any of the following?' Allows selection of Idacio.", + "answer": "False" + }, + { + "name": "CB101a", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Rinvoq (upadacitinib)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of the question 'Has the patient had a trial and failure of any of the following?' Allows selection of Rinvoq.", + "answer": "False" + }, + { + "name": "CB102a", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Tyenne SC (tocilizumab-aazg)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of the question 'Has the patient had a trial and failure of any of the following?' Allows selection of Tyenne SC.", + "answer": "False" + }, + { + "name": "CB103a", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Xeljanz/Xeljanz XR (tofacitinib)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of the question 'Has the patient had a trial and failure of any of the following?' Allows selection of Xeljanz/Xeljanz XR.", + "answer": "False" + }, + { + "name": "T104", + "page": 3, + "field_type_string": "Text", + "field_label": "When was the member\u2019s trial and failure of the preferred drug?", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Requires the date of trial and failure of the preferred drug. Dependent on the preceding 'Yes' to trial and failure question.", + "answer": "null" + }, + { + "name": "T105", + "page": 3, + "field_type_string": "Text", + "field_label": "Please describe the nature of the failure of the preferred drug", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Requires a description of the failure of the preferred drug. Dependent on the preceding 'Yes' to trial and failure question.", + "answer": "null" + }, + { + "name": "CB97", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Has the patient had a trial and failure of any of the following?' field. Indicates 'No'.", + "answer": "True" + }, + { + "name": "CB107z", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Enbrel (etanercept)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of the question 'Has the patient had an adverse reaction to any of the following?' Allows selection of Enbrel.", + "answer": "False" + }, + { + "name": "CB108z", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Humira (adalimumab)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of the question 'Has the patient had an adverse reaction to any of the following?' Allows selection of Humira.", + "answer": "False" + }, + { + "name": "CB109z", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Idacio (adalimumab-aacf)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of the question 'Has the patient had an adverse reaction to any of the following?' Allows selection of Idacio.", + "answer": "False" + }, + { + "name": "CB110z", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Rinvoq (upadacitinib)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of the question 'Has the patient had an adverse reaction to any of the following?' Allows selection of Rinvoq.", + "answer": "False" + }, + { + "name": "CB111z", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Tyenne SC (tocilizumab-aazg)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of the question 'Has the patient had an adverse reaction to any of the following?' Allows selection of Tyenne SC.", + "answer": "False" + }, + { + "name": "CB112z", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Xeljanz/Xeljanz XR (tofacitinib)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of the question 'Has the patient had an adverse reaction to any of the following?' Allows selection of Xeljanz/Xeljanz XR.", + "answer": "False" + }, + { + "name": "T113", + "page": 3, + "field_type_string": "Text", + "field_label": "When was the member\u2019s adverse reaction to the preferred drug?", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Requires the date of the adverse reaction to the preferred drug. Dependent on the preceding 'Yes' to adverse reaction question.", + "answer": "null" + }, + { + "name": "T114", + "page": 3, + "field_type_string": "Text", + "field_label": "Please describe the nature of the adverse reaction to the preferred drug", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Requires a description of the adverse reaction to the preferred drug. Dependent on the preceding 'Yes' to adverse reaction question.", + "answer": "null" + }, + { + "name": "CB106z", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Has the patient had an adverse reaction to any of the following?' field. Indicates 'No'.", + "answer": "True" + }, + { + "name": "T118", + "page": 3, + "field_type_string": "Text", + "field_label": "Please explain if there are any contraindications or other medical reason(s) that the patient cannot use any of the following preferred products when indicated for the patient's diagnosis?", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Requires an explanation of contraindications or reasons the patient cannot use preferred biosimilars. Dependent on the preceding 'Yes' to contraindications question.", + "answer": "null" + }, + { + "name": "CB115z", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Inflectra (infliximab-dyyb)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of the question regarding contraindications to preferred biosimilars. Allows selection of Inflectra.", + "answer": "False" + }, + { + "name": "CB116z", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Renflexis (infliximab-abda)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of the question regarding contraindications to preferred biosimilars. Allows selection of Renflexis.", + "answer": "False" + }, + { + "name": "CB117z", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Simponi Aria (golimumab)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of the question regarding contraindications to preferred biosimilars. Allows selection of Simponi Aria.", + "answer": "False" + }, + { + "name": "T125", + "page": 3, + "field_type_string": "Text", + "field_label": "Please explain if there are contraindications or any other medical reason(s) that the patient cannot use any of the following preferred products when indicated for the patient\u2019s diagnosis?", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Requires an explanation of contraindications or reasons the patient cannot use preferred biosimilars. Dependent on the preceding 'Yes' to contraindications question.", + "answer": "null" + }, + { + "name": "CB119z", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Enbrel (etanercept)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of the question regarding contraindications to preferred biosimilars. Allows selection of Enbrel.", + "answer": "False" + }, + { + "name": "CB120z", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Humira (adalimumab)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of the question regarding contraindications to preferred biosimilars. Allows selection of Humira.", + "answer": "False" + }, + { + "name": "CB121z", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Idacio (adalimumab-aacf)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of the question regarding contraindications to preferred biosimilars. Allows selection of Idacio.", + "answer": "False" + }, + { + "name": "CB122z", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Rinvoq (upadacitinib)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of the question regarding contraindications to preferred biosimilars. Allows selection of Rinvoq.", + "answer": "False" + }, + { + "name": "CB123z", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Tyenne SC (tocilizumab-aazg)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of the question regarding contraindications to preferred biosimilars. Allows selection of Tyenne SC.", + "answer": "False" + }, + { + "name": "CB124z", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Xeljanz/Xeljanz XR (tofacitinib)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of the question regarding contraindications to preferred biosimilars. Allows selection of Xeljanz/Xeljanz XR.", + "answer": "False" + }, + { + "name": "CB96.4.0", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Will Rituxan (rituximab) be used concomitantly with apremilast, tofacitinib, or other biologic DMARDs?' field. Indicates 'Yes'.", + "answer": "False" + }, + { + "name": "CB98", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Will Rituxan (rituximab) be used concomitantly with apremilast, tofacitinib, or other biologic DMARDs?' field. Indicates 'No'.", + "answer": "True" + }, + { + "name": "CB99.0", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Does the patient have a documented diagnosis of Philadelphia chromosome-negative acute lymphoid leukemia (ALL)?' field. Indicates 'Yes'.", + "answer": "False" + }, + { + "name": "CB100.0", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Does the patient have a documented diagnosis of Philadelphia chromosome-negative acute lymphoid leukemia (ALL)?' field. Indicates 'No'.", + "answer": "True" + }, + { + "name": "CB101.0", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Is Rituxan (rituximab) being used as induction/consolidation therapy?' field. Indicates 'Yes'.", + "answer": "False" + }, + { + "name": "CB102.0", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Is Rituxan (rituximab) being used as induction/consolidation therapy?' field. Indicates 'No'.", + "answer": "True" + }, + { + "name": "CB103", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Does the patient have a documented diagnosis of refractory autoimmune hemolytic anemia?' field. Indicates 'Yes'.", + "answer": "False" + }, + { + "name": "CB104", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Does the patient have a documented diagnosis of refractory autoimmune hemolytic anemia?' field. Indicates 'No'.", + "answer": "True" + }, + { + "name": "CB104a", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Wegener granulomatosis", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Anti-neutrophil cytoplasmic antibody-associated (ANCA-associated) vasculitides'. Allows selection of Wegener granulomatosis.", + "answer": "False" + }, + { + "name": "CB104b", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Churg-Strauss syndrome", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Anti-neutrophil cytoplasmic antibody-associated (ANCA-associated) vasculitides'. Allows selection of Churg-Strauss syndrome.", + "answer": "False" + }, + { + "name": "CB104c", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "microscopic polyangiitis", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Anti-neutrophil cytoplasmic antibody-associated (ANCA-associated) vasculitides'. Allows selection of microscopic polyangiitis.", + "answer": "False" + }, + { + "name": "CB104d", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "pauci-immune glomerulonephritis", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Anti-neutrophil cytoplasmic antibody-associated (ANCA-associated) vasculitides'. Allows selection of pauci-immune glomerulonephritis.", + "answer": "False" + }, + { + "name": "CB105", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Will Rituxan (rituximab) be given in conjunction with glucocorticoids?' field. Indicates 'Yes'.", + "answer": "True" + }, + { + "name": "CB106", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Will Rituxan (rituximab) be given in conjunction with glucocorticoids?' field. Indicates 'No'.", + "answer": "False" + }, + { + "name": "CB106a", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Does the patient have a documented diagnosis of corticosteroid-refractory autoimmune blistering disease?' field. Indicates 'Yes'.", + "answer": "False" + }, + { + "name": "CB107", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "pemphigus vulgaris", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Autoimmune blistering diseases, corticosteroid-refractory' selection. Allows selection of pemphigus vulgaris.", + "answer": "False" + }, + { + "name": "CB108", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "pemphigus folliaceus", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Autoimmune blistering diseases, corticosteroid-refractory' selection. Allows selection of pemphigus folliaceus.", + "answer": "False" + }, + { + "name": "CB109", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "bullous pemphigoid", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Autoimmune blistering diseases, corticosteroid-refractory' selection. Allows selection of bullous pemphigoid.", + "answer": "False" + }, + { + "name": "CB110", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "cicatricial pemphigoid", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Autoimmune blistering diseases, corticosteroid-refractory' selection. Allows selection of cicatricial pemphigoid.", + "answer": "False" + }, + { + "name": "CB111", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "epidermolysis bullosa acquisita", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Autoimmune blistering diseases, corticosteroid-refractory' selection. Allows selection of epidermolysis bullosa acquisita.", + "answer": "False" + }, + { + "name": "CB112", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "paraneoplastic pemphigus", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Autoimmune blistering diseases, corticosteroid-refractory' selection. Allows selection of paraneoplastic pemphigus.", + "answer": "False" + }, + { + "name": "CB113", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "None of the above", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Autoimmune blistering diseases, corticosteroid-refractory' selection. Indicates none of the listed conditions apply.", + "answer": "False" + }, + { + "name": "CB106b", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Does the patient have a documented diagnosis of corticosteroid-refractory autoimmune blistering disease?' field. Indicates 'No'.", + "answer": "True" + }, + { + "name": "CB114", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "AIDS-related B-cell lymphoma", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'B-cell lymphomas' selection. Allows selection of AIDS-related B-cell lymphoma.", + "answer": "False" + }, + { + "name": "CB115", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Burkitt lymphoma", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'B-cell lymphomas' selection. Allows selection of Burkitt lymphoma.", + "answer": "False" + }, + { + "name": "CB116", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Diffuse large B-cell lymphoma", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'B-cell lymphomas' selection. Allows selection of Diffuse large B-cell lymphoma.", + "answer": "False" + }, + { + "name": "CB117", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Follicular lymphoma", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'B-cell lymphomas' selection. Allows selection of Follicular lymphoma.", + "answer": "False" + }, + { + "name": "CB118", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Gastric MALT lymphoma", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'B-cell lymphomas' selection. Allows selection of Gastric MALT lymphoma.", + "answer": "False" + }, + { + "name": "CB119", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "High-grade B-Cell lymphoma", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'B-cell lymphomas' selection. Allows selection of High-grade B-Cell lymphoma.", + "answer": "False" + }, + { + "name": "CB120", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Mantle cell lymphoma", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'B-cell lymphomas' selection. Allows selection of Mantle cell lymphoma.", + "answer": "False" + }, + { + "name": "CB121", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Nodal marginal zone lymphoma", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'B-cell lymphomas' selection. Allows selection of Nodal marginal zone lymphoma.", + "answer": "False" + }, + { + "name": "CB122", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Nongastric MALT lymphoma", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'B-cell lymphomas' selection. Allows selection of Nongastric MALT lymphoma.", + "answer": "False" + }, + { + "name": "CB123", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Primary cutaneous B-cell lymphomas", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'B-cell lymphomas' selection. Allows selection of Primary cutaneous B-cell lymphomas.", + "answer": "False" + }, + { + "name": "CB124", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Splenic marginal zone lymphoma", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'B-cell lymphomas' selection. Allows selection of Splenic marginal zone lymphoma.", + "answer": "False" + }, + { + "name": "CB125", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Other:", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'B-cell lymphomas' selection. Checkbox for 'Other' type of lymphoma.", + "answer": "False" + }, + { + "name": "T126", + "page": 3, + "field_type_string": "Text", + "field_label": "Other:", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'B-cell lymphomas' selection. Text field to specify 'Other' lymphoma type.", + "answer": "null" + }, + { + "name": "T12", + "page": 4, + "field_type_string": "Text", + "field_label": "Patient First Name", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). The first name of the patient.", + "answer": "Shakh" + }, + { + "name": "T13", + "page": 4, + "field_type_string": "Text", + "field_label": "Patient Last Name", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). The last name of the patient.", + "answer": "Abdulla" + }, + { + "name": "T19", + "page": 4, + "field_type_string": "Text", + "field_label": "Patient Phone", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). The phone number of the patient.", + "answer": "865-395-3958" + }, + { + "name": "T14", + "page": 4, + "field_type_string": "Text", + "field_label": "Patient DOB (MM/DD/YYYY)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). The date of birth of the patient.", + "answer": "04/01/2001" + }, + { + "name": "CB127", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Does the patient have a documented diagnosis of multicentric Castleman's disease?' field. Indicates 'Yes'.", + "answer": "False" + }, + { + "name": "CB128", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Does the patient have a documented diagnosis of multicentric Castleman's disease?' field. Indicates 'No'.", + "answer": "True" + }, + { + "name": "CB129", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "leptomeningeal metastases from lymphoma", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Central nervous system lymphomas' selection. Allows selection of leptomeningeal metastases from lymphoma.", + "answer": "False" + }, + { + "name": "CB130", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "primary CNS lymphoma", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Central nervous system lymphomas' selection. Allows selection of primary CNS lymphoma.", + "answer": "False" + }, + { + "name": "CB131", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "none of the above", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Central nervous system lymphomas' selection. Indicates none of the listed conditions apply.", + "answer": "False" + }, + { + "name": "CB132", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "chronic lymphocytic leukemia (CLL)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Chronic or small lymphocytic leukemia' selection. Allows selection of chronic lymphocytic leukemia (CLL).", + "answer": "False" + }, + { + "name": "CB133", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "small lymphocytic leukemia", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Chronic or small lymphocytic leukemia' selection. Allows selection of small lymphocytic leukemia.", + "answer": "False" + }, + { + "name": "CB134", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "none of the above", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Chronic or small lymphocytic leukemia' selection. Indicates none of the listed conditions apply.", + "answer": "False" + }, + { + "name": "CB135", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Does the patient have a documented diagnosis of cryoglobulinemia?' field. Indicates 'Yes'.", + "answer": "False" + }, + { + "name": "CB136", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Does the patient have a documented diagnosis of cryoglobulinemia?' field. Indicates 'No'.", + "answer": "True" + }, + { + "name": "CB139", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Is there clinical documentation that the treatment with corticosteroids and other immunosuppressive agents was ineffective?' field. Indicates 'Yes'.", + "answer": "False" + }, + { + "name": "CB140", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Is there clinical documentation that the treatment with corticosteroids and other immunosuppressive agents was ineffective?' field. Indicates 'No'.", + "answer": "True" + }, + { + "name": "CB144", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Is there a documentation that Rituxan (rituximab) being used as last-resort treatment for chronic graft versus host disease (GVHD)?' field. Indicates 'Yes'.", + "answer": "False" + }, + { + "name": "CB145", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Is there a documentation that Rituxan (rituximab) being used as last-resort treatment for chronic graft versus host disease (GVHD)?' field. Indicates 'No'.", + "answer": "True" + }, + { + "name": "CB141", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "relapsed hairy cell leukemia", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Hairy cell leukemia' selection. Allows selection of relapsed hairy cell leukemia.", + "answer": "False" + }, + { + "name": "CB142", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "refractory hairy cell leukemia", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Hairy cell leukemia' selection. Allows selection of refractory hairy cell leukemia.", + "answer": "False" + }, + { + "name": "CB143", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "none of the above", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Hairy cell leukemia' selection. Indicates none of the listed conditions apply.", + "answer": "False" + }, + { + "name": "CB137", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Is there a documentation that Rituxan (rituximab) is being used for treatment or prevention (desensitization) of highly sensitized patients with antibody mediated rejection in heart transplant recipients and other solid organ transplant recipients?' field. Indicates 'Yes'.", + "answer": "False" + }, + { + "name": "CB146", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "heart transplant recipient", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of the question 'Please select which applies to the patient:'. Allows selection of heart transplant recipient.", + "answer": "False" + }, + { + "name": "CB147", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "other solid organ transplant recipient", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of the question 'Please select which applies to the patient:'. Allows selection of other solid organ transplant recipient.", + "answer": "False" + }, + { + "name": "CB138", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Is there a documentation that Rituxan (rituximab) is being used for treatment or prevention (desensitization) of highly sensitized patients with antibody mediated rejection in heart transplant recipients and other solid organ transplant recipients?' field. Indicates 'No'.", + "answer": "True" + }, + { + "name": "CB148", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "Bavencio (avelumab)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Immune checkpoint-inhibitor related encephalitis' selection. Allows selection of Bavencio.", + "answer": "False" + }, + { + "name": "CB149", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "Imfinzi (durvalumab)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Immune checkpoint-inhibitor related encephalitis' selection. Allows selection of Imfinzi.", + "answer": "False" + }, + { + "name": "CB150", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "Keytruda (pembrolizumab)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Immune checkpoint-inhibitor related encephalitis' selection. Allows selection of Keytruda.", + "answer": "False" + }, + { + "name": "CB151", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "Opdivo (nivolumab)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Immune checkpoint-inhibitor related encephalitis' selection. Allows selection of Opdivo.", + "answer": "False" + }, + { + "name": "CB152", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "Tecentriq (atezolizumab)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Immune checkpoint-inhibitor related encephalitis' selection. Allows selection of Tecentriq.", + "answer": "False" + }, + { + "name": "CB153", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "Yervoy (ipilimumab)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Immune checkpoint-inhibitor related encephalitis' selection. Allows selection of Yervoy.", + "answer": "False" + }, + { + "name": "CB154", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "Other:", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Immune checkpoint-inhibitor related encephalitis' selection. Checkbox for 'Other' immune checkpoint inhibitor.", + "answer": "False" + }, + { + "name": "T155", + "page": 4, + "field_type_string": "Text", + "field_label": "Other:", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Immune checkpoint-inhibitor related encephalitis' selection. Text field to specify 'Other' immune checkpoint inhibitor.", + "answer": "null" + }, + { + "name": "CB156", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Does the patient have a documented diagnosis of refractory immune or idiopathic thrombocytopenic purpura (ITP)?' field. Indicates 'Yes'.", + "answer": "False" + }, + { + "name": "CB158", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "refractory immune thrombocytopenic purpura", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Immune or idiopathic thrombocytopenic purpura' selection. Allows selection of refractory immune thrombocytopenic purpura.", + "answer": "False" + }, + { + "name": "CB159", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "idiopathic thrombocytopenic purpura (ITP)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Immune or idiopathic thrombocytopenic purpura' selection. Allows selection of idiopathic thrombocytopenic purpura (ITP).", + "answer": "False" + }, + { + "name": "CB157", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Does the patient have a documented diagnosis of refractory immune or idiopathic thrombocytopenic purpura (ITP)?' field. Indicates 'No'.", + "answer": "True" + }, + { + "name": "CB160", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Is Rituxan (rituximab) being used as rejection prophylaxis in sensitized kidney transplant recipients with donor specific antibodies?' field. Indicates 'Yes'.", + "answer": "False" + }, + { + "name": "CB161", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Is Rituxan (rituximab) being used as rejection prophylaxis in sensitized kidney transplant recipients with donor specific antibodies?' field. Indicates 'No'.", + "answer": "True" + }, + { + "name": "CB162", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Does the patient have a documented diagnosis of lymphocyte-predominant Hodgkin's lymphoma?' field. Indicates 'Yes'.", + "answer": "False" + }, + { + "name": "CB163", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Does the patient have a documented diagnosis of lymphocyte-predominant Hodgkin's lymphoma?' field. Indicates 'No'.", + "answer": "True" + }, + { + "name": "CB164", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "Relapsing-remitting MS (RRMS)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Multiple Sclerosis' selection. Allows selection of Relapsing-remitting MS (RRMS).", + "answer": "False" + }, + { + "name": "CB165", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "Secondary-progressive MS (SPMS)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Multiple Sclerosis' selection. Allows selection of Secondary-progressive MS (SPMS).", + "answer": "False" + }, + { + "name": "CB166", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "Primary-progressive MS (PPMS)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Multiple Sclerosis' selection. Allows selection of Primary-progressive MS (PPMS).", + "answer": "False" + }, + { + "name": "CB167", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "Progressive-relapsing MS (PRMS)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Multiple Sclerosis' selection. Allows selection of Progressive-relapsing MS (PRMS).", + "answer": "False" + }, + { + "name": "CB168", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Has the patient discontinued other medications used for treating MS?' field. Indicates 'Yes'.", + "answer": "False" + }, + { + "name": "CB169", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Has the patient discontinued other medications used for treating MS?' field. Indicates 'No'.", + "answer": "True" + }, + { + "name": "CB170", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Does the patient have a documented diagnosis of muscle-specific tyrosine kinase myasthenia gravis (MuSK-MG)?' field. Indicates 'Yes'.", + "answer": "False" + }, + { + "name": "CB172", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Has the patient had an unsatisfactory response to initial immunotherapy?' field. Indicates 'Yes'.", + "answer": "False" + }, + { + "name": "CB173", + "page": 4, + "field_type_string": "Text", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Has the patient had an unsatisfactory response to initial immunotherapy?' field. Indicates 'No'.", + "answer": "True" + }, + { + "name": "CB171", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Does the patient have a documented diagnosis of muscle-specific tyrosine kinase myasthenia gravis (MuSK-MG)?' field. Indicates 'No'.", + "answer": "True" + }, + { + "name": "CB174", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Does the patient have a documented diagnosis of neuromyelitis optica (Devic's disease)?' field. Indicates 'Yes'.", + "answer": "False" + }, + { + "name": "CB175", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Does the patient have a documented diagnosis of neuromyelitis optica (Devic's disease)?' field. Indicates 'No'.", + "answer": "True" + }, + { + "name": "CB176", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Was the treatment with at least one immunotherapy ineffective?' field. Indicates 'Yes'.", + "answer": "False" + }, + { + "name": "CB177", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Was the treatment with at least one immunotherapy ineffective?' field. Indicates 'No'.", + "answer": "True" + }, + { + "name": "CB178", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Does the patient have a documented diagnosis of opsoclonus-myoclonus-ataxia (OMA) associated with neuroblastoma?' field. Indicates 'Yes'.", + "answer": "False" + }, + { + "name": "CB179", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Does the patient have a documented diagnosis of opsoclonus-myoclonus-ataxia (OMA) associated with neuroblastoma?' field. Indicates 'No'.", + "answer": "True" + }, + { + "name": "CB180", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Is the patient refractory to steroids, chemotherapy and intravenous immunoglobulins?' field. Indicates 'Yes'.", + "answer": "False" + }, + { + "name": "T189", + "page": 4, + "field_type_string": "Text", + "field_label": "Medication:", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Opsoclonus-myoclonus-ataxia (opsoclonus myoclonus syndrome)' section. Field to provide names of medications tried.", + "answer": "null" + }, + { + "name": "T190", + "page": 4, + "field_type_string": "Text", + "field_label": "Date: (MM)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Opsoclonus-myoclonus-ataxia (opsoclonus myoclonus syndrome)' section. Field to provide the month of the date range for medications tried.", + "answer": "null" + }, + { + "name": "T191", + "page": 4, + "field_type_string": "Text", + "field_label": "Date: (DD)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Opsoclonus-myoclonus-ataxia (opsoclonus myoclonus syndrome)' section. Field to provide the day of the date range for medications tried.", + "answer": "null" + }, + { + "name": "T192", + "page": 4, + "field_type_string": "Text", + "field_label": "Date: (YYYY)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Opsoclonus-myoclonus-ataxia (opsoclonus myoclonus syndrome)' section. Field to provide the year of the date range for medications tried.", + "answer": "null" + }, + { + "name": "T193", + "page": 4, + "field_type_string": "Text", + "field_label": "Date: (MM)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Opsoclonus-myoclonus-ataxia (opsoclonus myoclonus syndrome)' section. Field to provide the month of the date range for medications tried.", + "answer": "null" + }, + { + "name": "T194", + "page": 4, + "field_type_string": "Text", + "field_label": "Date: (DD)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Opsoclonus-myoclonus-ataxia (opsoclonus myoclonus syndrome)' section. Field to provide the day of the date range for medications tried.", + "answer": "null" + }, + { + "name": "T195", + "page": 4, + "field_type_string": "Text", + "field_label": "Date: (YYYY)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Opsoclonus-myoclonus-ataxia (opsoclonus myoclonus syndrome)' section. Field to provide the year of the date range for medications tried.", + "answer": "null" + }, + { + "name": "T196", + "page": 4, + "field_type_string": "Text", + "field_label": "Medication:", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Opsoclonus-myoclonus-ataxia (opsoclonus myoclonus syndrome)' section. Field to provide the second medication name tried.", + "answer": "null" + }, + { + "name": "T197", + "page": 4, + "field_type_string": "Text", + "field_label": "Date: (MM)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Opsoclonus-myoclonus-ataxia (opsoclonus myoclonus syndrome)' section. Field to provide the month of the date range for the second medication tried.", + "answer": "null" + }, + { + "name": "T198", + "page": 4, + "field_type_string": "Text", + "field_label": "Date: (DD)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Opsoclonus-myoclonus-ataxia (opsoclonus myoclonus syndrome)' section. Field to provide the day of the date range for the second medication tried.", + "answer": "null" + }, + { + "name": "T199", + "page": 4, + "field_type_string": "Text", + "field_label": "Date: (YYYY)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Opsoclonus-myoclonus-ataxia (opsoclonus myoclonus syndrome)' section. Field to provide the year of the date range for the second medication tried.", + "answer": "null" + }, + { + "name": "T200", + "page": 4, + "field_type_string": "Text", + "field_label": "Date: (MM)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Opsoclonus-myoclonus-ataxia (opsoclonus myoclonus syndrome)' section. Field to provide the month of the date range for the second medication tried.", + "answer": "null" + }, + { + "name": "T201", + "page": 4, + "field_type_string": "Text", + "field_label": "Date: (DD)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Opsoclonus-myoclonus-ataxia (opsoclonus myoclonus syndrome)' section. Field to provide the day of the date range for the second medication tried.", + "answer": "null" + }, + { + "name": "T202", + "page": 4, + "field_type_string": "Text", + "field_label": "Date: (YYYY)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Opsoclonus-myoclonus-ataxia (opsoclonus myoclonus syndrome)' section. Field to provide the year of the date range for the second medication tried.", + "answer": "null" + }, + { + "name": "CB181", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Is the patient refractory to steroids, chemotherapy and intravenous immunoglobulins?' field. Indicates 'No'.", + "answer": "True" + }, + { + "name": "CB203", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Is Rituxan (rituximab) being used as treatment of post-transplant lymphoproliferative disorder?' field. Indicates 'Yes'.", + "answer": "False" + }, + { + "name": "CB204", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Is Rituxan (rituximab) being used as treatment of post-transplant lymphoproliferative disorder?' field. Indicates 'No'.", + "answer": "True" + }, + { + "name": "CB205", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Is Rituxan (rituximab) being used as prophylaxis for Epstein-Barr virus (EBV) post-transplant lymphoproliferative disorder?' field. Indicates 'Yes'.", + "answer": "False" + }, + { + "name": "CB206", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Is Rituxan (rituximab) being used as prophylaxis for Epstein-Barr virus (EBV) post-transplant lymphoproliferative disorder?' field. Indicates 'No'.", + "answer": "True" + }, + { + "name": "T12", + "page": 5, + "field_type_string": "Text", + "field_label": "Patient First Name", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). The first name of the patient.", + "answer": "Shakh" + }, + { + "name": "T13", + "page": 5, + "field_type_string": "Text", + "field_label": "Patient Last Name", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). The last name of the patient.", + "answer": "Abdulla" + }, + { + "name": "T19", + "page": 5, + "field_type_string": "Text", + "field_label": "Patient Phone", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). The phone number of the patient.", + "answer": "865-395-3958" + }, + { + "name": "T14", + "page": 5, + "field_type_string": "Text", + "field_label": "Patient DOB (MM/DD/YYYY)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). The date of birth of the patient.", + "answer": "04/01/2001" + }, + { + "name": "CB207", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "Mild", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Rheumatoid Arthritis' severity selection. Allows selection of Mild severity.", + "answer": "False" + }, + { + "name": "CB208", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "Moderate", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Rheumatoid Arthritis' severity selection. Allows selection of Moderate severity.", + "answer": "False" + }, + { + "name": "CB209", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "Severe", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Rheumatoid Arthritis' severity selection. Allows selection of Severe severity.", + "answer": "False" + }, + { + "name": "CB210", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Is there evidence that the disease is active?' field. Indicates 'Yes'.", + "answer": "False" + }, + { + "name": "CB211", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Is there evidence that the disease is active?' field. Indicates 'No'.", + "answer": "True" + }, + { + "name": "CB212", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Will Rituxan (rituximab) be used in combination with methotrexate?' field. Indicates 'Yes'.", + "answer": "False" + }, + { + "name": "CB213", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Will Rituxan (rituximab) be used in combination with methotrexate?' field. Indicates 'No'.", + "answer": "True" + }, + { + "name": "CB214", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Was treatment with methotrexate ineffective, not tolerated or contraindicated?' field. Indicates 'Yes'.", + "answer": "False" + }, + { + "name": "CB216", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "ineffective", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Was treatment with methotrexate ineffective, not tolerated or contraindicated?' selection. Allows selection of 'ineffective'.", + "answer": "False" + }, + { + "name": "CB217", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "not tolerated", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Was treatment with methotrexate ineffective, not tolerated or contraindicated?' selection. Allows selection of 'not tolerated'.", + "answer": "False" + }, + { + "name": "CB218", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "contraindicated", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Was treatment with methotrexate ineffective, not tolerated or contraindicated?' selection. Allows selection of 'contraindicated'.", + "answer": "False" + }, + { + "name": "CB215", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Was treatment with methotrexate ineffective, not tolerated or contraindicated?' field. Indicates 'No'.", + "answer": "True" + }, + { + "name": "CB223", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Was treatment with another conventional DMARD ineffective?' field. Indicates 'Yes'.", + "answer": "False" + }, + { + "name": "CB225", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "azathioprine", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Was treatment with another conventional DMARD ineffective?' selection. Allows selection of azathioprine.", + "answer": "False" + }, + { + "name": "CB226", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "cyclosporine", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Was treatment with another conventional DMARD ineffective?' selection. Allows selection of cyclosporine.", + "answer": "False" + }, + { + "name": "CB227", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "hydroxychloroquine", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Was treatment with another conventional DMARD ineffective?' selection. Allows selection of hydroxychloroquine.", + "answer": "False" + }, + { + "name": "CB228", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "leflunomide", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Was treatment with another conventional DMARD ineffective?' selection. Allows selection of leflunomide.", + "answer": "False" + }, + { + "name": "CB229", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "sulfasalazine", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Was treatment with another conventional DMARD ineffective?' selection. Allows selection of sulfasalazine.", + "answer": "False" + }, + { + "name": "CB224", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Was treatment with another conventional DMARD ineffective?' field. Indicates 'No'.", + "answer": "True" + }, + { + "name": "CB281", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Does the patient have a documented diagnosis of Sj\u00f6gren's syndrome?' field. Indicates 'Yes'.", + "answer": "False" + }, + { + "name": "CB282", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Does the patient have a documented diagnosis of Sj\u00f6gren's syndrome?' field. Indicates 'No'.", + "answer": "True" + }, + { + "name": "CB283", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Was treatment with corticosteroids and other immunosuppressive agents ineffective?' field. Indicates 'Yes'.", + "answer": "False" + }, + { + "name": "T285", + "page": 5, + "field_type_string": "Text", + "field_label": "Medication:", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Sj\u00f6gren syndrome' section. Field to provide the name of a corticosteroid or immunosuppressive agent used.", + "answer": "null" + }, + { + "name": "T286", + "page": 5, + "field_type_string": "Text", + "field_label": "Date: (MM)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Sj\u00f6gren syndrome' section. Field to provide the month of the date range for a corticosteroid or immunosuppressive agent used.", + "answer": "null" + }, + { + "name": "T287", + "page": 5, + "field_type_string": "Text", + "field_label": "Date: (DD)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Sj\u00f6gren syndrome' section. Field to provide the day of the date range for a corticosteroid or immunosuppressive agent used.", + "answer": "null" + }, + { + "name": "T288", + "page": 5, + "field_type_string": "Text", + "field_label": "Date: (YYYY)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Sj\u00f6gren syndrome' section. Field to provide the year of the date range for a corticosteroid or immunosuppressive agent used.", + "answer": "null" + }, + { + "name": "T289", + "page": 5, + "field_type_string": "Text", + "field_label": "Date: (MM)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Sj\u00f6gren syndrome' section. Field to provide the month of the date range for a corticosteroid or immunosuppressive agent used.", + "answer": "null" + }, + { + "name": "T290", + "page": 5, + "field_type_string": "Text", + "field_label": "Date: (DD)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Sj\u00f6gren syndrome' section. Field to provide the day of the date range for a corticosteroid or immunosuppressive agent used.", + "answer": "null" + }, + { + "name": "T291", + "page": 5, + "field_type_string": "Text", + "field_label": "Date: (YYYY)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Sj\u00f6gren syndrome' section. Field to provide the year of the date range for a corticosteroid or immunosuppressive agent used.", + "answer": "null" + }, + { + "name": "T292", + "page": 5, + "field_type_string": "Text", + "field_label": "Medication:", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Sj\u00f6gren syndrome' section. Field to provide the second name of a corticosteroid or immunosuppressive agent used.", + "answer": "null" + }, + { + "name": "T293", + "page": 5, + "field_type_string": "Text", + "field_label": "Date: (MM)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Sj\u00f6gren syndrome' section. Field to provide the month of the date range for the second corticosteroid or immunosuppressive agent used.", + "answer": "null" + }, + { + "name": "T294", + "page": 5, + "field_type_string": "Text", + "field_label": "Date: (DD)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Sj\u00f6gren syndrome' section. Field to provide the day of the date range for the second corticosteroid or immunosuppressive agent used.", + "answer": "null" + }, + { + "name": "T295", + "page": 5, + "field_type_string": "Text", + "field_label": "Date: (YYYY)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Sj\u00f6gren syndrome' section. Field to provide the year of the date range for the second corticosteroid or immunosuppressive agent used.", + "answer": "null" + }, + { + "name": "T296", + "page": 5, + "field_type_string": "Text", + "field_label": "Date: (MM)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Sj\u00f6gren syndrome' section. Field to provide the month of the date range for the second corticosteroid or immunosuppressive agent used.", + "answer": "null" + }, + { + "name": "T297", + "page": 5, + "field_type_string": "Text", + "field_label": "Date: (DD)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Sj\u00f6gren syndrome' section. Field to provide the day of the date range for the second corticosteroid or immunosuppressive agent used.", + "answer": "null" + }, + { + "name": "T298", + "page": 5, + "field_type_string": "Text", + "field_label": "Date: (YYYY)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Sj\u00f6gren syndrome' section. Field to provide the year of the date range for the second corticosteroid or immunosuppressive agent used.", + "answer": "null" + }, + { + "name": "CB284", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Was treatment with corticosteroids and other immunosuppressive agents ineffective?' field. Indicates 'No'.", + "answer": "True" + }, + { + "name": "CB299", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Does the patient have a documented diagnosis of refractory thrombotic thrombocytopenic purpura (TTP)?' field. Indicates 'Yes'.", + "answer": "False" + }, + { + "name": "CB300", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Does the patient have a documented diagnosis of refractory thrombotic thrombocytopenic purpura (TTP)?' field. Indicates 'No'.", + "answer": "True" + }, + { + "name": "CB301", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Does the patient have a documented diagnosis of Waldenstr\u00f6m macroglobulinemia?' field. Indicates 'Yes'.", + "answer": "False" + }, + { + "name": "CB302", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Does the patient have a documented diagnosis of Waldenstr\u00f6m macroglobulinemia?' field. Indicates 'No'.", + "answer": "True" + }, + { + "name": "CB303", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Is this continuation request a result of the patient receiving samples of Rituxan (rituximab)?' field. Indicates 'Yes'.", + "answer": "False" + }, + { + "name": "CB304", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Is this continuation request a result of the patient receiving samples of Rituxan (rituximab)?' field. Indicates 'No'.", + "answer": "True" + }, + { + "name": "T305", + "page": 5, + "field_type_string": "Text", + "field_label": "Please indicate the length of time on Rituxan (rituximab):", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). For continuation requests, requires the duration the patient has been on Rituxan.", + "answer": "null" + }, + { + "name": "CB310", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "Mild", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Rheumatoid Arthritis only' severity at baseline selection. Allows selection of Mild severity.", + "answer": "False" + }, + { + "name": "CB311", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "Moderate", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Rheumatoid Arthritis only' severity at baseline selection. Allows selection of Moderate severity.", + "answer": "False" + }, + { + "name": "CB312", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "Severe", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Rheumatoid Arthritis only' severity at baseline selection. Allows selection of Severe severity.", + "answer": "False" + }, + { + "name": "CB306", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Is there clinical documentation supporting disease stability?' field (for rheumatoid arthritis). Indicates 'Yes'.", + "answer": "False" + }, + { + "name": "CB307", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Is there clinical documentation supporting disease stability?' field (for rheumatoid arthritis). Indicates 'No'.", + "answer": "True" + }, + { + "name": "CB308", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Is there clinical documentation supporting disease improvement?' field (for rheumatoid arthritis). Indicates 'Yes'.", + "answer": "False" + }, + { + "name": "CB309", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Is there clinical documentation supporting disease improvement?' field (for rheumatoid arthritis). Indicates 'No'.", + "answer": "True" + }, + { + "name": "CB313", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Is there clinical documentation supporting disease stability?' field (for all other indications). Indicates 'Yes'.", + "answer": "True" + }, + { + "name": "CB314", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Is there clinical documentation supporting disease stability?' field (for all other indications). Indicates 'No'.", + "answer": "False" + }, + { + "name": "CB315", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Is there clinical documentation supporting disease improvement?' field (for all other indications). Indicates 'Yes'.", + "answer": "False" + }, + { + "name": "CB316", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Is there clinical documentation supporting disease improvement?' field (for all other indications). Indicates 'No'.", + "answer": "True" + }, + { + "name": "T317", + "page": 5, + "field_type_string": "Text", + "field_label": "Date: (MM)", + "context": "Subheading: H. ACKNOWLEDGEMENT. The month the request was completed by signature.", + "answer": "05" + }, + { + "name": "T318", + "page": 5, + "field_type_string": "Text", + "field_label": "Date: (DD)", + "context": "Subheading: H. ACKNOWLEDGEMENT. The day the request was completed by signature.", + "answer": "22" + }, + { + "name": "T319", + "page": 5, + "field_type_string": "Text", + "field_label": "Date: (YYYY)", + "context": "Subheading: H. ACKNOWLEDGEMENT. The year the request was completed by signature.", + "answer": "2024" + } + ] +} \ No newline at end of file diff --git a/Output Data/Abdulla/Extracted_Fields.json b/Output Data/Abdulla/Extracted_Fields.json new file mode 100644 index 00000000..e8810cce --- /dev/null +++ b/Output Data/Abdulla/Extracted_Fields.json @@ -0,0 +1,2349 @@ +{ + "fields": [ + { + "name": "CB1", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "Start of treatment", + "context": "Subheading: Start of treatment. Indicates if this is the start of a new treatment cycle for the patient." + }, + { + "name": "T2", + "page": 2, + "field_type_string": "Text", + "field_label": "Start date: (MM)", + "context": "Subheading: Start of treatment. Requires the month of the start date for a new treatment." + }, + { + "name": "T3", + "page": 2, + "field_type_string": "Text", + "field_label": "Start date: (DD)", + "context": "Subheading: Start of treatment. Requires the day of the start date for a new treatment." + }, + { + "name": "T4", + "page": 2, + "field_type_string": "Text", + "field_label": "Start date: (YYYY)", + "context": "Subheading: Start of treatment. Requires the year of the start date for a new treatment." + }, + { + "name": "CB5", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "Continuation of therapy", + "context": "Subheading: Continuation of therapy. Indicates if this request is for continuing an existing therapy." + }, + { + "name": "T6", + "page": 2, + "field_type_string": "Text", + "field_label": "Date of last treatment: (MM)", + "context": "Subheading: Continuation of therapy. Requires the month of the last treatment date for continuing therapy." + }, + { + "name": "T7", + "page": 2, + "field_type_string": "Text", + "field_label": "Date of last treatment: (DD)", + "context": "Subheading: Continuation of therapy. Requires the day of the last treatment date for continuing therapy." + }, + { + "name": "T8", + "page": 2, + "field_type_string": "Text", + "field_label": "Date of last treatment: (YYYY)", + "context": "Subheading: Continuation of therapy. Requires the year of the last treatment date for continuing therapy." + }, + { + "name": "T9", + "page": 2, + "field_type_string": "Text", + "field_label": "Precertification Requested By:", + "context": "Subheading: Precertification Requested By. Name of the person or entity requesting precertification." + }, + { + "name": "T10", + "page": 2, + "field_type_string": "Text", + "field_label": "Phone:", + "context": "Subheading: Precertification Requested By. Phone number of the person or entity requesting precertification." + }, + { + "name": "T11", + "page": 2, + "field_type_string": "Text", + "field_label": "Fax:", + "context": "Subheading: Precertification Requested By. Fax number of the person or entity requesting precertification." + }, + { + "name": "T12", + "page": 2, + "field_type_string": "Text", + "field_label": "Patient First Name", + "context": "Subheading: A. PATIENT INFORMATION. The first name of the patient." + }, + { + "name": "T13", + "page": 2, + "field_type_string": "Text", + "field_label": "Patient Last Name", + "context": "Subheading: A. PATIENT INFORMATION. The last name of the patient." + }, + { + "name": "T14", + "page": 2, + "field_type_string": "Text", + "field_label": "Patient DOB (MM/DD/YYYY)", + "context": "Subheading: A. PATIENT INFORMATION. The date of birth of the patient." + }, + { + "name": "T15", + "page": 2, + "field_type_string": "Text", + "field_label": "Address:", + "context": "Subheading: A. PATIENT INFORMATION. The street address of the patient." + }, + { + "name": "T16", + "page": 2, + "field_type_string": "Text", + "field_label": "City:", + "context": "Subheading: A. PATIENT INFORMATION. The city of the patient's address." + }, + { + "name": "T17", + "page": 2, + "field_type_string": "Text", + "field_label": "State:", + "context": "Subheading: A. PATIENT INFORMATION. The state of the patient's address." + }, + { + "name": "T18", + "page": 2, + "field_type_string": "Text", + "field_label": "ZIP:", + "context": "Subheading: A. PATIENT INFORMATION. The ZIP code of the patient's address." + }, + { + "name": "T19", + "page": 2, + "field_type_string": "Text", + "field_label": "Patient Phone", + "context": "Subheading: A. PATIENT INFORMATION. The primary phone number for the patient." + }, + { + "name": "T20", + "page": 2, + "field_type_string": "Text", + "field_label": "Work Phone:", + "context": "Subheading: A. PATIENT INFORMATION. The work phone number for the patient." + }, + { + "name": "T21", + "page": 2, + "field_type_string": "Text", + "field_label": "Cell Phone:", + "context": "Subheading: A. PATIENT INFORMATION. The cell phone number for the patient." + }, + { + "name": "T22", + "page": 2, + "field_type_string": "Text", + "field_label": "E-mail:", + "context": "Subheading: A. PATIENT INFORMATION. The email address for the patient." + }, + { + "name": "T24", + "page": 2, + "field_type_string": "Text", + "field_label": "lbs", + "context": "Subheading: A. PATIENT INFORMATION. Input field for current weight in pounds." + }, + { + "name": "T25", + "page": 2, + "field_type_string": "Text", + "field_label": "kgs", + "context": "Subheading: A. PATIENT INFORMATION. Input field for current weight in kilograms." + }, + { + "name": "T26", + "page": 2, + "field_type_string": "Text", + "field_label": "inches", + "context": "Subheading: A. PATIENT INFORMATION. Input field for height in inches." + }, + { + "name": "T27", + "page": 2, + "field_type_string": "Text", + "field_label": "cms", + "context": "Subheading: A. PATIENT INFORMATION. Input field for height in centimeters." + }, + { + "name": "T23", + "page": 2, + "field_type_string": "Text", + "field_label": "Allergies:", + "context": "Subheading: A. PATIENT INFORMATION. Field to list any known allergies for the patient." + }, + { + "name": "T28", + "page": 2, + "field_type_string": "Text", + "field_label": "Member ID #:", + "context": "Subheading: B. INSURANCE INFORMATION. The patient's insurance member identification number." + }, + { + "name": "T29", + "page": 2, + "field_type_string": "Text", + "field_label": "Group #:", + "context": "Subheading: B. INSURANCE INFORMATION. The patient's insurance group number." + }, + { + "name": "T30", + "page": 2, + "field_type_string": "Text", + "field_label": "Insured:", + "context": "Subheading: B. INSURANCE INFORMATION. The name of the insured individual (if different from patient)." + }, + { + "name": "CB31", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: B. INSURANCE INFORMATION. Relates to 'Does patient have other coverage?' field. Indicates 'Yes'." + }, + { + "name": "CB32", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: B. INSURANCE INFORMATION. Relates to 'Does patient have other coverage?' field. Indicates 'No'." + }, + { + "name": "T33", + "page": 2, + "field_type_string": "Text", + "field_label": "If yes, provide ID#:", + "context": "Subheading: B. INSURANCE INFORMATION. Requires the ID number if the patient has other coverage." + }, + { + "name": "T34", + "page": 2, + "field_type_string": "Text", + "field_label": "Carrier Name:", + "context": "Subheading: B. INSURANCE INFORMATION. The name of the insurance carrier." + }, + { + "name": "T35", + "page": 2, + "field_type_string": "Text", + "field_label": "Insured:", + "context": "Subheading: B. INSURANCE INFORMATION. The name of the insured (if different from patient)." + }, + { + "name": "T42", + "page": 2, + "field_type_string": "Text", + "field_label": "First Name:", + "context": "Subheading: C. PRESCRIBER INFORMATION. The first name of the prescribing healthcare provider." + }, + { + "name": "T43", + "page": 2, + "field_type_string": "Text", + "field_label": "Last Name:", + "context": "Subheading: C. PRESCRIBER INFORMATION. The last name of the prescribing healthcare provider." + }, + { + "name": "CB44", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "M.D.", + "context": "Subheading: C. PRESCRIBER INFORMATION. Checkbox to indicate the prescriber is an M.D." + }, + { + "name": "CB45", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "D.O.", + "context": "Subheading: C. PRESCRIBER INFORMATION. Checkbox to indicate the prescriber is a D.O." + }, + { + "name": "CB46", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "N.P.", + "context": "Subheading: C. PRESCRIBER INFORMATION. Checkbox to indicate the prescriber is a Nurse Practitioner (N.P.)." + }, + { + "name": "CB47", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "P.A.", + "context": "Subheading: C. PRESCRIBER INFORMATION. Checkbox to indicate the prescriber is a Physician Assistant (P.A.)." + }, + { + "name": "T48", + "page": 2, + "field_type_string": "Text", + "field_label": "Address:", + "context": "Subheading: C. PRESCRIBER INFORMATION. The street address of the prescribing healthcare provider." + }, + { + "name": "T49", + "page": 2, + "field_type_string": "Text", + "field_label": "City:", + "context": "Subheading: C. PRESCRIBER INFORMATION. The city of the prescribing healthcare provider's address." + }, + { + "name": "T50", + "page": 2, + "field_type_string": "Text", + "field_label": "State:", + "context": "Subheading: C. PRESCRIBER INFORMATION. The state of the prescribing healthcare provider's address." + }, + { + "name": "T51", + "page": 2, + "field_type_string": "Text", + "field_label": "ZIP:", + "context": "Subheading: C. PRESCRIBER INFORMATION. The ZIP code of the prescribing healthcare provider's address." + }, + { + "name": "T52", + "page": 2, + "field_type_string": "Text", + "field_label": "Phone:", + "context": "Subheading: C. PRESCRIBER INFORMATION. The phone number of the prescribing healthcare provider." + }, + { + "name": "T53", + "page": 2, + "field_type_string": "Text", + "field_label": "Fax:", + "context": "Subheading: C. PRESCRIBER INFORMATION. The fax number of the prescribing healthcare provider." + }, + { + "name": "T54", + "page": 2, + "field_type_string": "Text", + "field_label": "St Lic #:", + "context": "Subheading: C. PRESCRIBER INFORMATION. The state license number of the prescribing healthcare provider." + }, + { + "name": "T55", + "page": 2, + "field_type_string": "Text", + "field_label": "NPI #:", + "context": "Subheading: C. PRESCRIBER INFORMATION. The National Provider Identifier (NPI) of the prescribing healthcare provider." + }, + { + "name": "T56", + "page": 2, + "field_type_string": "Text", + "field_label": "DEA #:", + "context": "Subheading: C. PRESCRIBER INFORMATION. The Drug Enforcement Administration (DEA) number of the prescribing healthcare provider." + }, + { + "name": "T57", + "page": 2, + "field_type_string": "Text", + "field_label": "UPIN:", + "context": "Subheading: C. PRESCRIBER INFORMATION. The Unique Physician Identification Number (UPIN) of the prescribing healthcare provider." + }, + { + "name": "T58.0", + "page": 2, + "field_type_string": "Text", + "field_label": "Provider Email:", + "context": "Subheading: C. PRESCRIBER INFORMATION. The email address of the prescribing healthcare provider." + }, + { + "name": "T58.1", + "page": 2, + "field_type_string": "Text", + "field_label": "Office Contact Name:", + "context": "Subheading: C. PRESCRIBER INFORMATION. The name of the contact person in the prescriber's office." + }, + { + "name": "T59", + "page": 2, + "field_type_string": "Text", + "field_label": "Phone:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. Phone number for the dispensing provider/pharmacy." + }, + { + "name": "Provider Admin CB.1", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "Self-administered", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. Place of Administration. Indicates if the medication is self-administered by the patient." + }, + { + "name": "Provider Admin CB.2", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "Physician\u2019s Office", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. Place of Administration. Indicates if the medication is administered in a physician's office." + }, + { + "name": "Provider Admin CB.3", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "Home", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. Place of Administration. Indicates if the medication is administered at home." + }, + { + "name": "Provider Admin CB.4", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "Outpatient Infusion Center", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. Place of Administration. Indicates if the medication is administered at an outpatient infusion center." + }, + { + "name": "Provider Admin T.5", + "page": 2, + "field_type_string": "Text", + "field_label": "Name:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. Name of the Outpatient Infusion Center." + }, + { + "name": "Provider Admin CB.7", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "Home Infusion Center", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. Place of Administration. Indicates if the medication is administered at a home infusion center." + }, + { + "name": "Provider Admin T.6", + "page": 2, + "field_type_string": "Text", + "field_label": "Phone:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. Phone number for the Home Infusion Center." + }, + { + "name": "Provider Admin T.8", + "page": 2, + "field_type_string": "Text", + "field_label": "Agency Name:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. Name of the agency providing home infusion services." + }, + { + "name": "Provider Admin CB.10", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "Administration code(s)", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. Checkbox to indicate that administration codes (CPT) are provided." + }, + { + "name": "Provider Admin T.9", + "page": 2, + "field_type_string": "Text", + "field_label": "CPT:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. Current Procedural Terminology (CPT) code for administration." + }, + { + "name": "Provider Admin T.11A", + "page": 2, + "field_type_string": "Text", + "field_label": "Address:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. Street address of the dispensing provider/pharmacy." + }, + { + "name": "Provider Admin T.13", + "page": 2, + "field_type_string": "Text", + "field_label": "City:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. City of the dispensing provider/pharmacy." + }, + { + "name": "Provider Admin T.14", + "page": 2, + "field_type_string": "Text", + "field_label": "State:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. State of the dispensing provider/pharmacy." + }, + { + "name": "Provider Admin T.15", + "page": 2, + "field_type_string": "Text", + "field_label": "ZIP:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. ZIP code of the dispensing provider/pharmacy." + }, + { + "name": "Provider Admin T.16", + "page": 2, + "field_type_string": "Text", + "field_label": "Phone:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. Phone number of the dispensing provider/pharmacy." + }, + { + "name": "Provider Admin T.17A", + "page": 2, + "field_type_string": "Text", + "field_label": "Fax:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. Fax number of the dispensing provider/pharmacy." + }, + { + "name": "Provider Admin T.18", + "page": 2, + "field_type_string": "Text", + "field_label": "TIN:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. Taxpayer Identification Number (TIN) of the dispensing provider/pharmacy." + }, + { + "name": "Provider Admin T.19", + "page": 2, + "field_type_string": "Text", + "field_label": "PIN:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. Pharmacy Identification Number (PIN) of the dispensing provider/pharmacy." + }, + { + "name": "Provider Admin T.20", + "page": 2, + "field_type_string": "Text", + "field_label": "NPI:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. National Provider Identifier (NPI) of the dispensing provider/pharmacy." + }, + { + "name": "Provider Admin CB.21", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "Outpatient Dialysis Center", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. Dispensing Provider/Pharmacy. Indicates if the dispensing provider is an Outpatient Dialysis Center." + }, + { + "name": "Provider Admin CB.22", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "Physician\u2019s Office", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. Dispensing Provider/Pharmacy. Indicates if the dispensing provider is a Physician's Office." + }, + { + "name": "Provider Admin CB.23.0.0", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "Retail Pharmacy", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. Dispensing Provider/Pharmacy. Indicates if the dispensing provider is a Retail Pharmacy." + }, + { + "name": "Provider Admin CB.24.0.0", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "Specialty Pharmacy", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. Dispensing Provider/Pharmacy. Indicates if the dispensing provider is a Specialty Pharmacy." + }, + { + "name": "Provider Admin CB.25", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "Mail Order", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. Dispensing Provider/Pharmacy. Indicates if the dispensing provider is a Mail Order Pharmacy." + }, + { + "name": "Provider Admin CB.26", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "Other:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. Dispensing Provider/Pharmacy. Checkbox for 'Other' type of dispensing provider." + }, + { + "name": "Provider Admin T.27", + "page": 2, + "field_type_string": "Text", + "field_label": "Other:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. Dispensing Provider/Pharmacy. Text field to specify 'Other' dispensing provider type." + }, + { + "name": "Provider Admin T.28", + "page": 2, + "field_type_string": "Text", + "field_label": "Name:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. Name of the dispensing provider/pharmacy." + }, + { + "name": "Provider Admin T.29a", + "page": 2, + "field_type_string": "Text", + "field_label": "Address:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. Street address of the dispensing provider/pharmacy." + }, + { + "name": "Provider Admin T.30a", + "page": 2, + "field_type_string": "Text", + "field_label": "City:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. City of the dispensing provider/pharmacy." + }, + { + "name": "Provider Admin T.31", + "page": 2, + "field_type_string": "Text", + "field_label": "State:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. State of the dispensing provider/pharmacy." + }, + { + "name": "Provider Admin T.32", + "page": 2, + "field_type_string": "Text", + "field_label": "ZIP:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. ZIP code of the dispensing provider/pharmacy." + }, + { + "name": "Provider Admin T.33", + "page": 2, + "field_type_string": "Text", + "field_label": "Phone:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. Phone number of the dispensing provider/pharmacy." + }, + { + "name": "Provider Admin T.34", + "page": 2, + "field_type_string": "Text", + "field_label": "Fax:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. Fax number of the dispensing provider/pharmacy." + }, + { + "name": "Provider Admin T.35", + "page": 2, + "field_type_string": "Text", + "field_label": "TIN:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. Taxpayer Identification Number (TIN) of the dispensing provider/pharmacy." + }, + { + "name": "Provider Admin T.36", + "page": 2, + "field_type_string": "Text", + "field_label": "PIN:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. Pharmacy Identification Number (PIN) of the dispensing provider/pharmacy." + }, + { + "name": "Provider Admin T.37", + "page": 2, + "field_type_string": "Text", + "field_label": "NPI:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. National Provider Identifier (NPI) of the dispensing provider/pharmacy." + }, + { + "name": "CB60", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "Riabni (rituximab-arrx)", + "context": "Subheading: E. PRODUCT INFORMATION. Checkbox to select Riabni (rituximab-arrx) as the requested product." + }, + { + "name": "CB61", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "Rituxan (rituximab)", + "context": "Subheading: E. PRODUCT INFORMATION. Checkbox to select Rituxan (rituximab) as the requested product." + }, + { + "name": "CB62", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "Ruxience (rituximab-pvvr)", + "context": "Subheading: E. PRODUCT INFORMATION. Checkbox to select Ruxience (rituximab-pvvr) as the requested product." + }, + { + "name": "CB63", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "Truxima (rituximab-abbs)", + "context": "Subheading: E. PRODUCT INFORMATION. Checkbox to select Truxima (rituximab-abbs) as the requested product." + }, + { + "name": "T64", + "page": 2, + "field_type_string": "Text", + "field_label": "Dose:", + "context": "Subheading: E. PRODUCT INFORMATION. The dosage of the requested product." + }, + { + "name": "T65", + "page": 2, + "field_type_string": "Text", + "field_label": "Directions for Use:", + "context": "Subheading: E. PRODUCT INFORMATION. Instructions for how the product should be used." + }, + { + "name": "T66", + "page": 2, + "field_type_string": "Text", + "field_label": "HCPCS Code:", + "context": "Subheading: E. PRODUCT INFORMATION. Healthcare Common Procedure Coding System (HCPCS) code for the product." + }, + { + "name": "T67", + "page": 2, + "field_type_string": "Text", + "field_label": "Primary ICD Code:", + "context": "Subheading: F. DIAGNOSIS INFORMATION. The primary International Classification of Diseases (ICD) code for the patient's diagnosis." + }, + { + "name": "CB68", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "Other ICD Code:", + "context": "Subheading: F. DIAGNOSIS INFORMATION. Checkbox to indicate that an Other ICD Code is provided." + }, + { + "name": "T69", + "page": 2, + "field_type_string": "Text", + "field_label": "Other ICD Code:", + "context": "Subheading: F. DIAGNOSIS INFORMATION. Field to provide an additional International Classification of Diseases (ICD) code." + }, + { + "name": "CB70", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION. Relates to 'Has the patient had prior therapy with the requested product within the last 365 days?' field. Indicates 'Yes'." + }, + { + "name": "CB71", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION. Relates to 'Has the patient had prior therapy with the requested product within the last 365 days?' field. Indicates 'No'." + }, + { + "name": "CB72", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION. Relates to 'Has the patient had a trial and failure of any of the following rituximab biosimilars?' field. Indicates 'No'." + }, + { + "name": "CB73", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "Ruxience (rituximab-pvvr)", + "context": "Subheading: G. CLINICAL INFORMATION. Part of the question 'Has the patient had a trial and failure of any of the following rituximab biosimilars?' Allows selection of Ruxience." + }, + { + "name": "CB74", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "Truxima (rituximab-abbs)", + "context": "Subheading: G. CLINICAL INFORMATION. Part of the question 'Has the patient had a trial and failure of any of the following rituximab biosimilars?' Allows selection of Truxima." + }, + { + "name": "T75", + "page": 2, + "field_type_string": "Text", + "field_label": "When was the member\u2019s trial and failure of the preferred drug?", + "context": "Subheading: G. CLINICAL INFORMATION. Requires the date of trial and failure of the preferred drug." + }, + { + "name": "T76", + "page": 2, + "field_type_string": "Text", + "field_label": "Please describe the nature of the failure of the preferred drug", + "context": "Subheading: G. CLINICAL INFORMATION. Requires a description of the failure of the preferred drug." + }, + { + "name": "CB77", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION. Relates to 'Has the patient had an adverse reaction to any of the following rituximab biosimilars?' field. Indicates 'No'." + }, + { + "name": "CB78", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "Ruxience (rituximab-pvvr)", + "context": "Subheading: G. CLINICAL INFORMATION. Part of the question 'Has the patient had an adverse reaction to any of the following rituximab biosimilars?' Allows selection of Ruxience." + }, + { + "name": "CB79", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "Truxima (rituximab-abbs)", + "context": "Subheading: G. CLINICAL INFORMATION. Part of the question 'Has the patient had an adverse reaction to any of the following rituximab biosimilars?' Allows selection of Truxima." + }, + { + "name": "T80", + "page": 2, + "field_type_string": "Text", + "field_label": "When was the member\u2019s adverse reaction to the preferred drug?", + "context": "Subheading: G. CLINICAL INFORMATION. Requires the date of the adverse reaction to the preferred drug." + }, + { + "name": "T81", + "page": 2, + "field_type_string": "Text", + "field_label": "Please describe the nature of the adverse reaction to the preferred drug", + "context": "Subheading: G. CLINICAL INFORMATION. Requires a description of the adverse reaction to the preferred drug." + }, + { + "name": "T84", + "page": 2, + "field_type_string": "Text", + "field_label": "Please explain if there are any contraindications or other medical reason(s) that the patient cannot use any of the following preferred biosimilar products when indicated for the patient\u2019s diagnosis?", + "context": "Subheading: G. CLINICAL INFORMATION. Requires an explanation of contraindications or reasons the patient cannot use preferred biosimilars." + }, + { + "name": "CB82", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "Ruxience (rituximab-pvvr)", + "context": "Subheading: G. CLINICAL INFORMATION. Part of the question regarding contraindications to preferred biosimilars. Allows selection of Ruxience." + }, + { + "name": "CB83", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "Truxima (rituximab-abbs)", + "context": "Subheading: G. CLINICAL INFORMATION. Part of the question regarding contraindications to preferred biosimilars. Allows selection of Truxima." + }, + { + "name": "T12", + "page": 3, + "field_type_string": "Text", + "field_label": "Patient First Name", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). The first name of the patient." + }, + { + "name": "T13", + "page": 3, + "field_type_string": "Text", + "field_label": "Patient Last Name", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). The last name of the patient." + }, + { + "name": "T19", + "page": 3, + "field_type_string": "Text", + "field_label": "Patient Phone", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). The phone number of the patient." + }, + { + "name": "T14", + "page": 3, + "field_type_string": "Text", + "field_label": "Patient DOB (MM/DD/YYYY)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). The date of birth of the patient." + }, + { + "name": "CB86", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Inflectra (infliximab-dyyb)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of the question 'Has the patient had a trial and failure of any of the following?' Allows selection of Inflectra." + }, + { + "name": "CB87", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Renflexis (infliximab-abda)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of the question 'Has the patient had a trial and failure of any of the following?' Allows selection of Renflexis." + }, + { + "name": "CB88", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Simponi Aria (golimumab)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of the question 'Has the patient had a trial and failure of any of the following?' Allows selection of Simponi Aria." + }, + { + "name": "T89", + "page": 3, + "field_type_string": "Text", + "field_label": "When was the member\u2019s trial and failure of the preferred drug?", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Requires the date of trial and failure of the preferred drug. Dependent on the preceding 'Yes' to trial and failure question." + }, + { + "name": "T90", + "page": 3, + "field_type_string": "Text", + "field_label": "Please describe the nature of the failure of the preferred drug", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Requires a description of the failure of the preferred drug. Dependent on the preceding 'Yes' to trial and failure question." + }, + { + "name": "CB85", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Has the patient had a trial and failure of any of the following?' field. Indicates 'No'." + }, + { + "name": "CB92", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Inflectra (infliximab-dyyb)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of the question 'Has the patient had an adverse reaction to any of the following?' Allows selection of Inflectra." + }, + { + "name": "CB93", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Renflexis (infliximab-abda)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of the question 'Has the patient had an adverse reaction to any of the following?' Allows selection of Renflexis." + }, + { + "name": "CB94", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Simponi Aria (golimumab)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of the question 'Has the patient had an adverse reaction to any of the following?' Allows selection of Simponi Aria." + }, + { + "name": "T95", + "page": 3, + "field_type_string": "Text", + "field_label": "When was the member\u2019s adverse reaction to the preferred drug?", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Requires the date of the adverse reaction to the preferred drug. Dependent on the preceding 'Yes' to adverse reaction question." + }, + { + "name": "T96a", + "page": 3, + "field_type_string": "Text", + "field_label": "Please describe the nature of the adverse reaction to the preferred drug", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Requires a description of the adverse reaction to the preferred drug. Dependent on the preceding 'Yes' to adverse reaction question." + }, + { + "name": "CB91", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Has the patient had an adverse reaction to any of the following?' field. Indicates 'No'." + }, + { + "name": "CB98a", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Enbrel (etanercept)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of the question 'Has the patient had a trial and failure of any of the following?' Allows selection of Enbrel." + }, + { + "name": "CB99a", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Humira (adalimumab)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of the question 'Has the patient had a trial and failure of any of the following?' Allows selection of Humira." + }, + { + "name": "CB100a", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Idacio (adalimumab-aacf)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of the question 'Has the patient had a trial and failure of any of the following?' Allows selection of Idacio." + }, + { + "name": "CB101a", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Rinvoq (upadacitinib)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of the question 'Has the patient had a trial and failure of any of the following?' Allows selection of Rinvoq." + }, + { + "name": "CB102a", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Tyenne SC (tocilizumab-aazg)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of the question 'Has the patient had a trial and failure of any of the following?' Allows selection of Tyenne SC." + }, + { + "name": "CB103a", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Xeljanz/Xeljanz XR (tofacitinib)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of the question 'Has the patient had a trial and failure of any of the following?' Allows selection of Xeljanz/Xeljanz XR." + }, + { + "name": "T104", + "page": 3, + "field_type_string": "Text", + "field_label": "When was the member\u2019s trial and failure of the preferred drug?", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Requires the date of trial and failure of the preferred drug. Dependent on the preceding 'Yes' to trial and failure question." + }, + { + "name": "T105", + "page": 3, + "field_type_string": "Text", + "field_label": "Please describe the nature of the failure of the preferred drug", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Requires a description of the failure of the preferred drug. Dependent on the preceding 'Yes' to trial and failure question." + }, + { + "name": "CB97", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Has the patient had a trial and failure of any of the following?' field. Indicates 'No'." + }, + { + "name": "CB107z", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Enbrel (etanercept)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of the question 'Has the patient had an adverse reaction to any of the following?' Allows selection of Enbrel." + }, + { + "name": "CB108z", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Humira (adalimumab)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of the question 'Has the patient had an adverse reaction to any of the following?' Allows selection of Humira." + }, + { + "name": "CB109z", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Idacio (adalimumab-aacf)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of the question 'Has the patient had an adverse reaction to any of the following?' Allows selection of Idacio." + }, + { + "name": "CB110z", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Rinvoq (upadacitinib)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of the question 'Has the patient had an adverse reaction to any of the following?' Allows selection of Rinvoq." + }, + { + "name": "CB111z", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Tyenne SC (tocilizumab-aazg)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of the question 'Has the patient had an adverse reaction to any of the following?' Allows selection of Tyenne SC." + }, + { + "name": "CB112z", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Xeljanz/Xeljanz XR (tofacitinib)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of the question 'Has the patient had an adverse reaction to any of the following?' Allows selection of Xeljanz/Xeljanz XR." + }, + { + "name": "T113", + "page": 3, + "field_type_string": "Text", + "field_label": "When was the member\u2019s adverse reaction to the preferred drug?", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Requires the date of the adverse reaction to the preferred drug. Dependent on the preceding 'Yes' to adverse reaction question." + }, + { + "name": "T114", + "page": 3, + "field_type_string": "Text", + "field_label": "Please describe the nature of the adverse reaction to the preferred drug", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Requires a description of the adverse reaction to the preferred drug. Dependent on the preceding 'Yes' to adverse reaction question." + }, + { + "name": "CB106z", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Has the patient had an adverse reaction to any of the following?' field. Indicates 'No'." + }, + { + "name": "T118", + "page": 3, + "field_type_string": "Text", + "field_label": "Please explain if there are any contraindications or other medical reason(s) that the patient cannot use any of the following preferred products when indicated for the patient's diagnosis?", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Requires an explanation of contraindications or reasons the patient cannot use preferred biosimilars. Dependent on the preceding 'Yes' to contraindications question." + }, + { + "name": "CB115z", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Inflectra (infliximab-dyyb)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of the question regarding contraindications to preferred biosimilars. Allows selection of Inflectra." + }, + { + "name": "CB116z", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Renflexis (infliximab-abda)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of the question regarding contraindications to preferred biosimilars. Allows selection of Renflexis." + }, + { + "name": "CB117z", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Simponi Aria (golimumab)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of the question regarding contraindications to preferred biosimilars. Allows selection of Simponi Aria." + }, + { + "name": "T125", + "page": 3, + "field_type_string": "Text", + "field_label": "Please explain if there are contraindications or any other medical reason(s) that the patient cannot use any of the following preferred products when indicated for the patient\u2019s diagnosis?", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Requires an explanation of contraindications or reasons the patient cannot use preferred biosimilars. Dependent on the preceding 'Yes' to contraindications question." + }, + { + "name": "CB119z", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Enbrel (etanercept)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of the question regarding contraindications to preferred biosimilars. Allows selection of Enbrel." + }, + { + "name": "CB120z", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Humira (adalimumab)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of the question regarding contraindications to preferred biosimilars. Allows selection of Humira." + }, + { + "name": "CB121z", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Idacio (adalimumab-aacf)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of the question regarding contraindications to preferred biosimilars. Allows selection of Idacio." + }, + { + "name": "CB122z", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Rinvoq (upadacitinib)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of the question regarding contraindications to preferred biosimilars. Allows selection of Rinvoq." + }, + { + "name": "CB123z", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Tyenne SC (tocilizumab-aazg)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of the question regarding contraindications to preferred biosimilars. Allows selection of Tyenne SC." + }, + { + "name": "CB124z", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Xeljanz/Xeljanz XR (tofacitinib)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of the question regarding contraindications to preferred biosimilars. Allows selection of Xeljanz/Xeljanz XR." + }, + { + "name": "CB96.4.0", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Will Rituxan (rituximab) be used concomitantly with apremilast, tofacitinib, or other biologic DMARDs?' field. Indicates 'Yes'." + }, + { + "name": "CB98", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Will Rituxan (rituximab) be used concomitantly with apremilast, tofacitinib, or other biologic DMARDs?' field. Indicates 'No'." + }, + { + "name": "CB99.0", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Does the patient have a documented diagnosis of Philadelphia chromosome-negative acute lymphoid leukemia (ALL)?' field. Indicates 'Yes'." + }, + { + "name": "CB100.0", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Does the patient have a documented diagnosis of Philadelphia chromosome-negative acute lymphoid leukemia (ALL)?' field. Indicates 'No'." + }, + { + "name": "CB101.0", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Is Rituxan (rituximab) being used as induction/consolidation therapy?' field. Indicates 'Yes'." + }, + { + "name": "CB102.0", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Is Rituxan (rituximab) being used as induction/consolidation therapy?' field. Indicates 'No'." + }, + { + "name": "CB103", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Does the patient have a documented diagnosis of refractory autoimmune hemolytic anemia?' field. Indicates 'Yes'." + }, + { + "name": "CB104", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Does the patient have a documented diagnosis of refractory autoimmune hemolytic anemia?' field. Indicates 'No'." + }, + { + "name": "CB104a", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Wegener granulomatosis", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Anti-neutrophil cytoplasmic antibody-associated (ANCA-associated) vasculitides'. Allows selection of Wegener granulomatosis." + }, + { + "name": "CB104b", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Churg-Strauss syndrome", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Anti-neutrophil cytoplasmic antibody-associated (ANCA-associated) vasculitides'. Allows selection of Churg-Strauss syndrome." + }, + { + "name": "CB104c", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "microscopic polyangiitis", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Anti-neutrophil cytoplasmic antibody-associated (ANCA-associated) vasculitides'. Allows selection of microscopic polyangiitis." + }, + { + "name": "CB104d", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "pauci-immune glomerulonephritis", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Anti-neutrophil cytoplasmic antibody-associated (ANCA-associated) vasculitides'. Allows selection of pauci-immune glomerulonephritis." + }, + { + "name": "CB105", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Will Rituxan (rituximab) be given in conjunction with glucocorticoids?' field. Indicates 'Yes'." + }, + { + "name": "CB106", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Will Rituxan (rituximab) be given in conjunction with glucocorticoids?' field. Indicates 'No'." + }, + { + "name": "CB106a", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Does the patient have a documented diagnosis of corticosteroid-refractory autoimmune blistering disease?' field. Indicates 'Yes'." + }, + { + "name": "CB107", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "pemphigus vulgaris", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Autoimmune blistering diseases, corticosteroid-refractory' selection. Allows selection of pemphigus vulgaris." + }, + { + "name": "CB108", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "pemphigus folliaceus", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Autoimmune blistering diseases, corticosteroid-refractory' selection. Allows selection of pemphigus folliaceus." + }, + { + "name": "CB109", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "bullous pemphigoid", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Autoimmune blistering diseases, corticosteroid-refractory' selection. Allows selection of bullous pemphigoid." + }, + { + "name": "CB110", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "cicatricial pemphigoid", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Autoimmune blistering diseases, corticosteroid-refractory' selection. Allows selection of cicatricial pemphigoid." + }, + { + "name": "CB111", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "epidermolysis bullosa acquisita", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Autoimmune blistering diseases, corticosteroid-refractory' selection. Allows selection of epidermolysis bullosa acquisita." + }, + { + "name": "CB112", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "paraneoplastic pemphigus", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Autoimmune blistering diseases, corticosteroid-refractory' selection. Allows selection of paraneoplastic pemphigus." + }, + { + "name": "CB113", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "None of the above", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Autoimmune blistering diseases, corticosteroid-refractory' selection. Indicates none of the listed conditions apply." + }, + { + "name": "CB106b", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Does the patient have a documented diagnosis of corticosteroid-refractory autoimmune blistering disease?' field. Indicates 'No'." + }, + { + "name": "CB114", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "AIDS-related B-cell lymphoma", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'B-cell lymphomas' selection. Allows selection of AIDS-related B-cell lymphoma." + }, + { + "name": "CB115", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Burkitt lymphoma", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'B-cell lymphomas' selection. Allows selection of Burkitt lymphoma." + }, + { + "name": "CB116", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Diffuse large B-cell lymphoma", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'B-cell lymphomas' selection. Allows selection of Diffuse large B-cell lymphoma." + }, + { + "name": "CB117", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Follicular lymphoma", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'B-cell lymphomas' selection. Allows selection of Follicular lymphoma." + }, + { + "name": "CB118", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Gastric MALT lymphoma", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'B-cell lymphomas' selection. Allows selection of Gastric MALT lymphoma." + }, + { + "name": "CB119", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "High-grade B-Cell lymphoma", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'B-cell lymphomas' selection. Allows selection of High-grade B-Cell lymphoma." + }, + { + "name": "CB120", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Mantle cell lymphoma", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'B-cell lymphomas' selection. Allows selection of Mantle cell lymphoma." + }, + { + "name": "CB121", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Nodal marginal zone lymphoma", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'B-cell lymphomas' selection. Allows selection of Nodal marginal zone lymphoma." + }, + { + "name": "CB122", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Nongastric MALT lymphoma", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'B-cell lymphomas' selection. Allows selection of Nongastric MALT lymphoma." + }, + { + "name": "CB123", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Primary cutaneous B-cell lymphomas", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'B-cell lymphomas' selection. Allows selection of Primary cutaneous B-cell lymphomas." + }, + { + "name": "CB124", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Splenic marginal zone lymphoma", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'B-cell lymphomas' selection. Allows selection of Splenic marginal zone lymphoma." + }, + { + "name": "CB125", + "page": 3, + "field_type_string": "CheckBox", + "field_label": "Other:", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'B-cell lymphomas' selection. Checkbox for 'Other' type of lymphoma." + }, + { + "name": "T126", + "page": 3, + "field_type_string": "Text", + "field_label": "Other:", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'B-cell lymphomas' selection. Text field to specify 'Other' lymphoma type." + }, + { + "name": "T12", + "page": 4, + "field_type_string": "Text", + "field_label": "Patient First Name", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). The first name of the patient." + }, + { + "name": "T13", + "page": 4, + "field_type_string": "Text", + "field_label": "Patient Last Name", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). The last name of the patient." + }, + { + "name": "T19", + "page": 4, + "field_type_string": "Text", + "field_label": "Patient Phone", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). The phone number of the patient." + }, + { + "name": "T14", + "page": 4, + "field_type_string": "Text", + "field_label": "Patient DOB (MM/DD/YYYY)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). The date of birth of the patient." + }, + { + "name": "CB127", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Does the patient have a documented diagnosis of multicentric Castleman's disease?' field. Indicates 'Yes'." + }, + { + "name": "CB128", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Does the patient have a documented diagnosis of multicentric Castleman's disease?' field. Indicates 'No'." + }, + { + "name": "CB129", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "leptomeningeal metastases from lymphoma", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Central nervous system lymphomas' selection. Allows selection of leptomeningeal metastases from lymphoma." + }, + { + "name": "CB130", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "primary CNS lymphoma", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Central nervous system lymphomas' selection. Allows selection of primary CNS lymphoma." + }, + { + "name": "CB131", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "none of the above", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Central nervous system lymphomas' selection. Indicates none of the listed conditions apply." + }, + { + "name": "CB132", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "chronic lymphocytic leukemia (CLL)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Chronic or small lymphocytic leukemia' selection. Allows selection of chronic lymphocytic leukemia (CLL)." + }, + { + "name": "CB133", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "small lymphocytic leukemia", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Chronic or small lymphocytic leukemia' selection. Allows selection of small lymphocytic leukemia." + }, + { + "name": "CB134", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "none of the above", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Chronic or small lymphocytic leukemia' selection. Indicates none of the listed conditions apply." + }, + { + "name": "CB135", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Does the patient have a documented diagnosis of cryoglobulinemia?' field. Indicates 'Yes'." + }, + { + "name": "CB136", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Does the patient have a documented diagnosis of cryoglobulinemia?' field. Indicates 'No'." + }, + { + "name": "CB139", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Is there clinical documentation that the treatment with corticosteroids and other immunosuppressive agents was ineffective?' field. Indicates 'Yes'." + }, + { + "name": "CB140", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Is there clinical documentation that the treatment with corticosteroids and other immunosuppressive agents was ineffective?' field. Indicates 'No'." + }, + { + "name": "CB144", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Is there a documentation that Rituxan (rituximab) being used as last-resort treatment for chronic graft versus host disease (GVHD)?' field. Indicates 'Yes'." + }, + { + "name": "CB145", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Is there a documentation that Rituxan (rituximab) being used as last-resort treatment for chronic graft versus host disease (GVHD)?' field. Indicates 'No'." + }, + { + "name": "CB141", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "relapsed hairy cell leukemia", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Hairy cell leukemia' selection. Allows selection of relapsed hairy cell leukemia." + }, + { + "name": "CB142", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "refractory hairy cell leukemia", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Hairy cell leukemia' selection. Allows selection of refractory hairy cell leukemia." + }, + { + "name": "CB143", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "none of the above", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Hairy cell leukemia' selection. Indicates none of the listed conditions apply." + }, + { + "name": "CB137", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Is there a documentation that Rituxan (rituximab) is being used for treatment or prevention (desensitization) of highly sensitized patients with antibody mediated rejection in heart transplant recipients and other solid organ transplant recipients?' field. Indicates 'Yes'." + }, + { + "name": "CB146", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "heart transplant recipient", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of the question 'Please select which applies to the patient:'. Allows selection of heart transplant recipient." + }, + { + "name": "CB147", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "other solid organ transplant recipient", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of the question 'Please select which applies to the patient:'. Allows selection of other solid organ transplant recipient." + }, + { + "name": "CB138", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Is there a documentation that Rituxan (rituximab) is being used for treatment or prevention (desensitization) of highly sensitized patients with antibody mediated rejection in heart transplant recipients and other solid organ transplant recipients?' field. Indicates 'No'." + }, + { + "name": "CB148", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "Bavencio (avelumab)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Immune checkpoint-inhibitor related encephalitis' selection. Allows selection of Bavencio." + }, + { + "name": "CB149", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "Imfinzi (durvalumab)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Immune checkpoint-inhibitor related encephalitis' selection. Allows selection of Imfinzi." + }, + { + "name": "CB150", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "Keytruda (pembrolizumab)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Immune checkpoint-inhibitor related encephalitis' selection. Allows selection of Keytruda." + }, + { + "name": "CB151", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "Opdivo (nivolumab)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Immune checkpoint-inhibitor related encephalitis' selection. Allows selection of Opdivo." + }, + { + "name": "CB152", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "Tecentriq (atezolizumab)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Immune checkpoint-inhibitor related encephalitis' selection. Allows selection of Tecentriq." + }, + { + "name": "CB153", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "Yervoy (ipilimumab)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Immune checkpoint-inhibitor related encephalitis' selection. Allows selection of Yervoy." + }, + { + "name": "CB154", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "Other:", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Immune checkpoint-inhibitor related encephalitis' selection. Checkbox for 'Other' immune checkpoint inhibitor." + }, + { + "name": "T155", + "page": 4, + "field_type_string": "Text", + "field_label": "Other:", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Immune checkpoint-inhibitor related encephalitis' selection. Text field to specify 'Other' immune checkpoint inhibitor." + }, + { + "name": "CB156", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Does the patient have a documented diagnosis of refractory immune or idiopathic thrombocytopenic purpura (ITP)?' field. Indicates 'Yes'." + }, + { + "name": "CB158", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "refractory immune thrombocytopenic purpura", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Immune or idiopathic thrombocytopenic purpura' selection. Allows selection of refractory immune thrombocytopenic purpura." + }, + { + "name": "CB159", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "idiopathic thrombocytopenic purpura (ITP)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Immune or idiopathic thrombocytopenic purpura' selection. Allows selection of idiopathic thrombocytopenic purpura (ITP)." + }, + { + "name": "CB157", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Does the patient have a documented diagnosis of refractory immune or idiopathic thrombocytopenic purpura (ITP)?' field. Indicates 'No'." + }, + { + "name": "CB160", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Is Rituxan (rituximab) being used as rejection prophylaxis in sensitized kidney transplant recipients with donor specific antibodies?' field. Indicates 'Yes'." + }, + { + "name": "CB161", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Is Rituxan (rituximab) being used as rejection prophylaxis in sensitized kidney transplant recipients with donor specific antibodies?' field. Indicates 'No'." + }, + { + "name": "CB162", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Does the patient have a documented diagnosis of lymphocyte-predominant Hodgkin's lymphoma?' field. Indicates 'Yes'." + }, + { + "name": "CB163", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Does the patient have a documented diagnosis of lymphocyte-predominant Hodgkin's lymphoma?' field. Indicates 'No'." + }, + { + "name": "CB164", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "Relapsing-remitting MS (RRMS)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Multiple Sclerosis' selection. Allows selection of Relapsing-remitting MS (RRMS)." + }, + { + "name": "CB165", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "Secondary-progressive MS (SPMS)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Multiple Sclerosis' selection. Allows selection of Secondary-progressive MS (SPMS)." + }, + { + "name": "CB166", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "Primary-progressive MS (PPMS)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Multiple Sclerosis' selection. Allows selection of Primary-progressive MS (PPMS)." + }, + { + "name": "CB167", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "Progressive-relapsing MS (PRMS)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Multiple Sclerosis' selection. Allows selection of Progressive-relapsing MS (PRMS)." + }, + { + "name": "CB168", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Has the patient discontinued other medications used for treating MS?' field. Indicates 'Yes'." + }, + { + "name": "CB169", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Has the patient discontinued other medications used for treating MS?' field. Indicates 'No'." + }, + { + "name": "CB170", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Does the patient have a documented diagnosis of muscle-specific tyrosine kinase myasthenia gravis (MuSK-MG)?' field. Indicates 'Yes'." + }, + { + "name": "CB172", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Has the patient had an unsatisfactory response to initial immunotherapy?' field. Indicates 'Yes'." + }, + { + "name": "CB173", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Has the patient had an unsatisfactory response to initial immunotherapy?' field. Indicates 'No'." + }, + { + "name": "CB171", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Does the patient have a documented diagnosis of muscle-specific tyrosine kinase myasthenia gravis (MuSK-MG)?' field. Indicates 'No'." + }, + { + "name": "CB174", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Does the patient have a documented diagnosis of neuromyelitis optica (Devic's disease)?' field. Indicates 'Yes'." + }, + { + "name": "CB175", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Does the patient have a documented diagnosis of neuromyelitis optica (Devic's disease)?' field. Indicates 'No'." + }, + { + "name": "CB176", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Was the treatment with at least one immunotherapy ineffective?' field. Indicates 'Yes'." + }, + { + "name": "CB177", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Was the treatment with at least one immunotherapy ineffective?' field. Indicates 'No'." + }, + { + "name": "CB178", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Does the patient have a documented diagnosis of opsoclonus-myoclonus-ataxia (OMA) associated with neuroblastoma?' field. Indicates 'Yes'." + }, + { + "name": "CB179", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Does the patient have a documented diagnosis of opsoclonus-myoclonus-ataxia (OMA) associated with neuroblastoma?' field. Indicates 'No'." + }, + { + "name": "CB180", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Is the patient refractory to steroids, chemotherapy and intravenous immunoglobulins?' field. Indicates 'Yes'." + }, + { + "name": "T189", + "page": 4, + "field_type_string": "Text", + "field_label": "Medication:", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Opsoclonus-myoclonus-ataxia (opsoclonus myoclonus syndrome)' section. Field to provide names of medications tried." + }, + { + "name": "T190", + "page": 4, + "field_type_string": "Text", + "field_label": "Date: (MM)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Opsoclonus-myoclonus-ataxia (opsoclonus myoclonus syndrome)' section. Field to provide the month of the date range for medications tried." + }, + { + "name": "T191", + "page": 4, + "field_type_string": "Text", + "field_label": "Date: (DD)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Opsoclonus-myoclonus-ataxia (opsoclonus myoclonus syndrome)' section. Field to provide the day of the date range for medications tried." + }, + { + "name": "T192", + "page": 4, + "field_type_string": "Text", + "field_label": "Date: (YYYY)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Opsoclonus-myoclonus-ataxia (opsoclonus myoclonus syndrome)' section. Field to provide the year of the date range for medications tried." + }, + { + "name": "T193", + "page": 4, + "field_type_string": "Text", + "field_label": "Date: (MM)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Opsoclonus-myoclonus-ataxia (opsoclonus myoclonus syndrome)' section. Field to provide the month of the date range for medications tried." + }, + { + "name": "T194", + "page": 4, + "field_type_string": "Text", + "field_label": "Date: (DD)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Opsoclonus-myoclonus-ataxia (opsoclonus myoclonus syndrome)' section. Field to provide the day of the date range for medications tried." + }, + { + "name": "T195", + "page": 4, + "field_type_string": "Text", + "field_label": "Date: (YYYY)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Opsoclonus-myoclonus-ataxia (opsoclonus myoclonus syndrome)' section. Field to provide the year of the date range for medications tried." + }, + { + "name": "T196", + "page": 4, + "field_type_string": "Text", + "field_label": "Medication:", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Opsoclonus-myoclonus-ataxia (opsoclonus myoclonus syndrome)' section. Field to provide the second medication name tried." + }, + { + "name": "T197", + "page": 4, + "field_type_string": "Text", + "field_label": "Date: (MM)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Opsoclonus-myoclonus-ataxia (opsoclonus myoclonus syndrome)' section. Field to provide the month of the date range for the second medication tried." + }, + { + "name": "T198", + "page": 4, + "field_type_string": "Text", + "field_label": "Date: (DD)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Opsoclonus-myoclonus-ataxia (opsoclonus myoclonus syndrome)' section. Field to provide the day of the date range for the second medication tried." + }, + { + "name": "T199", + "page": 4, + "field_type_string": "Text", + "field_label": "Date: (YYYY)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Opsoclonus-myoclonus-ataxia (opsoclonus myoclonus syndrome)' section. Field to provide the year of the date range for the second medication tried." + }, + { + "name": "T200", + "page": 4, + "field_type_string": "Text", + "field_label": "Date: (MM)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Opsoclonus-myoclonus-ataxia (opsoclonus myoclonus syndrome)' section. Field to provide the month of the date range for the second medication tried." + }, + { + "name": "T201", + "page": 4, + "field_type_string": "Text", + "field_label": "Date: (DD)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Opsoclonus-myoclonus-ataxia (opsoclonus myoclonus syndrome)' section. Field to provide the day of the date range for the second medication tried." + }, + { + "name": "T202", + "page": 4, + "field_type_string": "Text", + "field_label": "Date: (YYYY)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Opsoclonus-myoclonus-ataxia (opsoclonus myoclonus syndrome)' section. Field to provide the year of the date range for the second medication tried." + }, + { + "name": "CB181", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Is the patient refractory to steroids, chemotherapy and intravenous immunoglobulins?' field. Indicates 'No'." + }, + { + "name": "CB203", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Is Rituxan (rituximab) being used as treatment of post-transplant lymphoproliferative disorder?' field. Indicates 'Yes'." + }, + { + "name": "CB204", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Is Rituxan (rituximab) being used as treatment of post-transplant lymphoproliferative disorder?' field. Indicates 'No'." + }, + { + "name": "CB205", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Is Rituxan (rituximab) being used as prophylaxis for Epstein-Barr virus (EBV) post-transplant lymphoproliferative disorder?' field. Indicates 'Yes'." + }, + { + "name": "CB206", + "page": 4, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Is Rituxan (rituximab) being used as prophylaxis for Epstein-Barr virus (EBV) post-transplant lymphoproliferative disorder?' field. Indicates 'No'." + }, + { + "name": "T12", + "page": 5, + "field_type_string": "Text", + "field_label": "Patient First Name", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). The first name of the patient." + }, + { + "name": "T13", + "page": 5, + "field_type_string": "Text", + "field_label": "Patient Last Name", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). The last name of the patient." + }, + { + "name": "T19", + "page": 5, + "field_type_string": "Text", + "field_label": "Patient Phone", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). The phone number of the patient." + }, + { + "name": "T14", + "page": 5, + "field_type_string": "Text", + "field_label": "Patient DOB (MM/DD/YYYY)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). The date of birth of the patient." + }, + { + "name": "CB207", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "Mild", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Rheumatoid Arthritis' severity selection. Allows selection of Mild severity." + }, + { + "name": "CB208", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "Moderate", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Rheumatoid Arthritis' severity selection. Allows selection of Moderate severity." + }, + { + "name": "CB209", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "Severe", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Rheumatoid Arthritis' severity selection. Allows selection of Severe severity." + }, + { + "name": "CB210", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Is there evidence that the disease is active?' field. Indicates 'Yes'." + }, + { + "name": "CB211", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Is there evidence that the disease is active?' field. Indicates 'No'." + }, + { + "name": "CB212", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Will Rituxan (rituximab) be used in combination with methotrexate?' field. Indicates 'Yes'." + }, + { + "name": "CB213", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Will Rituxan (rituximab) be used in combination with methotrexate?' field. Indicates 'No'." + }, + { + "name": "CB214", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Was treatment with methotrexate ineffective, not tolerated or contraindicated?' field. Indicates 'Yes'." + }, + { + "name": "CB216", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "ineffective", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Was treatment with methotrexate ineffective, not tolerated or contraindicated?' selection. Allows selection of 'ineffective'." + }, + { + "name": "CB217", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "not tolerated", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Was treatment with methotrexate ineffective, not tolerated or contraindicated?' selection. Allows selection of 'not tolerated'." + }, + { + "name": "CB218", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "contraindicated", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Was treatment with methotrexate ineffective, not tolerated or contraindicated?' selection. Allows selection of 'contraindicated'." + }, + { + "name": "CB215", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Was treatment with methotrexate ineffective, not tolerated or contraindicated?' field. Indicates 'No'." + }, + { + "name": "CB223", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Was treatment with another conventional DMARD ineffective?' field. Indicates 'Yes'." + }, + { + "name": "CB225", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "azathioprine", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Was treatment with another conventional DMARD ineffective?' selection. Allows selection of azathioprine." + }, + { + "name": "CB226", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "cyclosporine", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Was treatment with another conventional DMARD ineffective?' selection. Allows selection of cyclosporine." + }, + { + "name": "CB227", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "hydroxychloroquine", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Was treatment with another conventional DMARD ineffective?' selection. Allows selection of hydroxychloroquine." + }, + { + "name": "CB228", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "leflunomide", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Was treatment with another conventional DMARD ineffective?' selection. Allows selection of leflunomide." + }, + { + "name": "CB229", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "sulfasalazine", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Was treatment with another conventional DMARD ineffective?' selection. Allows selection of sulfasalazine." + }, + { + "name": "CB224", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Was treatment with another conventional DMARD ineffective?' field. Indicates 'No'." + }, + { + "name": "CB281", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Does the patient have a documented diagnosis of Sj\u00f6gren's syndrome?' field. Indicates 'Yes'." + }, + { + "name": "CB282", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Does the patient have a documented diagnosis of Sj\u00f6gren's syndrome?' field. Indicates 'No'." + }, + { + "name": "CB283", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Was treatment with corticosteroids and other immunosuppressive agents ineffective?' field. Indicates 'Yes'." + }, + { + "name": "T285", + "page": 5, + "field_type_string": "Text", + "field_label": "Medication:", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Sj\u00f6gren syndrome' section. Field to provide the name of a corticosteroid or immunosuppressive agent used." + }, + { + "name": "T286", + "page": 5, + "field_type_string": "Text", + "field_label": "Date: (MM)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Sj\u00f6gren syndrome' section. Field to provide the month of the date range for a corticosteroid or immunosuppressive agent used." + }, + { + "name": "T287", + "page": 5, + "field_type_string": "Text", + "field_label": "Date: (DD)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Sj\u00f6gren syndrome' section. Field to provide the day of the date range for a corticosteroid or immunosuppressive agent used." + }, + { + "name": "T288", + "page": 5, + "field_type_string": "Text", + "field_label": "Date: (YYYY)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Sj\u00f6gren syndrome' section. Field to provide the year of the date range for a corticosteroid or immunosuppressive agent used." + }, + { + "name": "T289", + "page": 5, + "field_type_string": "Text", + "field_label": "Date: (MM)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Sj\u00f6gren syndrome' section. Field to provide the month of the date range for a corticosteroid or immunosuppressive agent used." + }, + { + "name": "T290", + "page": 5, + "field_type_string": "Text", + "field_label": "Date: (DD)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Sj\u00f6gren syndrome' section. Field to provide the day of the date range for a corticosteroid or immunosuppressive agent used." + }, + { + "name": "T291", + "page": 5, + "field_type_string": "Text", + "field_label": "Date: (YYYY)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Sj\u00f6gren syndrome' section. Field to provide the year of the date range for a corticosteroid or immunosuppressive agent used." + }, + { + "name": "T292", + "page": 5, + "field_type_string": "Text", + "field_label": "Medication:", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Sj\u00f6gren syndrome' section. Field to provide the second name of a corticosteroid or immunosuppressive agent used." + }, + { + "name": "T293", + "page": 5, + "field_type_string": "Text", + "field_label": "Date: (MM)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Sj\u00f6gren syndrome' section. Field to provide the month of the date range for the second corticosteroid or immunosuppressive agent used." + }, + { + "name": "T294", + "page": 5, + "field_type_string": "Text", + "field_label": "Date: (DD)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Sj\u00f6gren syndrome' section. Field to provide the day of the date range for the second corticosteroid or immunosuppressive agent used." + }, + { + "name": "T295", + "page": 5, + "field_type_string": "Text", + "field_label": "Date: (YYYY)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Sj\u00f6gren syndrome' section. Field to provide the year of the date range for the second corticosteroid or immunosuppressive agent used." + }, + { + "name": "T296", + "page": 5, + "field_type_string": "Text", + "field_label": "Date: (MM)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Sj\u00f6gren syndrome' section. Field to provide the month of the date range for the second corticosteroid or immunosuppressive agent used." + }, + { + "name": "T297", + "page": 5, + "field_type_string": "Text", + "field_label": "Date: (DD)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Sj\u00f6gren syndrome' section. Field to provide the day of the date range for the second corticosteroid or immunosuppressive agent used." + }, + { + "name": "T298", + "page": 5, + "field_type_string": "Text", + "field_label": "Date: (YYYY)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Sj\u00f6gren syndrome' section. Field to provide the year of the date range for the second corticosteroid or immunosuppressive agent used." + }, + { + "name": "CB284", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Was treatment with corticosteroids and other immunosuppressive agents ineffective?' field. Indicates 'No'." + }, + { + "name": "CB299", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Does the patient have a documented diagnosis of refractory thrombotic thrombocytopenic purpura (TTP)?' field. Indicates 'Yes'." + }, + { + "name": "CB300", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Does the patient have a documented diagnosis of refractory thrombotic thrombocytopenic purpura (TTP)?' field. Indicates 'No'." + }, + { + "name": "CB301", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Does the patient have a documented diagnosis of Waldenstr\u00f6m macroglobulinemia?' field. Indicates 'Yes'." + }, + { + "name": "CB302", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Does the patient have a documented diagnosis of Waldenstr\u00f6m macroglobulinemia?' field. Indicates 'No'." + }, + { + "name": "CB303", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Is this continuation request a result of the patient receiving samples of Rituxan (rituximab)?' field. Indicates 'Yes'." + }, + { + "name": "CB304", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Is this continuation request a result of the patient receiving samples of Rituxan (rituximab)?' field. Indicates 'No'." + }, + { + "name": "T305", + "page": 5, + "field_type_string": "Text", + "field_label": "Please indicate the length of time on Rituxan (rituximab):", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). For continuation requests, requires the duration the patient has been on Rituxan." + }, + { + "name": "CB310", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "Mild", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Rheumatoid Arthritis only' severity at baseline selection. Allows selection of Mild severity." + }, + { + "name": "CB311", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "Moderate", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Rheumatoid Arthritis only' severity at baseline selection. Allows selection of Moderate severity." + }, + { + "name": "CB312", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "Severe", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Part of 'Rheumatoid Arthritis only' severity at baseline selection. Allows selection of Severe severity." + }, + { + "name": "CB306", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Is there clinical documentation supporting disease stability?' field (for rheumatoid arthritis). Indicates 'Yes'." + }, + { + "name": "CB307", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Is there clinical documentation supporting disease stability?' field (for rheumatoid arthritis). Indicates 'No'." + }, + { + "name": "CB308", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Is there clinical documentation supporting disease improvement?' field (for rheumatoid arthritis). Indicates 'Yes'." + }, + { + "name": "CB309", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Is there clinical documentation supporting disease improvement?' field (for rheumatoid arthritis). Indicates 'No'." + }, + { + "name": "CB313", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Is there clinical documentation supporting disease stability?' field (for all other indications). Indicates 'Yes'." + }, + { + "name": "CB314", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Is there clinical documentation supporting disease stability?' field (for all other indications). Indicates 'No'." + }, + { + "name": "CB315", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Is there clinical documentation supporting disease improvement?' field (for all other indications). Indicates 'Yes'." + }, + { + "name": "CB316", + "page": 5, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Relates to 'Is there clinical documentation supporting disease improvement?' field (for all other indications). Indicates 'No'." + }, + { + "name": "T317", + "page": 5, + "field_type_string": "Text", + "field_label": "Date: (MM)", + "context": "Subheading: H. ACKNOWLEDGEMENT. The month the request was completed by signature." + }, + { + "name": "T318", + "page": 5, + "field_type_string": "Text", + "field_label": "Date: (DD)", + "context": "Subheading: H. ACKNOWLEDGEMENT. The day the request was completed by signature." + }, + { + "name": "T319", + "page": 5, + "field_type_string": "Text", + "field_label": "Date: (YYYY)", + "context": "Subheading: H. ACKNOWLEDGEMENT. The year the request was completed by signature." + } + ] +} \ No newline at end of file diff --git a/Output Data/Abdulla/Filled_PA_Form.pdf b/Output Data/Abdulla/Filled_PA_Form.pdf new file mode 100644 index 00000000..e484285b Binary files /dev/null and b/Output Data/Abdulla/Filled_PA_Form.pdf differ diff --git a/Output Data/Akshay/Completed_Form_Fields.json b/Output Data/Akshay/Completed_Form_Fields.json new file mode 100644 index 00000000..e1ea5e95 --- /dev/null +++ b/Output Data/Akshay/Completed_Form_Fields.json @@ -0,0 +1,1004 @@ +{ + "answers": [ + { + "name": "Indicate CB.1", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "Start of treatment:", + "context": "Subheading: Please indicate. This checkbox indicates if the patient is starting treatment.", + "answer": "True" + }, + { + "name": "Indicate T.2", + "page": 1, + "field_type_string": "Text", + "field_label": "Start date (MM)", + "context": "Subheading: Please indicate. This field captures the month of the start date for the treatment.", + "answer": "null" + }, + { + "name": "Indicate T.3", + "page": 1, + "field_type_string": "Text", + "field_label": "Start date (DD)", + "context": "Subheading: Please indicate. This field captures the day of the start date for the treatment.", + "answer": "null" + }, + { + "name": "Indicate T.4", + "page": 1, + "field_type_string": "Text", + "field_label": "Start date (YYYY)", + "context": "Subheading: Please indicate. This field captures the year of the start date for the treatment.", + "answer": "null" + }, + { + "name": "Indicate CB.5", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "Continuation of therapy", + "context": "Subheading: Please indicate. This checkbox indicates if the patient is continuing therapy.", + "answer": "False" + }, + { + "name": "Indicate T.6", + "page": 1, + "field_type_string": "Text", + "field_label": "Date of last treatment (MM)", + "context": "Subheading: Please indicate. This field captures the month of the last treatment date for continuation of therapy.", + "answer": "null" + }, + { + "name": "Indicate T.7", + "page": 1, + "field_type_string": "Text", + "field_label": "Date of last treatment (DD)", + "context": "Subheading: Please indicate. This field captures the day of the last treatment date for continuation of therapy.", + "answer": "null" + }, + { + "name": "Indicate T.8", + "page": 1, + "field_type_string": "Text", + "field_label": "Date of last treatment (YYYY)", + "context": "Subheading: Please indicate. This field captures the year of the last treatment date for continuation of therapy.", + "answer": "null" + }, + { + "name": "Request by T", + "page": 1, + "field_type_string": "Text", + "field_label": "Precertification Requested By:", + "context": "Subheading: Precertification Requested By. This field captures the name of the person requesting precertification.", + "answer": "null" + }, + { + "name": "Phone T", + "page": 1, + "field_type_string": "Text", + "field_label": "Phone:", + "context": "Subheading: Precertification Requested By. This field captures the phone number of the person requesting precertification.", + "answer": "null" + }, + { + "name": "Fax T", + "page": 1, + "field_type_string": "Text", + "field_label": "Fax:", + "context": "Subheading: Precertification Requested By. This field captures the fax number of the person requesting precertification.", + "answer": "null" + }, + { + "name": "T11", + "page": 1, + "field_type_string": "Text", + "field_label": "Patient First Name", + "context": "Subheading: A. PATIENT INFORMATION. This field captures the first name of the patient.", + "answer": "Akshay" + }, + { + "name": "T12", + "page": 1, + "field_type_string": "Text", + "field_label": "Patient Last Name", + "context": "Subheading: A. PATIENT INFORMATION. This field captures the last name of the patient.", + "answer": "chaudhari" + }, + { + "name": "T13", + "page": 1, + "field_type_string": "Text", + "field_label": "Patient DOB (MM/DD/YYYY)", + "context": "Subheading: A. PATIENT INFORMATION. This field captures the date of birth of the patient.", + "answer": "02/17/1987" + }, + { + "name": "T14", + "page": 1, + "field_type_string": "Text", + "field_label": "Address:", + "context": "Subheading: A. PATIENT INFORMATION. This field captures the street address of the patient.", + "answer": "1460 El Camino Real" + }, + { + "name": "T15", + "page": 1, + "field_type_string": "Text", + "field_label": "City:", + "context": "Subheading: A. PATIENT INFORMATION. This field captures the city of the patient's address.", + "answer": "Arlington" + }, + { + "name": "T16", + "page": 1, + "field_type_string": "Text", + "field_label": "State:", + "context": "Subheading: A. PATIENT INFORMATION. This field captures the state of the patient's address.", + "answer": "VA" + }, + { + "name": "T17", + "page": 1, + "field_type_string": "Text", + "field_label": "ZIP:", + "context": "Subheading: A. PATIENT INFORMATION. This field captures the ZIP code of the patient's address.", + "answer": "22407" + }, + { + "name": "T18", + "page": 1, + "field_type_string": "Text", + "field_label": "Patient Phone", + "context": "Subheading: A. PATIENT INFORMATION. This field captures the patient's primary phone number.", + "answer": "570-599-6973" + }, + { + "name": "T19", + "page": 1, + "field_type_string": "Text", + "field_label": "Work Phone:", + "context": "Subheading: A. PATIENT INFORMATION. This field captures the patient's work phone number.", + "answer": "null" + }, + { + "name": "T20", + "page": 1, + "field_type_string": "Text", + "field_label": "Cell Phone:", + "context": "Subheading: A. PATIENT INFORMATION. This field captures the patient's cell phone number.", + "answer": "null" + }, + { + "name": "T21", + "page": 1, + "field_type_string": "Text", + "field_label": "Email:", + "context": "Subheading: A. PATIENT INFORMATION. This field captures the patient's email address.", + "answer": "null" + }, + { + "name": "T21B", + "page": 1, + "field_type_string": "Text", + "field_label": "lbs", + "context": "Subheading: A. PATIENT INFORMATION. This field captures the patient's weight in pounds.", + "answer": "190" + }, + { + "name": "T21C", + "page": 1, + "field_type_string": "Text", + "field_label": "kgs", + "context": "Subheading: A. PATIENT INFORMATION. This field captures the patient's weight in kilograms.", + "answer": "86.18" + }, + { + "name": "T21D", + "page": 1, + "field_type_string": "Text", + "field_label": "inches", + "context": "Subheading: A. PATIENT INFORMATION. This field captures the patient's height in inches.", + "answer": "73" + }, + { + "name": "T21E", + "page": 1, + "field_type_string": "Text", + "field_label": "cms", + "context": "Subheading: A. PATIENT INFORMATION. This field captures the patient's height in centimeters.", + "answer": "null" + }, + { + "name": "T21F", + "page": 1, + "field_type_string": "Text", + "field_label": "Allergies:", + "context": "Subheading: A. PATIENT INFORMATION. This field captures any known allergies for the patient.", + "answer": "ibuprofen, acetaminophen" + }, + { + "name": "Insurance Info T.1", + "page": 1, + "field_type_string": "Text", + "field_label": "Aetna Member ID #:", + "context": "Subheading: B. INSURANCE INFORMATION. This field captures the patient's Aetna Member ID number.", + "answer": "null" + }, + { + "name": "Insurance Info CB.4", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: B. INSURANCE INFORMATION. This checkbox indicates if the patient has other coverage.", + "answer": "False" + }, + { + "name": "Insurance Info CB.5", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: B. INSURANCE INFORMATION. This checkbox indicates if the patient does not have other coverage.", + "answer": "True" + }, + { + "name": "Insurance Info T.2", + "page": 1, + "field_type_string": "Text", + "field_label": "Group #:", + "context": "Subheading: B. INSURANCE INFORMATION. This field captures the patient's group number for their insurance.", + "answer": "null" + }, + { + "name": "Insurance Info T.6", + "page": 1, + "field_type_string": "Text", + "field_label": "If yes, provide ID#:", + "context": "Subheading: B. INSURANCE INFORMATION. This field captures the ID number if the patient has other coverage.", + "answer": "null" + }, + { + "name": "Insurance Info T.7", + "page": 1, + "field_type_string": "Text", + "field_label": "Carrier Name:", + "context": "Subheading: B. INSURANCE INFORMATION. This field captures the name of the insurance carrier if the patient has other coverage.", + "answer": "null" + }, + { + "name": "Insurance Info T.3", + "page": 1, + "field_type_string": "Text", + "field_label": "Insured:", + "context": "Subheading: B. INSURANCE INFORMATION. This field captures the name of the insured person if different from the patient.", + "answer": "Akshay chaudhari" + }, + { + "name": "Insurance Info T.8", + "page": 1, + "field_type_string": "Text", + "field_label": "Insured:", + "context": "Subheading: B. INSURANCE INFORMATION. This field captures the name of the insured person if different from the patient.", + "answer": "Akshay chaudhari" + }, + { + "name": "Insurance Info CB.9", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: B. INSURANCE INFORMATION. This checkbox indicates if the patient has Medicare.", + "answer": "False" + }, + { + "name": "Insurance Info CB.10", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: B. INSURANCE INFORMATION. This checkbox indicates if the patient does not have Medicare.", + "answer": "True" + }, + { + "name": "Insurance Info T.11", + "page": 1, + "field_type_string": "Text", + "field_label": "If yes, provide ID #:", + "context": "Subheading: B. INSURANCE INFORMATION. This field captures the Medicare ID number.", + "answer": "null" + }, + { + "name": "Insurance Info CB.12", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: B. INSURANCE INFORMATION. This checkbox indicates if the patient has Medicaid.", + "answer": "False" + }, + { + "name": "Insurance Info CB.13", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: B. INSURANCE INFORMATION. This checkbox indicates if the patient does not have Medicaid.", + "answer": "True" + }, + { + "name": "Insurance Info T.14", + "page": 1, + "field_type_string": "Text", + "field_label": "If yes, provide ID #:", + "context": "Subheading: B. INSURANCE INFORMATION. This field captures the Medicaid ID number.", + "answer": "null" + }, + { + "name": "Presc Info T.1", + "page": 1, + "field_type_string": "Text", + "field_label": "First Name:", + "context": "Subheading: C. PRESCRIBER INFORMATION. This field captures the prescriber's first name.", + "answer": "Timothy" + }, + { + "name": "Presc Info T.7", + "page": 1, + "field_type_string": "Text", + "field_label": "Address:", + "context": "Subheading: C. PRESCRIBER INFORMATION. This field captures the prescriber's street address.", + "answer": "2755 College Ave Ste. 100" + }, + { + "name": "Presc Info T.11", + "page": 1, + "field_type_string": "Text", + "field_label": "Phone:", + "context": "Subheading: C. PRESCRIBER INFORMATION. This field captures the prescriber's phone number.", + "answer": "203-818-3060" + }, + { + "name": "Presc Info T.12", + "page": 1, + "field_type_string": "Text", + "field_label": "Fax:", + "context": "Subheading: C. PRESCRIBER INFORMATION. This field captures the prescriber's fax number.", + "answer": "203-818-3061" + }, + { + "name": "Presc Info T.17", + "page": 1, + "field_type_string": "Text", + "field_label": "Provider Email:", + "context": "Subheading: C. PRESCRIBER INFORMATION. This field captures the prescriber's email address.", + "answer": "null" + }, + { + "name": "Presc Info T.2", + "page": 1, + "field_type_string": "Text", + "field_label": "Last Name:", + "context": "Subheading: C. PRESCRIBER INFORMATION. This field captures the prescriber's last name.", + "answer": "Adam" + }, + { + "name": "Presc Info CB.3", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "M.D.", + "context": "Subheading: C. PRESCRIBER INFORMATION. This checkbox indicates if the prescriber is an M.D.", + "answer": "True" + }, + { + "name": "Presc Info CB.4", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "D.O.", + "context": "Subheading: C. PRESCRIBER INFORMATION. This checkbox indicates if the prescriber is a D.O.", + "answer": "False" + }, + { + "name": "Presc Info CB.5", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "N.P.", + "context": "Subheading: C. PRESCRIBER INFORMATION. This checkbox indicates if the prescriber is an N.P.", + "answer": "False" + }, + { + "name": "Presc Info CB.6", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "P.A.", + "context": "Subheading: C. PRESCRIBER INFORMATION. This checkbox indicates if the prescriber is a P.A.", + "answer": "False" + }, + { + "name": "Presc Info T.8", + "page": 1, + "field_type_string": "Text", + "field_label": "City:", + "context": "Subheading: C. PRESCRIBER INFORMATION. This field captures the city of the prescriber's address.", + "answer": "Leesburg" + }, + { + "name": "Presc Info T.9", + "page": 1, + "field_type_string": "Text", + "field_label": "State:", + "context": "Subheading: C. PRESCRIBER INFORMATION. This field captures the state of the prescriber's address.", + "answer": "VA" + }, + { + "name": "Presc Info T.10", + "page": 1, + "field_type_string": "Text", + "field_label": "ZIP:", + "context": "Subheading: C. PRESCRIBER INFORMATION. This field captures the ZIP code of the prescriber's address.", + "answer": "20176" + }, + { + "name": "Presc Info T.13", + "page": 1, + "field_type_string": "Text", + "field_label": "St Lic #:", + "context": "Subheading: C. PRESCRIBER INFORMATION. This field captures the prescriber's state license number.", + "answer": "null" + }, + { + "name": "Presc Info T.14", + "page": 1, + "field_type_string": "Text", + "field_label": "NPI #:", + "context": "Subheading: C. PRESCRIBER INFORMATION. This field captures the prescriber's NPI number.", + "answer": "1331124163" + }, + { + "name": "Presc Info T.15", + "page": 1, + "field_type_string": "Text", + "field_label": "DEA #:", + "context": "Subheading: C. PRESCRIBER INFORMATION. This field captures the prescriber's DEA number.", + "answer": "null" + }, + { + "name": "Presc Info T.16", + "page": 1, + "field_type_string": "Text", + "field_label": "UPIN:", + "context": "Subheading: C. PRESCRIBER INFORMATION. This field captures the prescriber's UPIN number.", + "answer": "null" + }, + { + "name": "Presc Info T.18", + "page": 1, + "field_type_string": "Text", + "field_label": "Office Contact Name:", + "context": "Subheading: C. PRESCRIBER INFORMATION. This field captures the name of the office contact person.", + "answer": "null" + }, + { + "name": "Presc Info T.19", + "page": 1, + "field_type_string": "Text", + "field_label": "Phone:", + "context": "Subheading: C. PRESCRIBER INFORMATION. This field captures the phone number of the office contact person.", + "answer": "null" + }, + { + "name": "Presc Info CB.20", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "Gastroenterologist", + "context": "Subheading: C. PRESCRIBER INFORMATION. This checkbox indicates the prescriber's specialty is Gastroenterologist.", + "answer": "True" + }, + { + "name": "Presc Info CB.21", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "Other:", + "context": "Subheading: C. PRESCRIBER INFORMATION. This checkbox indicates the prescriber's specialty is Other. Dependent on field 'Other:' for specialty information.", + "answer": "False" + }, + { + "name": "Presc Info T.23", + "page": 1, + "field_type_string": "Text", + "field_label": "Other:", + "context": "Subheading: C. PRESCRIBER INFORMATION. This field captures the prescriber's specialty if 'Other' is selected.", + "answer": "null" + }, + { + "name": "Provider Admin CB.1", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "Self-administered", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. This checkbox indicates the place of administration is self-administered.", + "answer": "False" + }, + { + "name": "Provider Admin CB.2", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "Physician's Office", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. This checkbox indicates the place of administration is a physician's office.", + "answer": "null" + }, + { + "name": "Provider Admin CB.3", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "Outpatient Infusion Center", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. This checkbox indicates the place of administration is an outpatient infusion center.", + "answer": "null" + }, + { + "name": "Provider Admin T.4", + "page": 1, + "field_type_string": "Text", + "field_label": "Phone:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. This field captures the phone number for the outpatient infusion center.", + "answer": "null" + }, + { + "name": "Provider Admin T.5", + "page": 1, + "field_type_string": "Text", + "field_label": "Center Name:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. This field captures the name of the outpatient infusion center.", + "answer": "null" + }, + { + "name": "Provider Admin CB.6", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "Home Infusion Center", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. This checkbox indicates the place of administration is a home infusion center.", + "answer": "null" + }, + { + "name": "Provider Admin T.7", + "page": 1, + "field_type_string": "Text", + "field_label": "Phone:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. This field captures the phone number for the home infusion center.", + "answer": "null" + }, + { + "name": "Provider Admin T.8", + "page": 1, + "field_type_string": "Text", + "field_label": "Agency Name:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. This field captures the name of the agency for the home infusion center.", + "answer": "null" + }, + { + "name": "Provider Admin CB.9.0", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "Administration code(s)", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. This checkbox indicates that administration codes will be provided. Dependent on field 'CPT:' for the code.", + "answer": "False" + }, + { + "name": "Provider Admin T.10.0.0", + "page": 1, + "field_type_string": "Text", + "field_label": "CPT:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. This field captures the CPT code for administration.", + "answer": "null" + }, + { + "name": "Provider Admin T.10.1.0", + "page": 1, + "field_type_string": "Text", + "field_label": "Address:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. This field captures the address of the dispensing provider/pharmacy.", + "answer": "null" + }, + { + "name": "Provider Admin CB.11", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "Physician\u2019s Office", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. This checkbox indicates the dispensing provider/pharmacy is a Physician's Office.", + "answer": "null" + }, + { + "name": "Provider Admin CB.12", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "Retail Pharmacy", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. This checkbox indicates the dispensing provider/pharmacy is a Retail Pharmacy.", + "answer": "null" + }, + { + "name": "Provider Admin CB.13", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "Specialty Pharmacy", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. This checkbox indicates the dispensing provider/pharmacy is a Specialty Pharmacy.", + "answer": "True" + }, + { + "name": "Provider Admin CB.14", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "Other", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. This checkbox indicates the dispensing provider/pharmacy is Other.", + "answer": "False" + }, + { + "name": "Provider Admin T.17.0", + "page": 1, + "field_type_string": "Text", + "field_label": "Name:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. This field captures the name of the dispensing provider/pharmacy.", + "answer": "CVS Caremark" + }, + { + "name": "Provider Admin T.17.1", + "page": 1, + "field_type_string": "Text", + "field_label": "Address:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. This field captures the address of the dispensing provider/pharmacy.", + "answer": "1580 Postal Road" + }, + { + "name": "Provider Admin T.18", + "page": 1, + "field_type_string": "Text", + "field_label": "Phone:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. This field captures the phone number of the dispensing provider/pharmacy.", + "answer": "1-866-386-7882" + }, + { + "name": "Provider Admin T.19", + "page": 1, + "field_type_string": "Text", + "field_label": "Fax:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. This field captures the fax number of the dispensing provider/pharmacy.", + "answer": "null" + }, + { + "name": "Provider Admin T.20", + "page": 1, + "field_type_string": "Text", + "field_label": "TIN:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. This field captures the Taxpayer Identification Number (TIN) of the dispensing provider/pharmacy.", + "answer": "null" + }, + { + "name": "Provider Admin T.21", + "page": 1, + "field_type_string": "Text", + "field_label": "PIN:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. This field captures the Pharmacy Identification Number (PIN) of the dispensing provider/pharmacy.", + "answer": "null" + }, + { + "name": "Product T.1", + "page": 1, + "field_type_string": "Text", + "field_label": "Dose:", + "context": "Subheading: E. PRODUCT INFORMATION. This field captures the requested dose of Skyrizi.", + "answer": "600mg IV; 180mg SQ or 360mg SQ" + }, + { + "name": "Product T.2", + "page": 1, + "field_type_string": "Text", + "field_label": "Frequency:", + "context": "Subheading: E. PRODUCT INFORMATION. This field captures the requested frequency of Skyrizi.", + "answer": "Week 0, 4, 8 for induction; every 8 weeks for maintenance" + }, + { + "name": "Diagnosis T.1", + "page": 1, + "field_type_string": "Text", + "field_label": "Primary ICD Code:", + "context": "Subheading: F. DIAGNOSIS INFORMATION. This field captures the primary ICD code for the diagnosis.", + "answer": "K50.111" + }, + { + "name": "Diagnosis T.2", + "page": 1, + "field_type_string": "Text", + "field_label": "Secondary ICD Code:", + "context": "Subheading: F. DIAGNOSIS INFORMATION. This field captures the secondary ICD code for the diagnosis.", + "answer": "null" + }, + { + "name": "Diagnosis T.3", + "page": 1, + "field_type_string": "Text", + "field_label": "Other ICD Code:", + "context": "Subheading: F. DIAGNOSIS INFORMATION. This field captures any other relevant ICD codes for the diagnosis.", + "answer": "null" + }, + { + "name": "Clinical CB.0", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION. This checkbox indicates 'Yes' to the question about using the drug in combination with other biologics or targeted synthetic drugs.", + "answer": "False" + }, + { + "name": "Clinical CB.1", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION. This checkbox indicates 'No' to the question about using the drug in combination with other biologics or targeted synthetic drugs.", + "answer": "True" + }, + { + "name": "Clinical CB.2", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION. This checkbox indicates 'Yes' to the question about the patient having received prior therapy associated with an increased risk of tuberculosis (TB).", + "answer": "False" + }, + { + "name": "Clinical CB.3", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION. This checkbox indicates 'No' to the question about the patient having received prior therapy associated with an increased risk of tuberculosis (TB).", + "answer": "True" + }, + { + "name": "Clinical CB.4", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION. This checkbox indicates 'Yes' to the question about the patient having had a tuberculosis (TB) test within 6 months of initiating therapy.", + "answer": "False" + }, + { + "name": "Clinical CB.5", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION. This checkbox indicates 'No' to the question about the patient having had a tuberculosis (TB) test within 6 months of initiating therapy.", + "answer": "True" + }, + { + "name": "Clinical CB.6", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "PPD test", + "context": "Subheading: G. CLINICAL INFORMATION. This checkbox indicates that a PPD test was performed as part of the TB testing.", + "answer": "True" + }, + { + "name": "Clinical CB.7", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "interferon-release assay (IGRA)", + "context": "Subheading: G. CLINICAL INFORMATION. This checkbox indicates that an interferon-release assay (IGRA) was performed as part of the TB testing.", + "answer": "True" + }, + { + "name": "Clinical CB.8", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "chest x-ray", + "context": "Subheading: G. CLINICAL INFORMATION. This checkbox indicates that a chest x-ray was performed as part of the TB testing.", + "answer": "False" + }, + { + "name": "Clinical CB.9", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "positive", + "context": "Subheading: G. CLINICAL INFORMATION. This checkbox indicates a positive result for the tuberculosis (TB) test.", + "answer": "False" + }, + { + "name": "Clinical CB.10", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "negative", + "context": "Subheading: G. CLINICAL INFORMATION. This checkbox indicates a negative result for the tuberculosis (TB) test.", + "answer": "True" + }, + { + "name": "Clinical CB.11", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "unknown", + "context": "Subheading: G. CLINICAL INFORMATION. This checkbox indicates the result of the tuberculosis (TB) test is unknown.", + "answer": "False" + }, + { + "name": "Clinical CB.12", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "latent TB and treatment for latent TB has been initiated", + "context": "Subheading: G. CLINICAL INFORMATION. This checkbox indicates the patient has latent TB and treatment has been initiated.", + "answer": "False" + }, + { + "name": "Clinical CB.13", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "latent TB and treatment for latent TB has been completed", + "context": "Subheading: G. CLINICAL INFORMATION. This checkbox indicates the patient has latent TB and treatment has been completed.", + "answer": "False" + }, + { + "name": "Clinical CB.14", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "latent TB and treatment for latent TB has not been initiated", + "context": "Subheading: G. CLINICAL INFORMATION. This checkbox indicates the patient has latent TB and treatment has not been initiated.", + "answer": "False" + }, + { + "name": "Clinical CB.15", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "active TB", + "context": "Subheading: G. CLINICAL INFORMATION. This checkbox indicates the patient has active TB.", + "answer": "False" + }, + { + "name": "T11", + "page": 2, + "field_type_string": "Text", + "field_label": "Patient First Name", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). This field captures the first name of the patient.", + "answer": "Akshay" + }, + { + "name": "T12", + "page": 2, + "field_type_string": "Text", + "field_label": "Patient Last Name", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). This field captures the last name of the patient.", + "answer": "chaudhari" + }, + { + "name": "T18", + "page": 2, + "field_type_string": "Text", + "field_label": "Patient Phone", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). This field captures the patient's phone number.", + "answer": "570-599-6973" + }, + { + "name": "T13", + "page": 2, + "field_type_string": "Text", + "field_label": "Patient DOB (MM/DD/YYYY)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). This field captures the date of birth of the patient.", + "answer": "02/17/1987" + }, + { + "name": "Clinical CB.19", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Crohn's Disease (CD). This checkbox indicates 'Yes' to the question about diagnosis of moderately to severely active Crohn's disease (CD).", + "answer": "True" + }, + { + "name": "Clinical CB.20", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Crohn's Disease (CD). This checkbox indicates 'No' to the question about diagnosis of moderately to severely active Crohn's disease (CD).", + "answer": "False" + }, + { + "name": "Clinical CB.21", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Crohn's Disease (CD). This checkbox indicates 'Yes' to the question about the drug being prescribed by or in consultation with a gastroenterologist.", + "answer": "True" + }, + { + "name": "Clinical CB.22a", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Crohn's Disease (CD). This checkbox indicates 'No' to the question about the drug being prescribed by or in consultation with a gastroenterologist.", + "answer": "False" + }, + { + "name": "Clinical CB.23a", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Crohn's Disease (CD). This checkbox indicates 'Yes' to the question about the request being for initiation of therapy with the intravenous loading dose.", + "answer": "True" + }, + { + "name": "Clinical CB.24a", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Crohn's Disease (CD). This checkbox indicates 'No' to the question about the request being for initiation of therapy with the intravenous loading dose.", + "answer": "False" + }, + { + "name": "Clinical CB.25", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Crohn's Disease (CD). This checkbox indicates 'Yes' to the question about the patient currently receiving the requested drug.", + "answer": "False" + }, + { + "name": "Clinical CB.26", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Crohn's Disease (CD). This checkbox indicates 'No' to the question about the patient currently receiving the requested drug.", + "answer": "True" + }, + { + "name": "Clinical T.16", + "page": 2, + "field_type_string": "Text", + "field_label": "Please indicate loading dose at weeks 0, 4 and 8:", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Crohn's Disease (CD). This field captures the loading dose information if the patient is receiving it.", + "answer": "600mg IV" + }, + { + "name": "Clinical T.17", + "page": 2, + "field_type_string": "Text", + "field_label": "Please indicate maintenance dose:", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Crohn's Disease (CD). This field captures the maintenance dose information.", + "answer": "180mg SQ or 360mg SQ" + }, + { + "name": "Clinical T.18", + "page": 2, + "field_type_string": "Text", + "field_label": "weeks", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Crohn's Disease (CD). This field captures the frequency of the maintenance dose in weeks.", + "answer": "8" + }, + { + "name": "Clinical CB.27", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Crohn's Disease (CD). This checkbox indicates whether the patient has received 12 weeks of therapy or less.", + "answer": "True" + }, + { + "name": "Clinical CB.28a", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Crohn's Disease (CD). This checkbox indicates 'No' to the question about whether the patient has received 12 weeks of therapy or less.", + "answer": "False" + }, + { + "name": "Clinical T.42", + "page": 2, + "field_type_string": "Text", + "field_label": "Date: (MM)", + "context": "Subheading: H. ACKNOWLEDGEMENT. This field captures the month of the date the request was completed.", + "answer": "05" + }, + { + "name": "Clinical T.43", + "page": 2, + "field_type_string": "Text", + "field_label": "Date: (DD)", + "context": "Subheading: H. ACKNOWLEDGEMENT. This field captures the day of the date the request was completed.", + "answer": "30" + }, + { + "name": "Clinical T.44", + "page": 2, + "field_type_string": "Text", + "field_label": "Date: (YYYY)", + "context": "Subheading: H. ACKNOWLEDGEMENT. This field captures the year of the date the request was completed.", + "answer": "2023" + } + ] +} \ No newline at end of file diff --git a/Output Data/Akshay/Extracted_Fields.json b/Output Data/Akshay/Extracted_Fields.json new file mode 100644 index 00000000..44462f9f --- /dev/null +++ b/Output Data/Akshay/Extracted_Fields.json @@ -0,0 +1,879 @@ +{ + "fields": [ + { + "name": "Indicate CB.1", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "Start of treatment:", + "context": "Subheading: Please indicate. This checkbox indicates if the patient is starting treatment." + }, + { + "name": "Indicate T.2", + "page": 1, + "field_type_string": "Text", + "field_label": "Start date (MM)", + "context": "Subheading: Please indicate. This field captures the month of the start date for the treatment." + }, + { + "name": "Indicate T.3", + "page": 1, + "field_type_string": "Text", + "field_label": "Start date (DD)", + "context": "Subheading: Please indicate. This field captures the day of the start date for the treatment." + }, + { + "name": "Indicate T.4", + "page": 1, + "field_type_string": "Text", + "field_label": "Start date (YYYY)", + "context": "Subheading: Please indicate. This field captures the year of the start date for the treatment." + }, + { + "name": "Indicate CB.5", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "Continuation of therapy", + "context": "Subheading: Please indicate. This checkbox indicates if the patient is continuing therapy." + }, + { + "name": "Indicate T.6", + "page": 1, + "field_type_string": "Text", + "field_label": "Date of last treatment (MM)", + "context": "Subheading: Please indicate. This field captures the month of the last treatment date for continuation of therapy." + }, + { + "name": "Indicate T.7", + "page": 1, + "field_type_string": "Text", + "field_label": "Date of last treatment (DD)", + "context": "Subheading: Please indicate. This field captures the day of the last treatment date for continuation of therapy." + }, + { + "name": "Indicate T.8", + "page": 1, + "field_type_string": "Text", + "field_label": "Date of last treatment (YYYY)", + "context": "Subheading: Please indicate. This field captures the year of the last treatment date for continuation of therapy." + }, + { + "name": "Request by T", + "page": 1, + "field_type_string": "Text", + "field_label": "Precertification Requested By:", + "context": "Subheading: Precertification Requested By. This field captures the name of the person requesting precertification." + }, + { + "name": "Phone T", + "page": 1, + "field_type_string": "Text", + "field_label": "Phone:", + "context": "Subheading: Precertification Requested By. This field captures the phone number of the person requesting precertification." + }, + { + "name": "Fax T", + "page": 1, + "field_type_string": "Text", + "field_label": "Fax:", + "context": "Subheading: Precertification Requested By. This field captures the fax number of the person requesting precertification." + }, + { + "name": "T11", + "page": 1, + "field_type_string": "Text", + "field_label": "Patient First Name", + "context": "Subheading: A. PATIENT INFORMATION. This field captures the first name of the patient." + }, + { + "name": "T12", + "page": 1, + "field_type_string": "Text", + "field_label": "Patient Last Name", + "context": "Subheading: A. PATIENT INFORMATION. This field captures the last name of the patient." + }, + { + "name": "T13", + "page": 1, + "field_type_string": "Text", + "field_label": "Patient DOB (MM/DD/YYYY)", + "context": "Subheading: A. PATIENT INFORMATION. This field captures the date of birth of the patient." + }, + { + "name": "T14", + "page": 1, + "field_type_string": "Text", + "field_label": "Address:", + "context": "Subheading: A. PATIENT INFORMATION. This field captures the street address of the patient." + }, + { + "name": "T15", + "page": 1, + "field_type_string": "Text", + "field_label": "City:", + "context": "Subheading: A. PATIENT INFORMATION. This field captures the city of the patient's address." + }, + { + "name": "T16", + "page": 1, + "field_type_string": "Text", + "field_label": "State:", + "context": "Subheading: A. PATIENT INFORMATION. This field captures the state of the patient's address." + }, + { + "name": "T17", + "page": 1, + "field_type_string": "Text", + "field_label": "ZIP:", + "context": "Subheading: A. PATIENT INFORMATION. This field captures the ZIP code of the patient's address." + }, + { + "name": "T18", + "page": 1, + "field_type_string": "Text", + "field_label": "Patient Phone", + "context": "Subheading: A. PATIENT INFORMATION. This field captures the patient's primary phone number." + }, + { + "name": "T19", + "page": 1, + "field_type_string": "Text", + "field_label": "Work Phone:", + "context": "Subheading: A. PATIENT INFORMATION. This field captures the patient's work phone number." + }, + { + "name": "T20", + "page": 1, + "field_type_string": "Text", + "field_label": "Cell Phone:", + "context": "Subheading: A. PATIENT INFORMATION. This field captures the patient's cell phone number." + }, + { + "name": "T21", + "page": 1, + "field_type_string": "Text", + "field_label": "Email:", + "context": "Subheading: A. PATIENT INFORMATION. This field captures the patient's email address." + }, + { + "name": "T21B", + "page": 1, + "field_type_string": "Text", + "field_label": "lbs", + "context": "Subheading: A. PATIENT INFORMATION. This field captures the patient's weight in pounds." + }, + { + "name": "T21C", + "page": 1, + "field_type_string": "Text", + "field_label": "kgs", + "context": "Subheading: A. PATIENT INFORMATION. This field captures the patient's weight in kilograms." + }, + { + "name": "T21D", + "page": 1, + "field_type_string": "Text", + "field_label": "inches", + "context": "Subheading: A. PATIENT INFORMATION. This field captures the patient's height in inches." + }, + { + "name": "T21E", + "page": 1, + "field_type_string": "Text", + "field_label": "cms", + "context": "Subheading: A. PATIENT INFORMATION. This field captures the patient's height in centimeters." + }, + { + "name": "T21F", + "page": 1, + "field_type_string": "Text", + "field_label": "Allergies:", + "context": "Subheading: A. PATIENT INFORMATION. This field captures any known allergies for the patient." + }, + { + "name": "Insurance Info T.1", + "page": 1, + "field_type_string": "Text", + "field_label": "Aetna Member ID #:", + "context": "Subheading: B. INSURANCE INFORMATION. This field captures the patient's Aetna Member ID number." + }, + { + "name": "Insurance Info CB.4", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: B. INSURANCE INFORMATION. This checkbox indicates if the patient has other coverage." + }, + { + "name": "Insurance Info CB.5", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: B. INSURANCE INFORMATION. This checkbox indicates if the patient does not have other coverage." + }, + { + "name": "Insurance Info T.2", + "page": 1, + "field_type_string": "Text", + "field_label": "Group #:", + "context": "Subheading: B. INSURANCE INFORMATION. This field captures the patient's group number for their insurance." + }, + { + "name": "Insurance Info T.6", + "page": 1, + "field_type_string": "Text", + "field_label": "If yes, provide ID#:", + "context": "Subheading: B. INSURANCE INFORMATION. This field captures the ID number if the patient has other coverage." + }, + { + "name": "Insurance Info T.7", + "page": 1, + "field_type_string": "Text", + "field_label": "Carrier Name:", + "context": "Subheading: B. INSURANCE INFORMATION. This field captures the name of the insurance carrier if the patient has other coverage." + }, + { + "name": "Insurance Info T.3", + "page": 1, + "field_type_string": "Text", + "field_label": "Insured:", + "context": "Subheading: B. INSURANCE INFORMATION. This field captures the name of the insured person if different from the patient." + }, + { + "name": "Insurance Info T.8", + "page": 1, + "field_type_string": "Text", + "field_label": "Insured:", + "context": "Subheading: B. INSURANCE INFORMATION. This field captures the name of the insured person if different from the patient." + }, + { + "name": "Insurance Info CB.9", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: B. INSURANCE INFORMATION. This checkbox indicates if the patient has Medicare." + }, + { + "name": "Insurance Info CB.10", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: B. INSURANCE INFORMATION. This checkbox indicates if the patient does not have Medicare." + }, + { + "name": "Insurance Info T.11", + "page": 1, + "field_type_string": "Text", + "field_label": "If yes, provide ID #:", + "context": "Subheading: B. INSURANCE INFORMATION. This field captures the Medicare ID number." + }, + { + "name": "Insurance Info CB.12", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: B. INSURANCE INFORMATION. This checkbox indicates if the patient has Medicaid." + }, + { + "name": "Insurance Info CB.13", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: B. INSURANCE INFORMATION. This checkbox indicates if the patient does not have Medicaid." + }, + { + "name": "Insurance Info T.14", + "page": 1, + "field_type_string": "Text", + "field_label": "If yes, provide ID #:", + "context": "Subheading: B. INSURANCE INFORMATION. This field captures the Medicaid ID number." + }, + { + "name": "Presc Info T.1", + "page": 1, + "field_type_string": "Text", + "field_label": "First Name:", + "context": "Subheading: C. PRESCRIBER INFORMATION. This field captures the prescriber's first name." + }, + { + "name": "Presc Info T.7", + "page": 1, + "field_type_string": "Text", + "field_label": "Address:", + "context": "Subheading: C. PRESCRIBER INFORMATION. This field captures the prescriber's street address." + }, + { + "name": "Presc Info T.11", + "page": 1, + "field_type_string": "Text", + "field_label": "Phone:", + "context": "Subheading: C. PRESCRIBER INFORMATION. This field captures the prescriber's phone number." + }, + { + "name": "Presc Info T.12", + "page": 1, + "field_type_string": "Text", + "field_label": "Fax:", + "context": "Subheading: C. PRESCRIBER INFORMATION. This field captures the prescriber's fax number." + }, + { + "name": "Presc Info T.17", + "page": 1, + "field_type_string": "Text", + "field_label": "Provider Email:", + "context": "Subheading: C. PRESCRIBER INFORMATION. This field captures the prescriber's email address." + }, + { + "name": "Presc Info T.2", + "page": 1, + "field_type_string": "Text", + "field_label": "Last Name:", + "context": "Subheading: C. PRESCRIBER INFORMATION. This field captures the prescriber's last name." + }, + { + "name": "Presc Info CB.3", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "M.D.", + "context": "Subheading: C. PRESCRIBER INFORMATION. This checkbox indicates if the prescriber is an M.D." + }, + { + "name": "Presc Info CB.4", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "D.O.", + "context": "Subheading: C. PRESCRIBER INFORMATION. This checkbox indicates if the prescriber is a D.O." + }, + { + "name": "Presc Info CB.5", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "N.P.", + "context": "Subheading: C. PRESCRIBER INFORMATION. This checkbox indicates if the prescriber is a N.P." + }, + { + "name": "Presc Info CB.6", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "P.A.", + "context": "Subheading: C. PRESCRIBER INFORMATION. This checkbox indicates if the prescriber is a P.A." + }, + { + "name": "Presc Info T.8", + "page": 1, + "field_type_string": "Text", + "field_label": "City:", + "context": "Subheading: C. PRESCRIBER INFORMATION. This field captures the city of the prescriber's address." + }, + { + "name": "Presc Info T.9", + "page": 1, + "field_type_string": "Text", + "field_label": "State:", + "context": "Subheading: C. PRESCRIBER INFORMATION. This field captures the state of the prescriber's address." + }, + { + "name": "Presc Info T.10", + "page": 1, + "field_type_string": "Text", + "field_label": "ZIP:", + "context": "Subheading: C. PRESCRIBER INFORMATION. This field captures the ZIP code of the prescriber's address." + }, + { + "name": "Presc Info T.13", + "page": 1, + "field_type_string": "Text", + "field_label": "St Lic #:", + "context": "Subheading: C. PRESCRIBER INFORMATION. This field captures the prescriber's state license number." + }, + { + "name": "Presc Info T.14", + "page": 1, + "field_type_string": "Text", + "field_label": "NPI #:", + "context": "Subheading: C. PRESCRIBER INFORMATION. This field captures the prescriber's NPI number." + }, + { + "name": "Presc Info T.15", + "page": 1, + "field_type_string": "Text", + "field_label": "DEA #:", + "context": "Subheading: C. PRESCRIBER INFORMATION. This field captures the prescriber's DEA number." + }, + { + "name": "Presc Info T.16", + "page": 1, + "field_type_string": "Text", + "field_label": "UPIN:", + "context": "Subheading: C. PRESCRIBER INFORMATION. This field captures the prescriber's UPIN number." + }, + { + "name": "Presc Info T.18", + "page": 1, + "field_type_string": "Text", + "field_label": "Office Contact Name:", + "context": "Subheading: C. PRESCRIBER INFORMATION. This field captures the name of the office contact person." + }, + { + "name": "Presc Info T.19", + "page": 1, + "field_type_string": "Text", + "field_label": "Phone:", + "context": "Subheading: C. PRESCRIBER INFORMATION. This field captures the phone number of the office contact person." + }, + { + "name": "Presc Info CB.20", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "Gastroenterologist", + "context": "Subheading: C. PRESCRIBER INFORMATION. This checkbox indicates the prescriber's specialty is Gastroenterologist." + }, + { + "name": "Presc Info CB.21", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "Other:", + "context": "Subheading: C. PRESCRIBER INFORMATION. This checkbox indicates the prescriber's specialty is Other. Dependent on field 'Other:' for specialty information." + }, + { + "name": "Presc Info T.23", + "page": 1, + "field_type_string": "Text", + "field_label": "Other:", + "context": "Subheading: C. PRESCRIBER INFORMATION. This field captures the prescriber's specialty if 'Other' is selected." + }, + { + "name": "Provider Admin CB.1", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "Self-administered", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. This checkbox indicates the place of administration is self-administered." + }, + { + "name": "Provider Admin CB.2", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "Physician's Office", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. This checkbox indicates the place of administration is a physician's office." + }, + { + "name": "Provider Admin CB.3", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "Outpatient Infusion Center", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. This checkbox indicates the place of administration is an outpatient infusion center." + }, + { + "name": "Provider Admin T.4", + "page": 1, + "field_type_string": "Text", + "field_label": "Phone:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. This field captures the phone number for the outpatient infusion center." + }, + { + "name": "Provider Admin T.5", + "page": 1, + "field_type_string": "Text", + "field_label": "Center Name:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. This field captures the name of the outpatient infusion center." + }, + { + "name": "Provider Admin CB.6", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "Home Infusion Center", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. This checkbox indicates the place of administration is a home infusion center." + }, + { + "name": "Provider Admin T.7", + "page": 1, + "field_type_string": "Text", + "field_label": "Phone:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. This field captures the phone number for the home infusion center." + }, + { + "name": "Provider Admin T.8", + "page": 1, + "field_type_string": "Text", + "field_label": "Agency Name:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. This field captures the name of the agency for the home infusion center." + }, + { + "name": "Provider Admin CB.9.0", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "Administration code(s)", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. This checkbox indicates that administration codes will be provided. Dependent on field 'CPT:' for the code." + }, + { + "name": "Provider Admin T.10.0.0", + "page": 1, + "field_type_string": "Text", + "field_label": "CPT:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. This field captures the CPT code for administration." + }, + { + "name": "Provider Admin T.10.1.0", + "page": 1, + "field_type_string": "Text", + "field_label": "Address:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. This field captures the address of the dispensing provider/pharmacy." + }, + { + "name": "Provider Admin CB.11", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "Physician\u2019s Office", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. This checkbox indicates the dispensing provider/pharmacy is a Physician's Office." + }, + { + "name": "Provider Admin CB.12", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "Retail Pharmacy", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. This checkbox indicates the dispensing provider/pharmacy is a Retail Pharmacy." + }, + { + "name": "Provider Admin CB.13", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "Specialty Pharmacy", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. This checkbox indicates the dispensing provider/pharmacy is a Specialty Pharmacy." + }, + { + "name": "Provider Admin CB.14", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "Other", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. This checkbox indicates the dispensing provider/pharmacy is Other." + }, + { + "name": "Provider Admin T.17.0", + "page": 1, + "field_type_string": "Text", + "field_label": "Name:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. This field captures the name of the dispensing provider/pharmacy." + }, + { + "name": "Provider Admin T.17.1", + "page": 1, + "field_type_string": "Text", + "field_label": "Address:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. This field captures the address of the dispensing provider/pharmacy." + }, + { + "name": "Provider Admin T.18", + "page": 1, + "field_type_string": "Text", + "field_label": "Phone:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. This field captures the phone number of the dispensing provider/pharmacy." + }, + { + "name": "Provider Admin T.19", + "page": 1, + "field_type_string": "Text", + "field_label": "Fax:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. This field captures the fax number of the dispensing provider/pharmacy." + }, + { + "name": "Provider Admin T.20", + "page": 1, + "field_type_string": "Text", + "field_label": "TIN:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. This field captures the Taxpayer Identification Number (TIN) of the dispensing provider/pharmacy." + }, + { + "name": "Provider Admin T.21", + "page": 1, + "field_type_string": "Text", + "field_label": "PIN:", + "context": "Subheading: D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION. This field captures the Pharmacy Identification Number (PIN) of the dispensing provider/pharmacy." + }, + { + "name": "Product T.1", + "page": 1, + "field_type_string": "Text", + "field_label": "Dose:", + "context": "Subheading: E. PRODUCT INFORMATION. This field captures the requested dose of Skyrizi." + }, + { + "name": "Product T.2", + "page": 1, + "field_type_string": "Text", + "field_label": "Frequency:", + "context": "Subheading: E. PRODUCT INFORMATION. This field captures the requested frequency of Skyrizi." + }, + { + "name": "Diagnosis T.1", + "page": 1, + "field_type_string": "Text", + "field_label": "Primary ICD Code:", + "context": "Subheading: F. DIAGNOSIS INFORMATION. This field captures the primary ICD code for the diagnosis." + }, + { + "name": "Diagnosis T.2", + "page": 1, + "field_type_string": "Text", + "field_label": "Secondary ICD Code:", + "context": "Subheading: F. DIAGNOSIS INFORMATION. This field captures the secondary ICD code for the diagnosis." + }, + { + "name": "Diagnosis T.3", + "page": 1, + "field_type_string": "Text", + "field_label": "Other ICD Code:", + "context": "Subheading: F. DIAGNOSIS INFORMATION. This field captures any other relevant ICD codes for the diagnosis." + }, + { + "name": "Clinical CB.0", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION. This checkbox indicates 'Yes' to the question about using the drug in combination with other biologics or targeted synthetic drugs." + }, + { + "name": "Clinical CB.1", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION. This checkbox indicates 'No' to the question about using the drug in combination with other biologics or targeted synthetic drugs." + }, + { + "name": "Clinical CB.2", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION. This checkbox indicates 'Yes' to the question about the patient having received prior therapy associated with an increased risk of tuberculosis (TB)." + }, + { + "name": "Clinical CB.3", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION. This checkbox indicates 'No' to the question about the patient having received prior therapy associated with an increased risk of tuberculosis (TB)." + }, + { + "name": "Clinical CB.4", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION. This checkbox indicates 'Yes' to the question about the patient having had a tuberculosis (TB) test within 6 months of initiating therapy." + }, + { + "name": "Clinical CB.5", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION. This checkbox indicates 'No' to the question about the patient having had a tuberculosis (TB) test within 6 months of initiating therapy." + }, + { + "name": "Clinical CB.6", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "PPD test", + "context": "Subheading: G. CLINICAL INFORMATION. This checkbox indicates that a PPD test was performed as part of the TB testing." + }, + { + "name": "Clinical CB.7", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "interferon-release assay (IGRA)", + "context": "Subheading: G. CLINICAL INFORMATION. This checkbox indicates that an interferon-release assay (IGRA) was performed as part of the TB testing." + }, + { + "name": "Clinical CB.8", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "chest x-ray", + "context": "Subheading: G. CLINICAL INFORMATION. This checkbox indicates that a chest x-ray was performed as part of the TB testing." + }, + { + "name": "Clinical CB.9", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "positive", + "context": "Subheading: G. CLINICAL INFORMATION. This checkbox indicates a positive result for the tuberculosis (TB) test." + }, + { + "name": "Clinical CB.10", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "negative", + "context": "Subheading: G. CLINICAL INFORMATION. This checkbox indicates a negative result for the tuberculosis (TB) test." + }, + { + "name": "Clinical CB.11", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "unknown", + "context": "Subheading: G. CLINICAL INFORMATION. This checkbox indicates the result of the tuberculosis (TB) test is unknown." + }, + { + "name": "Clinical CB.12", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "latent TB and treatment for latent TB has been initiated", + "context": "Subheading: G. CLINICAL INFORMATION. This checkbox indicates the patient has latent TB and treatment has been initiated." + }, + { + "name": "Clinical CB.13", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "latent TB and treatment for latent TB has been completed", + "context": "Subheading: G. CLINICAL INFORMATION. This checkbox indicates the patient has latent TB and treatment has been completed." + }, + { + "name": "Clinical CB.14", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "latent TB and treatment for latent TB has not been initiated", + "context": "Subheading: G. CLINICAL INFORMATION. This checkbox indicates the patient has latent TB and treatment has not been initiated." + }, + { + "name": "Clinical CB.15", + "page": 1, + "field_type_string": "CheckBox", + "field_label": "active TB", + "context": "Subheading: G. CLINICAL INFORMATION. This checkbox indicates the patient has active TB." + }, + { + "name": "T11", + "page": 2, + "field_type_string": "Text", + "field_label": "Patient First Name", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). This field captures the first name of the patient." + }, + { + "name": "T12", + "page": 2, + "field_type_string": "Text", + "field_label": "Patient Last Name", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). This field captures the last name of the patient." + }, + { + "name": "T18", + "page": 2, + "field_type_string": "Text", + "field_label": "Patient Phone", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). This field captures the patient's phone number." + }, + { + "name": "T13", + "page": 2, + "field_type_string": "Text", + "field_label": "Patient DOB (MM/DD/YYYY)", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). This field captures the date of birth of the patient." + }, + { + "name": "Clinical CB.19", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Crohn's Disease (CD). This checkbox indicates 'Yes' to the question about diagnosis of moderately to severely active Crohn's disease (CD)." + }, + { + "name": "Clinical CB.20", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Crohn's Disease (CD). This checkbox indicates 'No' to the question about diagnosis of moderately to severely active Crohn's disease (CD)." + }, + { + "name": "Clinical CB.21", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Crohn's Disease (CD). This checkbox indicates 'Yes' to the question about the drug being prescribed by or in consultation with a gastroenterologist." + }, + { + "name": "Clinical CB.22a", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Crohn's Disease (CD). This checkbox indicates 'No' to the question about the drug being prescribed by or in consultation with a gastroenterologist." + }, + { + "name": "Clinical CB.23a", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Crohn's Disease (CD). This checkbox indicates 'Yes' to the question about the request being for initiation of therapy with the intravenous loading dose." + }, + { + "name": "Clinical CB.24a", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Crohn's Disease (CD). This checkbox indicates 'No' to the question about the request being for initiation of therapy with the intravenous loading dose." + }, + { + "name": "Clinical CB.25", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Crohn's Disease (CD). This checkbox indicates 'Yes' to the question about the patient currently receiving the requested drug." + }, + { + "name": "Clinical CB.26", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Crohn's Disease (CD). This checkbox indicates 'No' to the question about the patient currently receiving the requested drug." + }, + { + "name": "Clinical T.16", + "page": 2, + "field_type_string": "Text", + "field_label": "Please indicate loading dose at weeks 0, 4 and 8:", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Crohn's Disease (CD). This field captures the loading dose information if the patient is receiving it." + }, + { + "name": "Clinical T.17", + "page": 2, + "field_type_string": "Text", + "field_label": "Please indicate maintenance dose:", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Crohn's Disease (CD). This field captures the maintenance dose information." + }, + { + "name": "Clinical T.18", + "page": 2, + "field_type_string": "Text", + "field_label": "weeks", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Crohn's Disease (CD). This field captures the frequency of the maintenance dose in weeks." + }, + { + "name": "Clinical CB.27", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "Yes", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Crohn's Disease (CD). This checkbox indicates 'Yes' to the question about whether the patient has received 12 weeks of therapy or less." + }, + { + "name": "Clinical CB.28a", + "page": 2, + "field_type_string": "CheckBox", + "field_label": "No", + "context": "Subheading: G. CLINICAL INFORMATION (Continued). Crohn's Disease (CD). This checkbox indicates 'No' to the question about whether the patient has received 12 weeks of therapy or less." + }, + { + "name": "Clinical T.42", + "page": 2, + "field_type_string": "Text", + "field_label": "Date: (MM)", + "context": "Subheading: H. ACKNOWLEDGEMENT. This field captures the month of the date the request was completed." + }, + { + "name": "Clinical T.43", + "page": 2, + "field_type_string": "Text", + "field_label": "Date: (DD)", + "context": "Subheading: H. ACKNOWLEDGEMENT. This field captures the day of the date the request was completed." + }, + { + "name": "Clinical T.44", + "page": 2, + "field_type_string": "Text", + "field_label": "Date: (YYYY)", + "context": "Subheading: H. ACKNOWLEDGEMENT. This field captures the year of the date the request was completed." + } + ] +} \ No newline at end of file diff --git a/Output Data/Akshay/Filled_PA_Form.pdf b/Output Data/Akshay/Filled_PA_Form.pdf new file mode 100644 index 00000000..3ca842ca Binary files /dev/null and b/Output Data/Akshay/Filled_PA_Form.pdf differ diff --git a/Output Data/Amy/Completed_Form_Fields.json b/Output Data/Amy/Completed_Form_Fields.json new file mode 100644 index 00000000..b3f372cc --- /dev/null +++ b/Output Data/Amy/Completed_Form_Fields.json @@ -0,0 +1,220 @@ +{ + "answers": [ + { + "name": "member.last_name", + "page": 1, + "field_type_string": "Text", + "field_label": "Last name:", + "context": "Subheading: Member Information. The member's last name is required.", + "answer": "Chen" + }, + { + "name": "member.first_name", + "page": 1, + "field_type_string": "Text", + "field_label": "First name:", + "context": "Subheading: Member Information. The member's first name is required.", + "answer": "Amy" + }, + { + "name": "member.medicaid_id", + "page": 1, + "field_type_string": "Text", + "field_label": "Medicaid ID number:", + "context": "Subheading: Member Information. The member's Medicaid ID number is required.", + "answer": "null" + }, + { + "name": "member.dob", + "page": 1, + "field_type_string": "Date", + "field_label": "Date of birth:", + "context": "Subheading: Member Information. The member's date of birth is required.", + "answer": "1983-05-23" + }, + { + "name": "member.weight_kg", + "page": 1, + "field_type_string": "Text", + "field_label": "Weight in kilograms:", + "context": "Subheading: Member Information. The member's weight in kilograms is required.", + "answer": "50.9 kg" + }, + { + "name": "prescriber.last_name", + "page": 1, + "field_type_string": "Text", + "field_label": "Last name:", + "context": "Subheading: Prescriber information. The prescriber's last name is required.", + "answer": "Nicole" + }, + { + "name": "prescriber.first_name", + "page": 1, + "field_type_string": "Text", + "field_label": "First name:", + "context": "Subheading: Prescriber information. The prescriber's first name is required.", + "answer": "Angela" + }, + { + "name": "prescriber.npi_number", + "page": 1, + "field_type_string": "Text", + "field_label": "NPI number:", + "context": "Subheading: Prescriber information. The prescriber's NPI number is required.", + "answer": "null" + }, + { + "name": "prescriber.phone", + "page": 1, + "field_type_string": "Text", + "field_label": "Phone number:", + "context": "Subheading: Prescriber information. The prescriber's phone number is required.", + "answer": "421-771-9001" + }, + { + "name": "prescriber.fax", + "page": 1, + "field_type_string": "Text", + "field_label": "Fax number:", + "context": "Subheading: Prescriber information. The prescriber's fax number is required.", + "answer": "1-244-345-8459" + }, + { + "name": "drug.name", + "page": 1, + "field_type_string": "Text", + "field_label": "Drug name:", + "context": "Subheading: Drug information. The name of the drug is required.", + "answer": "VYEPTI" + }, + { + "name": "drug.strength", + "page": 1, + "field_type_string": "Text", + "field_label": "Drug strength:", + "context": "Subheading: Drug information. The strength of the drug is required.", + "answer": "100 mg/mL" + }, + { + "name": "drug.length_of_therapy", + "page": 1, + "field_type_string": "Text", + "field_label": "Length of therapy:", + "context": "Subheading: Drug information. The length of therapy is required.", + "answer": "null" + }, + { + "name": "drug.form", + "page": 1, + "field_type_string": "Text", + "field_label": "Drug form:", + "context": "Subheading: Drug information. The form of the drug is required.", + "answer": "solution" + }, + { + "name": "drug.dosing_frequency", + "page": 1, + "field_type_string": "Text", + "field_label": "Dosing frequency:", + "context": "Subheading: Drug information. The dosing frequency of the drug is required.", + "answer": "Once" + }, + { + "name": "drug.quantity", + "page": 1, + "field_type_string": "Text", + "field_label": "Quantity:", + "context": "Subheading: Drug information. The quantity of the drug is required.", + "answer": "1 mL" + }, + { + "name": "clinical.migraine_diagnosis_criteria", + "page": 2, + "field_type_string": "Radio", + "field_label": "Does the member have a diagnosis of migraine with or without aura based on International Classification of Headache Disorders (ICHD-III) diagnostic criteria?", + "context": "Subheading: Drug information. This question is part of the criteria for preventive treatment of migraine and requires a Yes or No answer.", + "answer": "True" + }, + { + "name": "clinical.age_over_18", + "page": 2, + "field_type_string": "Radio", + "field_label": "Is the member \u2265 18 years of age?", + "context": "Subheading: Drug information. This question is part of the criteria for preventive treatment of migraine and requires a Yes or No answer.", + "answer": "True" + }, + { + "name": "clinical.utilizing_prophylactic_modalities", + "page": 2, + "field_type_string": "Radio", + "field_label": "Has the member been utilizing prophylactic intervention modalities (for example, pharmacotherapy, behavioral therapy, physical therapy, etc.)?", + "context": "Subheading: Drug information. This question is part of the criteria for preventive treatment of migraine and requires a Yes or No answer.", + "answer": "True" + }, + { + "name": "clinical.chronic_migraine_diagnosis", + "page": 2, + "field_type_string": "Radio", + "field_label": "Does the member have a diagnosis of chronic migraines defined as 15 or more headache (tension-type-like and/or migraine-like) days per month for > three months?", + "context": "Subheading: Drug information. This question is part of the criteria for preventive treatment of migraine and requires a Yes or No answer. If 'Yes', additional criteria (a, b, c, d) must also be met.", + "answer": "True" + }, + { + "name": "clinical.frequent_episodic_migraine", + "page": 3, + "field_type_string": "Radio", + "field_label": "Does the member have diagnosis of frequent episodic migraines defined as at least five headache attacks lasting 4 to 72 hours (when untreated or unsuccessfully treated)?", + "context": "Subheading: Drug information. This question requires a Yes or No answer. If 'Yes', additional criteria (a, b) must also be met.", + "answer": "False" + }, + { + "name": "drug.vyepti_not_in_combination_cgrp", + "page": 3, + "field_type_string": "Radio", + "field_label": "Will Vyepti not be used in combination with prophylactic calcitonin gene-related peptide (CGRP) inhibitors? (for example, erenumab, galcanezumab, fremanezumab, atogepant, rimegepant, etc.)", + "context": "Subheading: Drug information. This question requires a Yes or No answer.", + "answer": "False" + }, + { + "name": "renewal.meet_initial_criteria", + "page": 3, + "field_type_string": "Radio", + "field_label": "Does the member continue to meet the initial criteria?", + "context": "Subheading: For renewal, complete the following questions to receive a 12-month approval. This question requires a Yes or No answer.", + "answer": "null" + }, + { + "name": "renewal.no_unacceptable_toxicity", + "page": 3, + "field_type_string": "Radio", + "field_label": "Does the member have an absence of unacceptable toxicity from the drug?", + "context": "Subheading: For renewal, complete the following questions to receive a 12-month approval. This question requires a Yes or No answer.", + "answer": "null" + }, + { + "name": "renewal.clinical_response", + "page": 3, + "field_type_string": "Radio", + "field_label": "Has the member experienced a clinical response as evidenced by:", + "context": "Subheading: For renewal, complete the following questions to receive a 12-month approval. This question requires a Yes or No answer. The response should be based on criteria a or b.", + "answer": "null" + }, + { + "name": "prescriber.signature", + "page": 3, + "field_type_string": "Signature", + "field_label": "Prescriber signature (required)", + "context": "Subheading: Prescriber signature (required). The prescriber's signature is required to confirm the accuracy of the information provided.", + "answer": "null" + }, + { + "name": "prescriber.date", + "page": 3, + "field_type_string": "Date", + "field_label": "Date", + "context": "Subheading: Prescriber signature (required). The date the prescriber signed is required.", + "answer": "null" + } + ] +} \ No newline at end of file diff --git a/Output Data/Amy/Extracted_Fields.json b/Output Data/Amy/Extracted_Fields.json new file mode 100644 index 00000000..a3811195 --- /dev/null +++ b/Output Data/Amy/Extracted_Fields.json @@ -0,0 +1,193 @@ +{ + "fields": [ + { + "name": "member.last_name", + "page": 1, + "field_type_string": "Text", + "field_label": "Last name:", + "context": "Subheading: Member Information. The member's last name is required." + }, + { + "name": "member.first_name", + "page": 1, + "field_type_string": "Text", + "field_label": "First name:", + "context": "Subheading: Member Information. The member's first name is required." + }, + { + "name": "member.medicaid_id", + "page": 1, + "field_type_string": "Text", + "field_label": "Medicaid ID number:", + "context": "Subheading: Member Information. The member's Medicaid ID number is required." + }, + { + "name": "member.dob", + "page": 1, + "field_type_string": "Date", + "field_label": "Date of birth:", + "context": "Subheading: Member Information. The member's date of birth is required." + }, + { + "name": "member.weight_kg", + "page": 1, + "field_type_string": "Text", + "field_label": "Weight in kilograms:", + "context": "Subheading: Member Information. The member's weight in kilograms is required." + }, + { + "name": "prescriber.last_name", + "page": 1, + "field_type_string": "Text", + "field_label": "Last name:", + "context": "Subheading: Prescriber information. The prescriber's last name is required." + }, + { + "name": "prescriber.first_name", + "page": 1, + "field_type_string": "Text", + "field_label": "First name:", + "context": "Subheading: Prescriber information. The prescriber's first name is required." + }, + { + "name": "prescriber.npi_number", + "page": 1, + "field_type_string": "Text", + "field_label": "NPI number:", + "context": "Subheading: Prescriber information. The prescriber's NPI number is required." + }, + { + "name": "prescriber.phone", + "page": 1, + "field_type_string": "Text", + "field_label": "Phone number:", + "context": "Subheading: Prescriber information. The prescriber's phone number is required." + }, + { + "name": "prescriber.fax", + "page": 1, + "field_type_string": "Text", + "field_label": "Fax number:", + "context": "Subheading: Prescriber information. The prescriber's fax number is required." + }, + { + "name": "drug.name", + "page": 1, + "field_type_string": "Text", + "field_label": "Drug name:", + "context": "Subheading: Drug information. The name of the drug is required." + }, + { + "name": "drug.strength", + "page": 1, + "field_type_string": "Text", + "field_label": "Drug strength:", + "context": "Subheading: Drug information. The strength of the drug is required." + }, + { + "name": "drug.length_of_therapy", + "page": 1, + "field_type_string": "Text", + "field_label": "Length of therapy:", + "context": "Subheading: Drug information. The length of therapy is required." + }, + { + "name": "drug.form", + "page": 1, + "field_type_string": "Text", + "field_label": "Drug form:", + "context": "Subheading: Drug information. The form of the drug is required." + }, + { + "name": "drug.dosing_frequency", + "page": 1, + "field_type_string": "Text", + "field_label": "Dosing frequency:", + "context": "Subheading: Drug information. The dosing frequency of the drug is required." + }, + { + "name": "drug.quantity", + "page": 1, + "field_type_string": "Text", + "field_label": "Quantity:", + "context": "Subheading: Drug information. The quantity of the drug is required." + }, + { + "name": "clinical.migraine_diagnosis_criteria", + "page": 2, + "field_type_string": "Radio", + "field_label": "Does the member have a diagnosis of migraine with or without aura based on International Classification of Headache Disorders (ICHD-III) diagnostic criteria?", + "context": "Subheading: Drug information. This question is part of the criteria for preventive treatment of migraine and requires a Yes or No answer." + }, + { + "name": "clinical.age_over_18", + "page": 2, + "field_type_string": "Radio", + "field_label": "Is the member \u2265 18 years of age?", + "context": "Subheading: Drug information. This question is part of the criteria for preventive treatment of migraine and requires a Yes or No answer." + }, + { + "name": "clinical.utilizing_prophylactic_modalities", + "page": 2, + "field_type_string": "Radio", + "field_label": "Has the member been utilizing prophylactic intervention modalities (for example, pharmacotherapy, behavioral therapy, physical therapy, etc.)?", + "context": "Subheading: Drug information. This question is part of the criteria for preventive treatment of migraine and requires a Yes or No answer." + }, + { + "name": "clinical.chronic_migraine_diagnosis", + "page": 2, + "field_type_string": "Radio", + "field_label": "Does the member have a diagnosis of chronic migraines defined as 15 or more headache (tension-type-like and/or migraine-like) days per month for > three months?", + "context": "Subheading: Drug information. This question is part of the criteria for preventive treatment of migraine and requires a Yes or No answer. If 'Yes', additional criteria (a, b, c, d) must also be met." + }, + { + "name": "clinical.frequent_episodic_migraine", + "page": 3, + "field_type_string": "Radio", + "field_label": "Does the member have diagnosis of frequent episodic migraines defined as at least five headache attacks lasting 4 to 72 hours (when untreated or unsuccessfully treated)?", + "context": "Subheading: Drug information. This question requires a Yes or No answer. If 'Yes', additional criteria (a, b) must also be met." + }, + { + "name": "drug.vyepti_not_in_combination_cgrp", + "page": 3, + "field_type_string": "Radio", + "field_label": "Will Vyepti not be used in combination with prophylactic calcitonin gene-related peptide (CGRP) inhibitors? (for example, erenumab, galcanezumab, fremanezumab, atogepant, rimegepant, etc.)", + "context": "Subheading: Drug information. This question requires a Yes or No answer." + }, + { + "name": "renewal.meet_initial_criteria", + "page": 3, + "field_type_string": "Radio", + "field_label": "Does the member continue to meet the initial criteria?", + "context": "Subheading: For renewal, complete the following questions to receive a 12-month approval. This question requires a Yes or No answer." + }, + { + "name": "renewal.no_unacceptable_toxicity", + "page": 3, + "field_type_string": "Radio", + "field_label": "Does the member have an absence of unacceptable toxicity from the drug?", + "context": "Subheading: For renewal, complete the following questions to receive a 12-month approval. This question requires a Yes or No answer." + }, + { + "name": "renewal.clinical_response", + "page": 3, + "field_type_string": "Radio", + "field_label": "Has the member experienced a clinical response as evidenced by:", + "context": "Subheading: For renewal, complete the following questions to receive a 12-month approval. This question requires a Yes or No answer. The response should be based on criteria a or b." + }, + { + "name": "prescriber.signature", + "page": 3, + "field_type_string": "Signature", + "field_label": "Prescriber signature (required)", + "context": "Subheading: Prescriber signature (required). The prescriber's signature is required to confirm the accuracy of the information provided." + }, + { + "name": "prescriber.date", + "page": 3, + "field_type_string": "Date", + "field_label": "Date", + "context": "Subheading: Prescriber signature (required). The date the prescriber signed is required." + } + ] +} \ No newline at end of file diff --git a/Output Data/Amy/Filled_PA_Form.pdf b/Output Data/Amy/Filled_PA_Form.pdf new file mode 100644 index 00000000..6aa926f1 Binary files /dev/null and b/Output Data/Amy/Filled_PA_Form.pdf differ diff --git a/dev.py b/dev.py new file mode 100644 index 00000000..7ec3775d --- /dev/null +++ b/dev.py @@ -0,0 +1,450 @@ +import base64 +import os +import json +import pathlib +from typing import List, Optional +from pydantic import BaseModel, Field +from mistralai import Mistral +from dotenv import load_dotenv +from google import genai +from google.genai import types +from prompts import get_ocr_analysis_prompt, get_system_prompt, get_system_data_collection_prompt, get_data_collection_prompt, get_pdf_analysis_prompt +from datetime import datetime +import pymupdf +import time + +# Load environment variables from .env file +load_dotenv() + +# Timing function +def time_step(step_name: str): + """Decorator to time a function execution.""" + def decorator(func): + def wrapper(*args, **kwargs): + start_time = time.time() + result = func(*args, **kwargs) + end_time = time.time() + duration = end_time - start_time + print(f"⏱️ {step_name} completed in {duration:.2f} seconds") + return result + return wrapper + return decorator + +# Pydantic models for structured data +class ImageData(BaseModel): + id: str + top_left_x: int + top_left_y: int + bottom_right_x: int + bottom_right_y: int + image_base64: str + +class PageDimensions(BaseModel): + dpi: int + height: int + width: int + +class OCRPage(BaseModel): + index: int + markdown: str + images: List[ImageData] + dimensions: PageDimensions + +class OCRResponse(BaseModel): + pages: List[OCRPage] + +class PAFormField(BaseModel): + name: str + page: int + field_type_string: str + field_label: str + context: str = Field(default="") + +class PAFormAnswer(BaseModel): + name: str + page: int + field_type_string: str + field_label: str + context: str + answer: str = Field(default="Answer to the question based on the provided referral package data.") + +class PAFormFields(BaseModel): + fields: List[PAFormField] + +class PAFormAnswers(BaseModel): + answers: List[PAFormAnswer] + +def encode_pdf(pdf_path): + """Encode the pdf to base64.""" + try: + with open(pdf_path, "rb") as pdf_file: + return base64.b64encode(pdf_file.read()).decode('utf-8') + except FileNotFoundError: + print(f"Error: The file {pdf_path} was not found.") + return None + except Exception as e: # General exception handling + print(f"Error: {e}") + return None + +# Path to your pdf +pa_pdf_path = "./Input Data/Amy/PA.pdf" + +# Getting the base64 string +base64_pdf = encode_pdf(pa_pdf_path) + +# Start overall timing +overall_start_time = time.time() + +''' +STEP 1: +PyMuPDF PDF Breakdown + +Parses over the PA PDF and returns a breakdown of the PDF with its pages, fields, field options, and more. +''' + +@time_step("Step 1: PyMuPDF Field Extraction") +def extract_pa_pdf_fields(pdf_path: str) -> dict: + doc = pymupdf.open(pdf_path) + fields = [] + for page_num, page in enumerate(doc, start=1): + widgets = page.widgets() + for w in widgets: + field = { + "name": w.field_name, + "type": w.field_type, + "value": w.field_value, + "page": page_num, + "field_type": w.field_type, + "field_type_string": w.field_type_string, + "field_label": w.field_label, + } + fields.append(field) + return fields +pa_pdf_fields = extract_pa_pdf_fields(pa_pdf_path) + +# Convert list of fields to object format expected by PAFormFields +pa_pdf_fields_obj = {"fields": pa_pdf_fields} + +structured_pa_pdf_fields = PAFormFields.model_validate(pa_pdf_fields_obj) + + +''' +STEP 2: +Mistral OCR API Call +- model: mistral-ocr-latest +- document: + - type: document_url + - document_url: base64 encoded pdf +- include_image_base64: True +- response_format: markdown + +Parses over the Base64 encoded PA PDF and returns a JSON object with markdown text +containing the contents of the PDF. +''' + + +mistrtal_api_key = os.environ["MISTRAL_API_KEY"] +client = Mistral(api_key=mistrtal_api_key) + +@time_step("Step 2: OCR Processing") +def process_pdf_with_ocr(pdf_path: str) -> OCRResponse: + """Process a PDF file with OCR and return structured response.""" + + # Encode the PDF to base64 + base64_pdf = encode_pdf(pdf_path) + if not base64_pdf: + raise FileNotFoundError(f"PDF file not found at {pdf_path}") + + # Initialize Mistral client + mistral_api_key = os.environ["MISTRAL_API_KEY"] + client = Mistral(api_key=mistral_api_key) + + # Process PDF with OCR + ocr_response = client.ocr.process( + model="mistral-ocr-latest", + document={ + "type": "document_url", + "document_url": f"data:application/pdf;base64,{base64_pdf}" + }, + include_image_base64=True, + ) + + # Convert Mistral response to our Pydantic model + try: + structured_response = OCRResponse( + pages=[ + OCRPage( + index=page.index, + markdown=page.markdown, + images=[ + ImageData( + id=image.id, + top_left_x=image.top_left_x, + top_left_y=image.top_left_y, + bottom_right_x=image.bottom_right_x, + bottom_right_y=image.bottom_right_y, + image_base64=image.image_base64 + ) + for image in page.images + ], + dimensions=PageDimensions( + dpi=page.dimensions.dpi, + height=page.dimensions.height, + width=page.dimensions.width + ) + ) + for i, page in enumerate(ocr_response.pages or []) + ] + ) + + return structured_response + + except Exception as e: + print(f"Error processing OCR response: {e}") + raise + +# Process the PA form +try: + structured_response = process_pdf_with_ocr(pa_pdf_path) + print("Successfully processed PA form with OCR") +except Exception as e: + print(f"Error in OCR processing: {e}") + exit(1) + +''' +STEP 3: +LLM Pre-Processing API Call +- model: gemini-2.5-flash-preview-05-20 +- text: + - type: markdown + - markdown: markdown text from the OCR response +- response_format: json_object + +Parses over the markdown text from the OCR response and returns a JSON object with +the fillable fields parsed out and their corresponding value types. +''' +@time_step("Step 3: LLM Analysis") +def process_with_llm(system_prompt: str, prompt: str, pdf_path: str = None, response_format: str = None, model: str = "gemini-2.5-flash-lite-preview-06-17",) -> str: + """Process OCR text with LLMs to extract structured information.""" + + + + client = genai.Client(api_key=os.environ["GOOGLE_API_KEY"]) + + if pdf_path: + gemini_upload_filepath = pathlib.Path(pdf_path) + + response = client.models.generate_content( + model=model, + config=types.GenerateContentConfig( + system_instruction=system_prompt, + response_mime_type="application/json", + response_schema=response_format + ), + contents=[ + types.Part.from_bytes( + data=gemini_upload_filepath.read_bytes(), + mime_type='application/pdf', + ), + prompt] + ) + else: + response = client.models.generate_content( + model=model, + config=types.GenerateContentConfig( + system_instruction=system_prompt, + response_mime_type="application/json", + response_schema=response_format + ), + contents=[prompt] + ) + # print(response.text) + return response.text + + + +try: + # Process all pages from the OCR response + llm_analysis = process_with_llm(system_prompt=get_system_prompt(), + prompt=get_pdf_analysis_prompt( + pa_pdf_fields=structured_pa_pdf_fields, ocr_text=structured_response), + response_format=PAFormFields, + pdf_path=pa_pdf_path) + print("Successfully processed PA form with LLM including OCR + PyMuPDF") +except Exception as e: + print(f"Error in LLM processing: {e}") + + +''' +STEP 4: +Saving LLM Processing of PA Form + +Saves the processed OCR content with the fields, field options, and descriptions to a JSON folder organized by the patient's name similar to how it is provided in input data. +''' + +@time_step("Step 4: Data Saving") +def save_processed_data(patient_name: str, ocr_response: OCRResponse, llm_analysis: dict): + """Save processed data in a nested folder structure matching input data organization.""" + + # Create output directory structure + output_base = "Output Data" + patient_dir = os.path.join(output_base, patient_name) + os.makedirs(patient_dir, exist_ok=True) + + # Save LLM analysis + llm_file = os.path.join(patient_dir, "Extracted_Fields.json") + with open(llm_file, 'w') as f: + json.dump(llm_analysis, f, indent=2) + + print(f"Processed data saved to {patient_dir}") + +# Extract patient name from input path and save processed data +patient_name = os.path.basename(os.path.dirname(pa_pdf_path)) +save_processed_data(patient_name, structured_response, json.loads(llm_analysis)) + + +''' +Step 5: +AI Gathering of Necessary Field Data for Entry +- model: gemini-2.5-flash-preview-05-20 +- text: + - type: application/json + - llm_analysis + - type: application/pdf + - referral_package.pdf +- response_format: json_object + +Provided an OCR derived referral package and the OCR derived fields, the AI model will be allowed to collect the information it deems necessary to fill in the fields appropriately. The AI model will be passed the extracted fields and the extracted referral package pdf. +''' + +@time_step("Step 6: OCR Field Data Collection") +def gather_field_input_data_ocr(llm_analysis: dict): + + + try: + referral_package_pdf_path = "./Input Data/Amy/referral_package.pdf" + referral_package_structured_response = process_pdf_with_ocr(referral_package_pdf_path) + + output_base = "Output Data" + patient_dir = os.path.join(output_base, "Amy") + os.makedirs(patient_dir, exist_ok=True) + + except Exception as e: + print(f"Error in OCR processing: {e}") + exit(1) + + try: + # Process all pages from the OCR response + field_data_text = process_with_llm(get_system_data_collection_prompt(), + prompt=get_data_collection_prompt(llm_analysis, referral_package_ocr=referral_package_structured_response), + response_format=PAFormAnswers, + pdf_path=referral_package_pdf_path, + model="gemini-2.5-flash-preview-05-20") + except Exception as e: + print(f"Error in LLM processing: {e}") + + field_data = json.loads(field_data_text) + + # Save the field data + patient_name = os.path.basename(os.path.dirname(pa_pdf_path)) + output_dir = os.path.join("Output Data", patient_name) + field_data_file = os.path.join(output_dir, "Completed_Form_Fields.json") + + with open(field_data_file, 'w') as f: + json.dump(field_data, f, indent=2) + + print(f"Field data saved to {field_data_file}") + return field_data + +try: + filled_field_data = gather_field_input_data_ocr(json.loads(llm_analysis)) + print("Successfully processed PA and referral packaged with AI OCR + Gemini Document Analysis") +except Exception as e: + print(f"Error in field data gathering: {e}") + + +''' +Step 7: +Filling in the fields using PyMuPDF + +Using the completed form fields gathered from the previous step, PyMuPDF will be used to fill in the fields in the PA form. +''' + +@time_step("Step 7: PyMuPDF Field Filling") +def fill_fields_with_pymupdf(completed_form_fields: dict, input_pdf_path: str): + """Fill fields in the PA form using PyMuPDF based on field identifiers.""" + + # Open the PDF document + doc = pymupdf.open(input_pdf_path) + + # Create output path + patient_name = os.path.basename(os.path.dirname(input_pdf_path)) + output_dir = os.path.join("Output Data", patient_name) + os.makedirs(output_dir, exist_ok=True) + output_pdf_path = os.path.join(output_dir, "Filled_PA_Form.pdf") + + # Create a map of field names and their corresponding answers + answer_map = { + (answer["name"], answer["page"]): answer["answer"] + for answer in completed_form_fields["answers"] + } + + # Fill the fields in the PDF + filled_count = 0 + for page_num, page in enumerate(doc, start=1): + widgets = page.widgets() + for widget in widgets: + field_name = widget.field_name + if (field_name, page_num) in answer_map: + answer = answer_map[(field_name, page_num)] + + # Skip null values - leave field blank + if answer is None or answer == "null" or answer == "": + continue + + # Handle checkbox fields differently + if widget.field_type == pymupdf.PDF_WIDGET_TYPE_CHECKBOX: + # Only check if answer explicitly indicates it should be checked + should_check = answer.lower() in ["checked", "true", "yes", "1", "on"] + widget.field_value = should_check + print(f"Checkbox '{field_name}' on page {page_num}: {'checked' if should_check else 'unchecked'} (answer: {answer})") + else: + # For non-checkbox fields, set value directly + widget.field_value = answer + # print(f"Filled field '{field_name}' on page {page_num} with value: {answer}") + + widget.update() + filled_count += 1 + + # Save the filled PDF + doc.save(output_pdf_path) + doc.close() + + print(f"Successfully filled {filled_count} fields") + print(f"Filled PDF saved to: {output_pdf_path}") + + return { + "filled_fields_count": filled_count, + "total_fields_found": len(answer_map), + "output_path": output_pdf_path + } + +# Process the field filling +try: + + # Fill the fields + filling_result = fill_fields_with_pymupdf( + completed_form_fields=filled_field_data, + input_pdf_path=pa_pdf_path + ) + + print("Successfully completed field filling with PyMuPDF") + print(filling_result) + +except Exception as e: + print(f"Error in field filling: {e}") + +# End overall timing +overall_end_time = time.time() +overall_duration = overall_end_time - overall_start_time +print(f"\n🎯 Total processing time: {overall_duration:.2f} seconds ({overall_duration/60:.2f} minutes)") \ No newline at end of file diff --git a/my-new-file.txt b/my-new-file.txt deleted file mode 100644 index e69de29b..00000000 diff --git a/prompts.py b/prompts.py new file mode 100644 index 00000000..a0b7244f --- /dev/null +++ b/prompts.py @@ -0,0 +1,177 @@ +def get_system_prompt() -> str: + return ''' + ### Identity + Your role is to accurately extract all fillable fields from OCR'd medical pre-authorization forms for automated processing. The extracted data will be used to auto-fill these forms for insured patients. + + --- + + ### Input Data + + You will receive the following: + + * **OCR Text:** Provided in markdown format, separated by page. + * **Pre-extracted Fields:** A list of known fillable fields from the PA form. + * **Optional Data:** Image coordinate data and page dimensions, to be used only for resolving ambiguity. + * **Multi-page Fields:** Some fields may span across multiple pages. + * **Guidance:** The pre-extracted fields serve as a guide to help identify present fields in the OCR text. + + --- + + ### Instructions + + Your primary goal is to provide **context for all fillable fields**, retaining their original names and identifiers from the provided list. + + 1. **Categorization:** Group fields under appropriate subheadings (e.g., "Patient Information," "Clinical Information"). + 2. **Context String:** For each field, provide a context string that includes: + * A description of the field's subheading. + * What information is needed to fill out the field. + * Any **dependencies**: If a field's presence or value depends on another field (e.g., a "Yes" answer to a prior question), clearly state this dependency within the context string, including the dependent field's identifying information. + + --- + + ### Output Specification + + Your entire output **MUST** be a single, valid JSON object. + * The return value must be a list of 'PAFormField' objects, each strictly conforming to the `PAFormField` structure below: + + # PAFormField Structure # + + ```json + { + [ + { + "name": "CB1", + "page": 1 + "field_type_string": "CheckBox", + "field_label": "Start of treatment" + "context": "" # This will be an empty string when provided + } + ] + } + ``` + # Example Output # + + { + [ + { + "name": "clinical.failure.desc", + "page": 1, + "field_type_string": "Tx", + "field_label": "If yes, please describe the failure", + "context": "Subheading: B. CLINICAL INFORMATION. Dependent on field 'Has the patient failed therapy with a preferred product?' having value 'Yes'." + } + ] + } + + ''' + +def get_ocr_analysis_prompt(ocr_text: str, pa_pdf_fields: str) -> str: + return f''' + + Based on the provided system prompt, review the following OCR markdown and field list to provide appropriate context for each field. + + # PA Form Fields # + {pa_pdf_fields} + + # OCR Text # + {ocr_text} + +''' + +def get_pdf_analysis_prompt(pa_pdf_fields: str, ocr_text: str) -> str: + return f''' + + Based on the provided system prompt, review the following OCR markdown and field list to provide appropriate context for each field. If a field seems to be missing in the OCR text, but provided in the field list, reference the provided PA PDF to help solidify your understanding of the field. Generally, the fields will not be duplicated in the PA form, so each provided field in the field list can be treated as a unique field. + + # PA Form Fields # + {pa_pdf_fields} + + # OCR Text # + {ocr_text} +''' + + +def get_system_data_collection_prompt() -> str: + return ''' + Identity: + You are an AI medical data extraction engine. Your task is to populate a structured form in JSON by extracting relevant clinical and administrative data from unstructured medical text (e.g., OCR'd referral documents). + + Inputs: + - form_schema (JSON): Defines each form field with metadata including label, type, and context. + - referral_document_text (String): The full OCR-extracted referral package text containing patient, provider, and clinical information. + + Guiding Principles: + 1. High-Confidence Inference Allowed: + You are permitted to safely infer a negative answer to clinical history questions if the condition is not mentioned anywhere in the document. For example, if a field asks whether the patient has one of several conditions, and none are mentioned anywhere, you may assume the answer is "No" (e.g., false for boolean fields or an empty list for multi-selects). + + 2. No Fabrication of Specifics: + Never fabricate concrete identifiers or details such as phone numbers, addresses, ICD codes, etc. These should only be included if explicitly mentioned. + + 3. Contextual Inference of Dependent Fields: + If a parent field logically implies a dependent field (e.g., “Request Type” is “Start of treatment” → look for "Start Date"), attempt to complete dependent fields accordingly. Otherwise, leave them null. + + Core Instructions: + 1. Populate Fields Intelligently: + For each field in form_schema, populate it using the referral text. Use logical deduction only when it’s safe and obvious (e.g., silence implies absence of condition). Do not overreach. + + 2. Improved Handling of Dependencies: + For fields with depends_on, represent them nestingly in the JSON output to reflect the dependency relationship. + + 3. Formatting Rules: + - Dates: Use "YYYY-MM-DD" format. + - Units: Combine numeric values with standardized units (e.g., "150 lbs"). + - Options & Booleans: Output must exactly match defined options. Booleans must reflect affirmations (true) or negations (false). + - Multi-select: Return as array of matched items. + - Missing or Null Fields: If a field is truly missing or ambiguous, set its value to null. Some fields may not need a value because they are dependent on another field and should not be filled because their dependency is not met. + + Output Format: + Return a single JSON object matching the PAFormAnswers structure below: + + # PAFormAnswers Structure # + + ```json + { + [ + { + "name": "CB1", + "page": 1 + "field_type_string": "CheckBox", + "field_label": "Start of treatment" + "context": "Subheading: Start of treatment/Continuation of therapy. This checkbox indicates if the request is for the start of a new treatment." + "answer:" "" # This will be an empty string when provided + } + ] + } + ``` + + # Example Output # + + ```json + { + [ + { + "name": "CB1", + "page": 1 + "field_type_string": "CheckBox", + "field_label": "Start of treatment" + "context": "Subheading: Start of treatment/Continuation of therapy. This checkbox indicates if the request is for the start of a new treatment." + "answer:" "True" + } + ] + } + ``` + +''' + +def get_data_collection_prompt(llm_analysis: str, referral_package_ocr="") -> str: + return f''' + +Based on the provided system prompt, review the form fields along with the provided referral package to identify the appropriate information needed in order to fill out the fields for this customer. If no value is present for the referral package OCR, refer to the provided referral_package PDF for values. + +# LLM Extracted Fields # + +{llm_analysis} + +# Referral Package OCR # +{referral_package_ocr} +''' \ No newline at end of file diff --git a/requirements.txt b/requirements.txt new file mode 100644 index 00000000..36683605 --- /dev/null +++ b/requirements.txt @@ -0,0 +1,34 @@ +aiohappyeyeballs==2.6.1 +aiohttp==3.12.13 +aiosignal==1.3.2 +annotated-types==0.7.0 +anyio==4.9.0 +attrs==25.3.0 +backoff==2.2.1 +certifi==2025.4.26 +charset-normalizer==3.4.2 +distro==1.9.0 +eval_type_backport==0.2.2 +frozenlist==1.7.0 +h11==0.16.0 +httpcore==1.0.9 +httpx==0.28.1 +idna==3.10 +jiter==0.10.0 +mistralai==1.8.2 +multidict==6.4.4 +openai==1.12.0 +orjson==3.10.18 +propcache==0.3.2 +pydantic==2.11.7 +pydantic_core==2.33.2 +python-dateutil==2.9.0.post0 +python-dotenv==1.0.0 +requests==2.32.4 +six==1.17.0 +sniffio==1.3.1 +tqdm==4.67.1 +typing-inspection==0.4.1 +typing_extensions==4.14.0 +urllib3==2.4.0 +yarl==1.20.1