Universal API Implementation Guide
1.1.20 - ci-build

Universal API Implementation Guide - Local Development build (v1.1.20) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

Questionnaire: External - Lucentis Questionnaire

Official URL: https://fhir.developer.gene.com/Questionnaire/questionnaireLucentis Version: 1.1.20
Active as of 2025-06-25 Computable Name: Lucentis

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

LinkIDTextCardinalityTypeDescription & Constraintsdoco
.. LucentisExample of questionnaire to be filled out when submitting enrollment bundle for product Lucentis.Questionnairehttps://fhir.developer.gene.com/Questionnaire/questionnaireLucentis#1.1.20
... applied-for-bipaBIPA Service Request Applied?0..1boolean
... applied-for-starterStarter Service Request Applied?0..1boolean
... applied-for-copayCopay Service Request Applied?0..1boolean
... applied-for-appealsAppeals Service Request Applied?0..1boolean
... applied-for-pfPatient Foundation Service Request Applied?0..1boolean
... lucentis-s-p-neededSpecialty Pharmacy Needed for Dispensing?1..1stringEnable When: applied-for-bipa =
... contact-patientDo not contact patient1..1boolean
... prescription-planIs this a Prescription plan?1..1boolean
... treatment-startedHas treatment started?1..1booleanEnable When: applied-for-copay =
... adotAnticipated Date of Treatment (Optional)0..1booleanEnable When:
... posPlace of Service1..1booleanEnable When:
... eligibility-reasonEligibility Reason1..1booleanEnable When: applied-for-pf =
... lucentis-drug-allergiesDrug Allergies?1..1stringEnable When: applied-for-pf =
... lucentis-other-drug-allergiesOther Drug Allergies?1..1stringEnable When: lucentis-drug-allergies =
... lucentis-other-prescriptionOther Medicines Prescribed1..1stringEnable When: applied-for-pf =
... shipment-optionsShipment Options1..1stringEnable When: applied-for-pf =
... ship-toShip To1..1stringEnable When: applied-for-pf =
... site-of-treatment-2Third-party Site of Treatment1..1reference

doco Documentation for this format