"ui:options":
  title: "Requisition"
"ui:submitButtonOptions":
  norender: true
"ui:hideItemTitle": true
"ui:tabbed": true
"ui:tabs":
  - "specimen-information"
  - "patient-information"
  - "provider-information"
  - "order-information"
sample_request:
  "ui:tab": "specimen-information"
  "ui:row": true
  send_kit:
    "ui:widget": "radio"
    "ui:column": "col-sm-2"
  send_kit_address:
    "ui:widget": "hidden"
  type:
    "ui:widget": "select"
    "ui:column": "col-sm-4"
    "ui:enumDisabled":
      - DATA
      - WATER
      - POSITIVE_CONTROL
subject:
  "ui:tab": "patient-information"
  name:
    "ui:order":
      - "first"
      - "middle"
      - "last"
      - "*"
    "ui:row": true
    first:
      "ui:column": "col-sm-5"
    middle:
      "ui:column": "col-sm-2"
    last:
      "ui:column": "col-sm-5"
    credentials:
      "ui:widget": "hidden"
  demographics:
    "ui:row": true
    dob:
      "ui:column": "col-sm-6"
    sex:
      "ui:column": "col-sm-6"
      "ui:enumDisabled":
        - OTHER
    gender:
      "ui:widget": "hidden"
  contact_info:
    items:
      "ui:row": true
      "ui:orderable": false
      "ui:copyable": false
      "ui:addRemove": false
      "ui:hideItemTitle": true
      address:
        "ui:row": true
        street_address:
          "ui:column": "col-12"
        city:
          "ui:column": "col-sm-6"
        region:
          "ui:column": "col-sm-6"
        postal_code:
          "ui:column": "col-sm-6"
        country:
          # "ui:column": "col-sm-6"
          "ui:widget": "hidden"
      email:
        "ui:column": "col-sm-6"
        "ui:options":
          inputType: "email"
      phone:
        "ui:column": "col-sm-6"
        "ui:widget": "PhoneNumberWidget"
      fax:
        "ui:widget": "hidden"
  ancestry:
    "ui:field": "typeAheadField"
    "ui:typeahead":
      choices:
        - id: WHITE
          label: White
        - id: HISPANIC
          label: Hispanic
        - id: BLACK_AFRICAN_AMERICAN
          label: Black/African American
        - id: EAST_ASIAN
          label: East Asian
        - id: SOUTH_ASIAN
          label: South Asian
        - id: ASHKENAZI_JEWISH
          label: Ashkenazi Jewish
        - id: OTHER
          label: Other
      allowNew: false
guardian:
  "ui:tab": "patient-information"
  "ui:hideItemTitle": true
  name:
    "ui:title": Parent or Guardian
    "ui:order":
      - "first"
      - "middle"
      - "last"
      - "*"
    "ui:row": true
    first:
      "ui:column": "col-sm-5"
    middle:
      "ui:column": "col-sm-2"
    last:
      "ui:column": "col-sm-5"
    credentials:
      "ui:widget": "hidden"
remote_mrn:
  "ui:tab": "patient-information"
billing:
  "ui:tab": "patient-information"
  "ui:hideItemTitle": true
  "ui:widget": "radio"
  billing_type:
    "ui:widget": "hidden"
  billing_code:
    "ui:widget": "hidden"
  stripe_paymentintent_id:
    "ui:widget": "hidden"
  promo_code:
    "ui:widget": "hidden"
  self_pay:
    "ui:widget": "hidden"
  insurance:
    "ui:title": Insurance Billing (Commercial, Medicaid, Medicare)
    items:
      "ui:order":
        - company
        - phone
        - member_id
        - prior_auth_number
        - relationship_to_policyholder
        - relationship_to_policyholder_other
        - policyholder
        - "*"
      "ui:hideItemTitle": true
      "ui:row": true
      "ui:orderable": false
      company:
        "ui:column": "col-sm-6"
      phone:
        "ui:column": "col-sm-6"
        "ui:widget": "PhoneNumberWidget"
      member_id:
        "ui:column": "col-sm-6"
      prior_auth_number:
        "ui:column": "col-sm-6"
      relationship_to_policyholder:
        "ui:column": "col-sm-6"
      relationship_to_policyholder_other:
        "ui:column": "col-sm-6"
      policyholder:
        "ui:order":
          - "name"
          - "demographics"
          - "contact_info"
          - "*"
        name:
          "ui:order":
            - "first"
            - "middle"
            - "last"
            - "*"
          "ui:row": true
          first:
            "ui:column": "col-sm-5"
          middle:
            "ui:column": "col-sm-2"
          last:
            "ui:column": "col-sm-5"
          credentials:
            "ui:widget": "hidden"
        demographics:
          "ui:row": true
          dob:
            "ui:column": "col-sm-6"
          sex:
            "ui:column": "col-sm-6"
            "ui:enumDisabled":
              - OTHER
        contact_info:
          items:
            "ui:order":
              - "prefill_button"
              - "address"
              - "*"
            "ui:row": true
            "ui:orderable": false
            "ui:copyable": false
            "ui:addRemove": false
            "ui:hideItemTitle": true
            prefill_button:
              "ui:widget": "PrefillButton"
              "ui:hideItemTitle": true
              "ui:options":
                buttonText: "Prefill from Patient Information"
                sourceBaseKey: "root.subject.contact_info.0"
                listOfValues:
                  - "address.street_address"
                  - "address.city"
                  - "address.region"
                  - "address.postal_code"
                  - "address.country"
            address:
              "ui:row": true
              street_address:
                "ui:column": "col-12"
                "ui:widget": "AddressWidget"
              city:
                "ui:column": "col-sm-6"
              region:
                "ui:column": "col-sm-6"
                "ui:description": "State, province, or other country-specific region. New York is not available at this time."
              postal_code:
                "ui:column": "col-sm-6"
              country:
                "ui:widget": "hidden"
consents_granted: 
  "ui:widget": "checkboxes"
  "ui:tab": "order-information"
clinicians:
  "ui:tab": "provider-information"
  "ui:field": "typeAheadField"
  "ui:typeahead":
    choices:
      - label: "NOT A CLINICIAN-CLINIC 1-123456789"
        id: "123456789-CLdev1"
      - label: "ALSO NOT A CLINICIAN-CLINIC 2-012345678"
        id: "012345678-CLdev2"
preferred_report_delivery:
  "ui:tab": "provider-information"
  "ui:column": "col-sm-4"
product_ids:
  "ui:widget": "checkboxes"
  "ui:inline": true
  "ui:tab": "order-information"
pre_test_counseling:
  "ui:tab": "order-information"
  "ui:column": "col-sm-6"
  "ui:widget": "radio"
post_test_counseling:
  "ui:tab": "order-information"
  "ui:column": "col-sm-6"
  "ui:widget": "radio"
  "ui:enumDisabled":
    - VUS_OR_POSITIVE_RESULT
indications:
  "ui:tab": "order-information"
trf:
  "ui:widget": "file"
  "ui:tab": "order-information"
additional_files:
  "ui:tab": "order-information"
