{
   "ui:options": {
      "title": "Requisition"
   },
   "ui:submitButtonOptions": {
      "norender": true
   },
   "ui:hideItemTitle": true,
   "ui:tabbed": true,
   "ui:tabs": [
      "testing-information",
      "patient-information",
      "billing-information",
      "specimen-information"
   ],
   "ui:order": [
      "rerequisition",
      "campaign_code",
      "clinicians",
      "preferred_report_delivery",
      "product_type",
      "product_subtype",
      "product_ids",
      "relative",
      "fvt_variants",
      "*"
   ],
   "rerequisition": {
      "ui:tab": "testing-information",
      "ui:widget": "hidden"
   },
   "campaign_code": {
      "ui:tab": "testing-information",
      "ui:widget": "hidden"
   },
   "clinicians": {
      "ui:tab": "testing-information",
      "ui:field": "typeAheadField",
      "ui:typeahead": {
         "choices": [
            {
               "label": "NOT A CLINICIAN-CLINIC 1-123456789",
               "id": "CN-usd-222222"
            },
            {
               "label": "ALSO NOT A CLINICIAN-CLINIC 2-012345678",
               "id": "CN-xyz-111111"
            }
         ]
      }
   },
   "preferred_report_delivery": {
      "ui:tab": "testing-information",
      "ui:column": "col-sm-4",
      "ui:widget": "hidden"
   },
   "product_type": {
      "ui:widget": "radio",
      "ui:tab": "testing-information"
   },
   "product_subtype": {
      "ui:widget": "radio",
      "ui:tab": "testing-information"
   },
   "product_ids": {
      "ui:widget": "checkboxes",
      "ui:tab": "testing-information"
   },
   "relative": {
      "ui:tab": "testing-information",
      "ui:row": true,
      "relationship": {
         "ui:tab": "testing-information",
         "ui:column": "col-sm-12"
      },
      "requisition": {
         "ui:tab": "testing-information",
         "ui:column": "col-sm-6"
      },
      "dob": {
         "ui:tab": "testing-information",
         "ui:column": "col-sm-6"
      }
   },
   "fvt_variants": {
      "ui:widget": "checkboxes",
      "ui:tab": "testing-information"
   },
   "pre_test_counseling": {
      "ui:tab": "testing-information",
      "ui:column": "col-sm-6",
      "ui:widget": "hidden"
   },
   "post_test_counseling": {
      "ui:tab": "testing-information",
      "ui:column": "col-sm-6",
      "ui:widget": "radio",
      "ui:enumDisabled": [
         "VUS_OR_POSITIVE_RESULT"
      ]
   },
   "indications": {
      "ui:tab": "testing-information"
   },
   "additional_files": {
      "ui:tab": "testing-information",
      "ui:widget": "FileWidget"
   },
   "consents_granted": {
      "ui:hideItemTitle": true,
      "ui:widget": "CheckboxesDetailedWidget",
      "ui:checkboxLabel": "I acknowledge my consent",
      "ui:tab": "testing-information"
   },
   "subject": {
      "ui:tab": "patient-information",
      "ui:order": [
         "name",
         "demographics",
         "ancestry",
         "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"
            ]
         },
         "gender": {
            "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
         }
      },
      "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",
                  "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"
               }
            },
            "email": {
               "ui:column": "col-sm-6",
               "ui:options": {
                  "inputType": "email"
               }
            },
            "phone": {
               "ui:column": "col-sm-6",
               "ui:widget": "PhoneNumberWidget"
            },
            "fax": {
               "ui:widget": "hidden"
            }
         }
      }
   },
   "remote_mrn": {
      "ui:tab": "patient-information"
   },
   "guardian": {
      "ui:tab": "patient-information",
      "ui:widget": "hidden",
      "name": {
         "ui:hideItemTitle": true,
         "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"
         }
      }
   },
   "billing": {
      "ui:tab": "billing-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 Information",
         "items": {
            "ui:order": [
               "company",
               "phone",
               "member_id",
               "group_number",
               "prior_auth_number",
               "relationship_to_policyholder",
               "relationship_to_policyholder_other",
               "policyholder",
               "epsdt_coverage",
               "*"
            ],
            "ui:hideItemTitle": true,
            "ui:row": true,
            "ui:orderable": false,
            "company": {
               "ui:column": "col-sm-6",
               "ui:field": "typeAheadField",
               "ui:typeahead": {
                  "allowNew": true,
                  "multiple": false,
                  "choices": [
                     {
                        "id": "BCBS Texas",
                        "label": "BCBS Texas"
                     },
                     {
                        "id": "BCBS Texas - HMO",
                        "label": "BCBS Texas - HMO"
                     },
                     {
                        "id": "BCBS Texas - POS",
                        "label": "BCBS Texas - POS"
                     },
                     {
                        "id": "BCBS TEXAS - PPO",
                        "label": "BCBS TEXAS - PPO"
                     },
                     {
                        "id": "Cigna Healthcare",
                        "label": "Cigna Healthcare"
                     },
                     {
                        "id": "Cigna Healthcare - HMO",
                        "label": "Cigna Healthcare - HMO"
                     },
                     {
                        "id": "Cigna Healthcare - POS",
                        "label": "Cigna Healthcare - POS"
                     },
                     {
                        "id": "Cigna Healthcare - PPO",
                        "label": "Cigna Healthcare - PPO"
                     },
                     {
                        "id": "Healthy Blue Kansas",
                        "label": "Healthy Blue Kansas"
                     },
                     {
                        "id": "Humana",
                        "label": "Humana"
                     },
                     {
                        "id": "Humana - HMO",
                        "label": "Humana - HMO"
                     },
                     {
                        "id": "Humana - POS",
                        "label": "Humana - POS"
                     },
                     {
                        "id": "Humana - PPO",
                        "label": "Humana - PPO"
                     },
                     {
                        "id": "Medicare California - Part B (Northern)",
                        "label": "Medicare California - Part B (Northern)"
                     },
                     {
                        "id": "Medicaid California (Medi-Cal)",
                        "label": "Medicaid California (Medi-Cal)"
                     },
                     {
                        "id": "Medicaid Hawaii",
                        "label": "Medicaid Hawaii"
                     },
                     {
                        "id": "Medicaid Kansas",
                        "label": "Medicaid Kansas"
                     },
                     {
                        "id": "Medicaid Kentucky",
                        "label": "Medicaid Kentucky"
                     },
                     {
                        "id": "Medicaid Louisiana",
                        "label": "Medicaid Louisiana"
                     },
                     {
                        "id": "Medicaid Maine",
                        "label": "Medicaid Maine"
                     },
                     {
                        "id": "Medicaid North Carolina",
                        "label": "Medicaid North Carolina"
                     },
                     {
                        "id": "Medicaid Nebraska",
                        "label": "Medicaid Nebraska"
                     },
                     {
                        "id": "Medicaid New Hampshire",
                        "label": "Medicaid New Hampshire"
                     },
                     {
                        "id": "Medicaid New Jersey",
                        "label": "Medicaid New Jersey"
                     },
                     {
                        "id": "Medicaid Washington",
                        "label": "Medicaid Washington"
                     },
                     {
                        "id": "Tricare East Region",
                        "label": "Tricare East Region"
                     }
                  ]
               }
            },
            "phone": {
               "ui:column": "col-sm-6",
               "ui:widget": "PhoneNumberWidget"
            },
            "member_id": {
               "ui:column": "col-sm-6"
            },
            "group_number": {
               "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"
            },
            "epsdt_coverage": {
               "ui:classNames": "epsdt-form-fieldset",
               "ui:row": true,
               "medicaid_plan": {
                  "ui:column": "col-sm-6"
               },
               "medicaid_number": {
                  "ui:column": "col-sm-6"
               },
               "attestations": {
                  "ui:widget": "checkboxes"
               }
            },
            "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."
                        },
                        "postal_code": {
                           "ui:column": "col-sm-6"
                        },
                        "country": {
                           "ui:widget": "hidden"
                        }
                     }
                  }
               }
            }
         }
      }
   },
   "sample_request": {
      "ui:tab": "specimen-information",
      "ui:hideItemTitle": true,
      "ui:row": true,
      "ui:order": [
         "type",
         "send_kit",
         "*"
      ],
      "send_kit": {
         "ui:widget": "radio",
         "ui:title": "Send Kit to Patient",
         "ui:column": "col-12"
      },
      "send_kit_address": {
         "ui:widget": "hidden"
      },
      "type": {
         "ui:widget": "select",
         "ui:column": "col-sm-4",
         "ui:enumDisabled": [
            "DNA",
            "DATA",
            "SALIVA",
            "WATER",
            "POSITIVE_CONTROL"
         ]
      }
   }
}