{ "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:readonly": true, "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" }, "optional_consents": { "ui:tab": "testing-information", "ui:column": "col-12", "ui:field": "CheckboxGroupWidget", "ui:optional": true, "hie_opt_in": { "ui:title": "Consent to Health Information Exchange", "ui:checkboxLabel": "Check this box if your patient wishes to participate in Health Information Exchange. This will improve the accuracy of our analyses for your patient.", "ui:link": "/consents?consents=HIE_ACCESS__TREATMENT" }, "research_contact_opt_in": { "ui:title": "Consent to Research", "ui:checkboxLabel": "Check this box if the patient consents to being contacted by MyOme regarding research studies or clinical trial opportunities.", "ui:link": "/consents?consents=CONTACT__RESEARCH_OPPORTUNITIES" }, "transactional_sms_opt_in": { "ui:title": "Consent to SMS and Phone Communication for Order Updates", "ui:checkboxLabel": "Check this box if the patient consents to receiving phone calls or text messages regarding updates related to the current testing order.", "ui:link": "/consents?consents=CONTACT__TRANSACTIONAL_SMS" }, "marketing_opt_in": { "ui:title": "Consent to Marketing Contact", "ui:checkboxLabel": "Check this box if the patient consents to receiving marketing or promotional communications from MyOme via email, phone call, or text message.", "ui:link": "/consents?consents=CONTACT__MARKETING" } }, "consents_granted": { "ui:hideItemTitle": true, "ui:widget": "CheckboxesDetailedWidget", "ui:checkboxLabel": "I acknowledge my consent", "ui:link": "/consents?consents=GENERAL", "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. For US addresses: 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", "ui:description": "Select insurance company from the drop-down list. If you don't see the payor you're looking for, type in the full name and choose the new selection.", "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": "AARP Medicare Complete (Medicare Advantage)", "label": "AARP Medicare Complete (Medicare Advantage)" }, { "id": "Aetna - CVS Health", "label": "Aetna - CVS Health" }, { "id": "Aetna Affordable Health Choices", "label": "Aetna Affordable Health Choices" }, { "id": "Aetna Better Health of California", "label": "Aetna Better Health of California" }, { "id": "Aetna Better Health of Louisiana", "label": "Aetna Better Health of Louisiana" }, { "id": "Aetna Better Health of New Jersey", "label": "Aetna Better Health of New Jersey" }, { "id": "Aetna Medicare Advantage", "label": "Aetna Medicare Advantage" }, { "id": "Amerigroup New Jersey", "label": "Amerigroup New Jersey" }, { "id": "Amerigroup New Mexico", "label": "Amerigroup New Mexico" }, { "id": "Amerigroup Texas", "label": "Amerigroup Texas" }, { "id": "Amerigroup/Wellpoint Arizona", "label": "Amerigroup/Wellpoint Arizona" }, { "id": "Amerigroup/Wellpoint New Jersey", "label": "Amerigroup/Wellpoint New Jersey" }, { "id": "Anthem BCBS Medi-Cal", "label": "Anthem BCBS Medi-Cal" }, { "id": "BCBS Alabama", "label": "BCBS Alabama" }, { "id": "BCBS Arizona", "label": "BCBS Arizona" }, { "id": "BCBS Arkansas", "label": "BCBS Arkansas" }, { "id": "BCBS Florida", "label": "BCBS Florida" }, { "id": "BCBS Hawaii", "label": "BCBS Hawaii" }, { "id": "BCBS Illinois", "label": "BCBS Illinois" }, { "id": "BCBS Louisiana", "label": "BCBS Louisiana" }, { "id": "BCBS New Mexico", "label": "BCBS New Mexico" }, { "id": "BCBS Texas", "label": "BCBS Texas" }, { "id": "Cigna Healthcare", "label": "Cigna Healthcare" }, { "id": "Cigna Healthcare for Seniors (AZ Medicare)", "label": "Cigna Healthcare for Seniors (AZ Medicare)" }, { "id": "Cigna Medicare Advantage", "label": "Cigna Medicare Advantage" }, { "id": "EmblemHealth Plan, Inc.", "label": "EmblemHealth Plan, Inc." }, { "id": "Florida Health Care Plans", "label": "Florida Health Care Plans" }, { "id": "Health Net of California (Medi-Cal)", "label": "Health Net of California (Medi-Cal)" }, { "id": "Health Net of California (Medicare Advantage)", "label": "Health Net of California (Medicare Advantage)" }, { "id": "Healthy Blue (KanCare)", "label": "Healthy Blue (KanCare)" }, { "id": "Horizon BCBS New Jersey", "label": "Horizon BCBS New Jersey" }, { "id": "Horizon Health New Jersey (MCO)", "label": "Horizon Health New Jersey (MCO)" }, { "id": "Horizon New Jersey Health (Medicare Advantage)", "label": "Horizon New Jersey Health (Medicare Advantage)" }, { "id": "Humana", "label": "Humana" }, { "id": "Humana (Medicare Advantage)", "label": "Humana (Medicare Advantage)" }, { "id": "Inland Empire Health Plan", "label": "Inland Empire Health Plan" }, { "id": "Medicaid Alabama", "label": "Medicaid Alabama" }, { "id": "Medicaid Alaska", "label": "Medicaid Alaska" }, { "id": "Medicaid Arizona", "label": "Medicaid Arizona" }, { "id": "Medicaid Arkansas", "label": "Medicaid Arkansas" }, { "id": "Medicaid California (Medi-Cal)", "label": "Medicaid California (Medi-Cal)" }, { "id": "Medicaid Colorado", "label": "Medicaid Colorado" }, { "id": "Medicaid Connecticut", "label": "Medicaid Connecticut" }, { "id": "Medicaid Delaware", "label": "Medicaid Delaware" }, { "id": "Medicaid District Of Colombia", "label": "Medicaid District Of Colombia" }, { "id": "Medicaid Florida", "label": "Medicaid Florida" }, { "id": "Medicaid Georgia", "label": "Medicaid Georgia" }, { "id": "Medicaid Hawaii", "label": "Medicaid Hawaii" }, { "id": "Medicaid Idaho", "label": "Medicaid Idaho" }, { "id": "Medicaid Illinois", "label": "Medicaid Illinois" }, { "id": "Medicaid Indiana", "label": "Medicaid Indiana" }, { "id": "Medicaid Iowa", "label": "Medicaid Iowa" }, { "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 Maryland", "label": "Medicaid Maryland" }, { "id": "Medicaid Massachusetts", "label": "Medicaid Massachusetts" }, { "id": "Medicaid Michigan", "label": "Medicaid Michigan" }, { "id": "Medicaid Minnesota", "label": "Medicaid Minnesota" }, { "id": "Medicaid Mississippi", "label": "Medicaid Mississippi" }, { "id": "Medicaid Missouri (Healthnet)", "label": "Medicaid Missouri (Healthnet)" }, { "id": "Medicaid Montana", "label": "Medicaid Montana" }, { "id": "Medicaid Nebraska", "label": "Medicaid Nebraska" }, { "id": "Medicaid Nevada", "label": "Medicaid Nevada" }, { "id": "Medicaid New Hampshire", "label": "Medicaid New Hampshire" }, { "id": "Medicaid New Jersey", "label": "Medicaid New Jersey" }, { "id": "Medicaid New Mexico", "label": "Medicaid New Mexico" }, { "id": "Medicaid New York", "label": "Medicaid New York" }, { "id": "Medicaid North Carolina", "label": "Medicaid North Carolina" }, { "id": "Medicaid North Dakota", "label": "Medicaid North Dakota" }, { "id": "Medicaid Ohio", "label": "Medicaid Ohio" }, { "id": "Medicaid Oklahoma", "label": "Medicaid Oklahoma" }, { "id": "Medicaid Oregon", "label": "Medicaid Oregon" }, { "id": "Medicaid Pennsylvania", "label": "Medicaid Pennsylvania" }, { "id": "Medicaid Rhode Island", "label": "Medicaid Rhode Island" }, { "id": "Medicaid South Carolina", "label": "Medicaid South Carolina" }, { "id": "Medicaid South Dakota", "label": "Medicaid South Dakota" }, { "id": "Medicaid Tennessee (Tenncare)", "label": "Medicaid Tennessee (Tenncare)" }, { "id": "Medicaid Texas", "label": "Medicaid Texas" }, { "id": "Medicaid Utah", "label": "Medicaid Utah" }, { "id": "Medicaid Vermont", "label": "Medicaid Vermont" }, { "id": "Medicaid Virgin Islands", "label": "Medicaid Virgin Islands" }, { "id": "Medicaid Virginia", "label": "Medicaid Virginia" }, { "id": "Medicaid Washington", "label": "Medicaid Washington" }, { "id": "Medicaid West Virginia", "label": "Medicaid West Virginia" }, { "id": "Medicaid Wisconsin", "label": "Medicaid Wisconsin" }, { "id": "Medicaid Wyoming", "label": "Medicaid Wyoming" }, { "id": "Medicare California - Part B (Northern)", "label": "Medicare California - Part B (Northern)" }, { "id": "Medicare Railroad Retirement", "label": "Medicare Railroad Retirement" }, { "id": "Texas Childrens Health Plan", "label": "Texas Childrens Health Plan" }, { "id": "Tricare East Region", "label": "Tricare East Region" }, { "id": "TriCare for Life", "label": "TriCare for Life" }, { "id": "UMR", "label": "UMR" }, { "id": "United Healthcare", "label": "United Healthcare" }, { "id": "United Healthcare (Medicare Advantage)", "label": "United Healthcare (Medicare Advantage)" }, { "id": "Wellcare by Allwell (Medicare Advantage)", "label": "Wellcare by Allwell (Medicare Advantage)" }, { "id": "WellPoint", "label": "WellPoint" } ] } }, "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" ] } } }