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
        ui:order:
          - "street_address"
          - "street_address_2"
          - "city"
          - "region"
          - "postal_code"
          - "country"
          - "*"
        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
              ui:order:
                - "street_address"
                - "street_address_2"
                - "city"
                - "region"
                - "postal_code"
                - "country"
                - "*"
              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
