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new_referral_request_payload.json
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new_referral_request_payload.json
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{
"request_id":"0e1d5e34-63d7-4bb2-8e22-9376943ab56f",
"agency":{
"host":"https://csi.uat.alayacare.com",
"name":"Gem City Home Care",
"timezone":"America/Denver",
"branch_id":1050,
"alayamarket_org_id":"91c79089-a3ca-4cca-acf4-52fc1f1302c6"
},
"client":{
"id":1094,
"zip":"45458",
"city":"Dayton",
"email":"janesmithers@example.com",
"state":"OH",
"gender":"F",
"address":"1700 Lyons Road",
"country":"US",
"birthday":"1998-05-07",
"timezone":"America/Denver",
"last_name":"Smithers",
"first_name":"Jane",
"phone_main":"555-123-4567"
},
"files":[
{
"file_name":"physician_order_form.pdf",
"file_value":"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"
}
],
"form_data":{
"form_id":14,
"form_name":"CSI New Referral Request",
"form_schema_id":"89a3b8ba-0009-464b-a2a0-06c49cbcd745",
"created_at":"2023-05-23T15:27:14+00:00",
"created_by":"Administrator",
"fields":[
{
"type":null,
"field_id":311,
"field_type":"medical_history",
"field_label":"ICD-10 Diagnosis",
"field_value":[
{
"values":[
{
"field_key":"diagnosis",
"field_value":"A000=Cholera due to Vibrio cholerae 01, biovar cholerae"
},
{
"field_key":"treatment",
"field_value":"None"
},
{
"field_key":"start_date",
"field_value":"2023-05-11"
},
{
"field_key":"end_date",
"field_value":null
},
{
"field_key":"notes",
"field_value":"Condition is ongoing"
}
]
},
{
"values":[
{
"field_key":"diagnosis",
"field_value":"E0800=Diabetes mellitus due to underlying condition with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC)"
},
{
"field_key":"treatment",
"field_value":null
},
{
"field_key":"start_date",
"field_value":null
},
{
"field_key":"end_date",
"field_value":null
},
{
"field_key":"notes",
"field_value":null
}
]
}
]
},
{
"type":null,
"field_id":313,
"field_type":"text",
"field_label":"Physician first name",
"field_value":"Jeremy"
},
{
"type":null,
"field_id":316,
"field_type":"text",
"field_label":"Physician last name",
"field_value":"Smith"
},
{
"type":null,
"field_id":317,
"field_type":"number",
"field_label":"Physician NPI",
"field_value":12234567
},
{
"type":null,
"field_id":318,
"field_type":"text",
"field_label":"Physician phone number",
"field_value":"555-444-1111"
},
{
"type":null,
"field_id":319,
"field_type":"picture",
"field_label":"Physician order (PDF)",
"field_value":"https://csi.uat.alayacare.com/api/v1/files/form/submissions/1094/14/5f2bfe25-d273-431d-8d0d-c46de8448069/1pixel.png"
},
{
"type":null,
"field_id":320,
"field_type":"list",
"field_label":"Service Requested",
"field_value":{
"option":{
"name":"PT",
"value":"PT"
}
}
},
{
"type":null,
"field_id":321,
"field_type":"date",
"field_label":"Service start date",
"field_value":"2023-05-31"
},
{
"type":null,
"field_id":322,
"field_type":"date",
"field_label":"Service end date",
"field_value":"2023-07-31"
},
{
"type":null,
"field_id":323,
"field_type":"text",
"field_label":"Service frequency",
"field_value":"Twice a week"
},
{
"type":null,
"field_id":324,
"field_type":"text",
"field_label":"Service authorizations",
"field_value":"10 visits total"
},
{
"type":null,
"field_id":325,
"field_type":"text",
"field_label":"Primary insurance name",
"field_value":"ABC Insurers"
},
{
"type":null,
"field_id":326,
"field_type":"text",
"field_label":"Primary insurance phone number",
"field_value":"555-111-1111"
},
{
"type":null,
"field_id":327,
"field_type":"text",
"field_label":"Primary insurance group",
"field_value":"AB Insurers grop"
},
{
"type":null,
"field_id":328,
"field_type":"text",
"field_label":"Primary subscriber ID",
"field_value":"1111111"
},
{
"type":null,
"field_id":329,
"field_type":"text",
"field_label":"Primary subscriber full name",
"field_value":"William Smith"
},
{
"type":null,
"field_id":330,
"field_type":"date",
"field_label":"Primary subscriber birthday",
"field_value":"2003-05-23"
},
{
"type":null,
"field_id":437,
"field_type":"checkbox",
"field_label":"Secondary insurance needed?",
"field_value":true
},
{
"type":null,
"field_id":332,
"field_type":"text",
"field_label":"Secondary insurance name",
"field_value":"XYZ Insurers"
},
{
"type":null,
"field_id":333,
"field_type":"text",
"field_label":"Secondary insurance phone number",
"field_value":"555-222-2222"
},
{
"type":null,
"field_id":334,
"field_type":"text",
"field_label":"Secondary insurance group",
"field_value":"XYZ Insurers group"
},
{
"type":null,
"field_id":335,
"field_type":"text",
"field_label":"Secondary subscriber ID",
"field_value":"2222222"
},
{
"type":null,
"field_id":336,
"field_type":"text",
"field_label":"Secondary subscriber full name",
"field_value":"Amy Smith"
},
{
"type":null,
"field_id":337,
"field_type":"date",
"field_label":"Secondary subscriber birthday",
"field_value":"2004-05-13"
},
{
"type":"text",
"field_id":338,
"field_type":"demographics",
"field_label":"Phone (Main)",
"field_value":"555-123-4567"
},
{
"type":"text",
"field_id":339,
"field_type":"demographics",
"field_label":"Email",
"field_value":"janesmithers@example.com"
},
{
"type":"bday",
"field_id":342,
"field_type":"demographics",
"field_label":"Date of Birth",
"field_value":"1998-05-07"
},
{
"type":"list",
"field_id":343,
"field_type":"demographics",
"field_label":"Gender",
"field_value":{
"option":{
"name":"F",
"value":"F"
}
}
},
{
"type":"text",
"field_id":344,
"field_type":"demographics",
"field_label":"Address",
"field_value":"1700 Lyons Road"
},
{
"type":"text",
"field_id":346,
"field_type":"demographics",
"field_label":"City",
"field_value":"Dayton"
},
{
"type":"list",
"field_id":347,
"field_type":"demographics",
"field_label":"State",
"field_value":{
"option":{
"name":"OH",
"value":"OH"
}
}
},
{
"type":"text",
"field_id":348,
"field_type":"demographics",
"field_label":"Zip Code",
"field_value":"45458"
}
]
}
}