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1
__skip__Display prioritySection keySection NameLabelPlaceholderOptional LabelDescriptionSale PSSProvider
Case State to enable
Field's display priority
Field Typefield_keyInlineDefault ValueValuesHTML ContentRelated FieldsCONDITIONAL VALUEJSONROLE CONFIGINCLUDE ONLYEXCLUDE ONLY
CASE STATE PERMS
ENVHTML5 LabelError Labeladditional_component_props JSONcustomFormIOfield
2
4compliance_verificationComplianceTalking pointHIDEVIEWHIDE0contentcompliance_talking_point
<p class='rf-alert rf-alert-info'>All compliance questions must be completed in order to transfer the patient to the provider. Please ask all questions in the compliance section below.</p>
3
4compliance_verificationComplianceDo you consent to receive medical treatment?EDITRESHIDE1radio
compliance_verification_verified_consent_to_treat_41589
Yes;No
<span class='formio-main-label'>Do you consent to receive medical treatment? &nbsp; <span class='formio-required-dot'>*</span><div class='formio-optional-label'></div>
{
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}
}
],
"trigger": {
"type": "javascript",
"javascript": "result = moment(window.currentCase.created_at).isAfter('2024-02-19')"
}
}
]
}
4
4compliance_verificationCompliance
Do you agree to speak with a licensed telehealth provider today?
EDITRESHIDE0radiocompliance_verification_agree_to_speakYes;No{
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}
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"trigger": {
"type": "javascript",
"javascript": "result = moment(window.currentCase.metadata.case_parent_created_at).isBefore('2025-05-28')"
}
}
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}
5
4compliance_verificationComplianceDo you give permission to have a video consultation with a medical healthcare provider?EDITRESHIDE1radiocompliance_verification_video_consultationYes;No{
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],
"trigger": {
"type": "javascript",
"javascript": "result = !window?.currentCase?.case_data?.rawjson?.compliance_verification_video_consultation"
}
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],
"description": "Only apply when phone number was provided"
}
6
4compliance_verificationComplianceTo confirm your consent, please state your full name, date of birth and current address?EDITRESHIDE1radiocompliance_verification_verified_telehealth_providerYes;No{
"append_logic": [
{
"name": "APPEND_LOGIC-hideRes20JSep",
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{
"name": "APPEND_LOGIC-hideRes20JSep",
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}
}
],
"trigger": {
"type": "javascript",
"javascript": "result = moment(window.currentCase.metadata.case_parent_created_at).isBefore('2025-05-28')"
}
}
]
}
7
4compliance_verificationComplianceIf we get disconnected, may we call you back at this number?EDITRESHIDE2radiocompliance_verification_call_backYes;No{
"append_logic": [
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"name": "APPEND_LOGIC-hideRes20JSep",
"actions": [
{
"name": "APPEND_LOGIC-hideRes20JSep",
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"state": true,
"property": {
"type": "boolean",
"label": "Hidden",
"value": "hidden"
}
}
],
"trigger": {
"type": "javascript",
"javascript": "result = moment(window.currentCase.metadata.case_parent_created_at).isBefore('2025-05-28')"
}
}
]
}
8
4compliance_verificationComplianceAre you able to make your own medical decisions or does someone else make them for you?EDITRESHIDE3radio
compliance_verification_verified_medical_decision_41589
Yes;No{
"append_logic": [
{
"name": "APPEND_LOGIC-hideRes20JSep",
"actions": [
{
"name": "APPEND_LOGIC-hideRes20JSep",
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"property": {
"type": "boolean",
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"value": "hidden"
}
}
],
"trigger": {
"type": "javascript",
"javascript": "result = moment(window.currentCase.created_at).isBefore('2022-10-05')"
}
}
]
}
9
4compliance_verificationComplianceDo you agree to having a telehealth provider bill your insurance?EDITRESHIDE4radio
compliance_verification_verified_consent_to_bill_41589
Yes;No{
"append_logic": [
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"actions": [
{
"name": "APPEND_LOGIC-hideRes20JSep",
"type": "property",
"state": true,
"property": {
"type": "boolean",
"label": "Hidden",
"value": "hidden"
}
}
],
"trigger": {
"type": "javascript",
"javascript": "result = moment(window.currentCase.created_at).isBefore('2022-10-05')|| (window.currentCase.metadata.mss_parent_id=='e1d06753-9e11-46a6-abfe-fc64554fef06')"
}
}
]
}
10
4compliance_verificationComplianceAre you currently in a hospice, hospital, nursing home, or any other type of care facility?EDITRESHIDE5radiocompliance_verification_verified_currently_hospiceYes;No{
"append_logic": [
{
"name": "APPEND_LOGIC-hideRes20JSep",
"actions": [
{
"name": "APPEND_LOGIC-hideRes20JSep",
"type": "property",
"state": true,
"property": {
"type": "boolean",
"label": "Hidden",
"value": "hidden"
}
}
],
"trigger": {
"type": "javascript",
"javascript": "result = moment(window.currentCase.created_at).isBefore('2024-03-01') || (window.currentCase.case_data.rawjson.hide_field_by_MG == true) || (window.currentCase.metadata.mss_parent_id=='e1d06753-9e11-46a6-abfe-fc64554fef06')"
}
}
]
}
11
4compliance_verificationComplianceHave you ever had a genetic screening?EDITRESHIDE6radio
compliance_verification_verified_patient_previously_taken_genetic_test_41589
Yes;No{
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"name": "APPEND_LOGIC-hideRes20JSep",
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}
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"trigger": {
"type": "javascript",
"javascript": "result = moment(window.currentCase.created_at).isBefore('2024-03-01') || (window.currentCase.case_data.rawjson.hide_field_by_MG == true) || (window.currentCase.metadata.mss_parent_id==undefined)"
}
}
]
}
12
4compliance_verificationComplianceHas anyone offered you any money or an incentive for you to take a genetic test?EDITRESHIDE7radiocompliance_verification_verified_moneyYes;No{
"append_logic": [
{
"name": "APPEND_LOGIC-hideRes20JSep",
"actions": [
{
"name": "APPEND_LOGIC-hideRes20JSep",
"type": "property",
"state": true,
"property": {
"type": "boolean",
"label": "Hidden",
"value": "hidden"
}
}
],
"trigger": {
"type": "javascript",
"javascript": "result = moment(window.currentCase.created_at).isBefore('2024-03-01') || (window.currentCase.case_data.rawjson.hide_field_by_MG == true) || (window.currentCase.metadata.mss_parent_id==undefined) || (window.currentCase.metadata.mss_parent_id=='e1d06753-9e11-46a6-abfe-fc64554fef06')"
}
}
]
}
13
4compliance_verificationComplianceHas any sales agent represented themselves as being with Medicare?EDITRESHIDE8radiocompliance_verification_verified_with_medicalYes;No{
"append_logic": [
{
"name": "APPEND_LOGIC-hideRes20JSep",
"actions": [
{
"name": "APPEND_LOGIC-hideRes20JSep",
"type": "property",
"state": true,
"property": {
"type": "boolean",
"label": "Hidden",
"value": "hidden"
}
}
],
"trigger": {
"type": "javascript",
"javascript": "result = moment(window.currentCase.created_at).isBefore('2024-03-01') || (window.currentCase.case_data.rawjson.hide_field_by_MG == true) || (window.currentCase.metadata.mss_parent_id=='e1d06753-9e11-46a6-abfe-fc64554fef06')"
}
}
]
}
14
4compliance_verificationComplianceHas patient ever completed a medicare wellness program visit?EDITRESHIDE9radio
compliance_verification_verified_patient_wellness_program
Yes;No
{ "calculateValue": "if(data.compliance_verification_verified_patient_wellness_program == 'No') {\ndata.compliance_verification_verified_patient_wellness_program_past = value\n; compliance_verification_verified_patient_wellness_program_past.disableOnInvalid = true}" }
15
4compliance_verificationComplianceHas patient completed a medicare wellness program visit in the past year?EDITRESHIDE10radio
compliance_verification_verified_patient_wellness_program_past
Yes;No
{"conditional": {
"show": true,
"when": "compliance_verification_verified_patient_wellness_program",
"eq": "Yes"
},
"clearOnHide": true}
{
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{
"name": "APPEND_LOGIC-Res28June",
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{
"name": "APPEND_LOGIC-Res28June",
"type": "property",
"state": true,
"property": {
"type": "boolean",
"label": "Required",
"value": "validate.required"
}
}
],
"trigger": {
"type": "javascript",
"javascript": "result = moment(window.currentCase.created_at).isAfter('2023-11-02')"
}
},
{
"name": "APPEND_LOGIC-requiredlabelRes28June",
"actions": [
{
"name": "APPEND_LOGIC-requiredlabelRes28June",
"type": "property",
"property": {
"type": "string",
"label": "Label",
"value": "label"
},
"text": "<span class=\"formio-main-label\">Has patient completed a medicare wellness program visit in the past year?&nbsp;</strong></span> <span class=\"formio-required-dot\">*</span><div class=\"formio-optional-label\"></div> "
}
],
"trigger": {
"type": "javascript",
"javascript": "result = moment(window.currentCase.created_at).isAfter('2023-11-02')"
}
}
]
}
16
4compliance_verificationComplianceDo you consent to receive <span style="font-weight: bold; text-decoration: underline;">SMS</span> notifications about your test results and consultation?EDITRESHIDE11radiocompliance_verification_sms_notiYes;No{
"append_logic": [
{
"name": "APPEND_LOGIC-hideRes20JSep",
"actions": [
{
"name": "APPEND_LOGIC-hideRes20JSep",
"type": "property",
"state": true,
"property": {
"type": "boolean",
"label": "Hidden",
"value": "hidden"
}
}
],
"trigger": {
"type": "javascript",
"javascript": "result = moment(window.currentCase.created_at).isBefore('2025-10-09')"
}
}
],
"description": "These SMS may include: notifications when your results are available, reminders for scheduled appointments, updates if an appointment is rescheduled, and links to join video calls with your provider."
}
17
4compliance_verificationComplianceDo you consent to receive <span style="font-weight: bold; text-decoration: underline;">Email</span> notifications about your test results and consultation?EDITRESHIDE12radiocompliance_verification_email_notiYes;No{
"append_logic": [
{
"name": "APPEND_LOGIC-hideRes20JSep",
"actions": [
{
"name": "APPEND_LOGIC-hideRes20JSep",
"type": "property",
"state": true,
"property": {
"type": "boolean",
"label": "Hidden",
"value": "hidden"
}
}
],
"trigger": {
"type": "javascript",
"javascript": "result = moment(window.currentCase.created_at).isBefore('2025-10-09')"
}
}
],
"description": "These Email may include: notifications when your results are available, reminders for scheduled appointments, updates if an appointment is rescheduled, and links to join video calls with your provider."
}
18
4compliance_verificationComplianceDo you consent to receive <span style="font-weight: bold; text-decoration: underline;">voice reminder</span> about your consultation?EDITRESHIDE13radiocompliance_verification_voice_notiYes;No{
"append_logic": [
{
"name": "APPEND_LOGIC-hideRes20JSep",
"actions": [
{
"name": "APPEND_LOGIC-hideRes20JSep",
"type": "property",
"state": true,
"property": {
"type": "boolean",
"label": "Hidden",
"value": "hidden"
}
}
],
"trigger": {
"type": "javascript",
"javascript": "result = moment(window.currentCase.created_at).isBefore('2025-10-09')"
}
}
],
"description": "If an appointment is scheduled, we can give you a reminder call on the appointment date."
}
19
4compliance_verificationComplianceDo you give consent for us to contact you in the future to discuss any additional health services that can benefit you? EDITRESHIDE14radiocompliance_verification_verified_additional_healthYes;No{
"append_logic": [
{
"name": "APPEND_LOGIC-hideRes20JSep",
"actions": [
{
"name": "APPEND_LOGIC-hideRes20JSep",
"type": "property",
"state": true,
"property": {
"type": "boolean",
"label": "Hidden",
"value": "hidden"
}
}
],
"trigger": {
"type": "javascript",
"javascript": "result = moment(window.currentCase.created_at).isBefore('2024-03-01') || (window.currentCase.metadata.mss_parent_id=='e1d06753-9e11-46a6-abfe-fc64554fef06')"
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]
}
20
4compliance_verificationComplianceDo you confirm all the above information is true and accurate?EDITRESHIDE15radiocompliance_verification_verified_confirm_allYes;No{
"append_logic": [
{
"name": "APPEND_LOGIC-hideRes20JSep",
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{
"name": "APPEND_LOGIC-hideRes20JSep",
"type": "property",
"state": true,
"property": {
"type": "boolean",
"label": "Hidden",
"value": "hidden"
}
}
],
"trigger": {
"type": "javascript",
"javascript": "result = moment(window.currentCase.created_at).isBefore('2024-03-01') || (window.currentCase.case_data.rawjson.hide_field_by_MG == true) || (window.currentCase.metadata.mss_parent_id=='e1d06753-9e11-46a6-abfe-fc64554fef06')"
}
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}
21
4compliance_verificationCompliancePatient was unsuitable for videoEDITEDITHIDE16checkboxcompliance_verification_verified_patient_no_video{
"append_logic": [
{
"name": "APPEND_LOGIC-hideRes20JSep",
"actions": [
{
"name": "APPEND_LOGIC-hideRes20JSep",
"type": "property",
"state": true,
"property": {
"type": "boolean",
"label": "Hidden",
"value": "hidden"
}
}
],
"trigger": {
"type": "javascript",
"javascript": "result = moment(window.currentCase.created_at).isBefore('2024-02-20') || (window.currentCase.metadata.mss_parent_id=='e1d06753-9e11-46a6-abfe-fc64554fef06') || (moment(window.currentCase.metadata.case_parent_created_at).isAfter('2025-07-28') && window?.currentCase?.case_data?.rawjson?.compliance_verification_video_consultation)"
}
}
]
}
22
4compliance_verificationComplianceWhen you meet with the provider for your telehealth consultation, will you prefer video call or audio call only?EDITRESHIDE17radiocompliance_verification_when_you_meet_with_the_provider_for_your_telehealth_consultation_will_you_prefer_video_call_or_audio_call_onlyVideo Call;Audio Only{
"append_logic": [
{
"name": "APPEND_LOGIC-hideRes20JSep",
"actions": [
{
"name": "APPEND_LOGIC-hideRes20JSep",
"type": "property",
"state": true,
"property": {
"type": "boolean",
"label": "Hidden",
"value": "hidden"
}
}
],
"trigger": {
"type": "javascript",
"javascript": "result = moment(window.currentCase.created_at).isBefore('2022-10-05')"
}
}
]
}
23
4compliance_verificationComplianceReason for audio-only:EDITEDITHIDE17selectcompliance_verification_reason_for_audio_onlyPatient declined video/prefer audio;Device doesn't have a camera;Poor internet/connectivity{
"conditional": {
"show": true,
"when": "compliance_verification_when_you_meet_with_the_provider_for_your_telehealth_consultation_will_you_prefer_video_call_or_audio_call_only",
"eq": "Audio Only"
}
}		{
"append_logic": [
{
"name": "APPEND_LOGIC-hideRes20JSep",
"actions": [
{
"name": "APPEND_LOGIC-hideRes20JSep",
"type": "property",
"state": true,
"property": {
"type": "boolean",
"label": "Hidden",
"value": "hidden"
}
}
],
"trigger": {
"type": "javascript",
"javascript": "result = moment(window.currentCase.created_at).isBefore('2022-10-05')"
}
},
{
"name": "APPEND_LOGIC-requireAudioCallOnly",
"trigger": {
"type": "javascript",
"javascript": "result = data.compliance_verification_when_you_meet_with_the_provider_for_your_telehealth_consultation_will_you_prefer_video_call_or_audio_call_only === 'Audio Only';"
},
"actions": [
{
"name": "act_require",
"type": "property",
"state": true,
"property": {
"label": "Required",
"value": "validate.required",
"type": "boolean"
}
}
]
},
{
"name": "APPEND_LOGIC-requireAudioCallOnlyLabel",
"trigger": {
"type": "javascript",
"javascript": "result = data.compliance_verification_when_you_meet_with_the_provider_for_your_telehealth_consultation_will_you_prefer_video_call_or_audio_call_only === 'Audio Only';"
},
"actions": [
{
"name": "act_label_required",
"type": "property",
"property": {
"type": "string",
"label": "Label",
"value": "label"
},
"text": "<span class=\"formio-main-label\">Reason for audio-only:</span> <span class=\"formio-required-dot\">*</span><div class=\"formio-optional-label\"></div>"
}
]
}
]
}
24
4compliance_verificationComplianceTalking pointEDITVIEWHIDE17contentcompliance_talking_point_99
<p class='rf-alert rf-alert-info'>It is crucial that Gender, DOB and Address are correct. If there are errors please make corrections manually.</p>
25
4compliance_verificationComplianceVerified Patient GenderEDITRESHIDE18checkbox
compliance_verification_verified_patient_gender_41589
<span class='formio-main-label'>Verified Patient Gender &nbsp; <strong>{{component.patient_gender}} <span class='formio-required-dot'>*</span></strong> <div class='formio-optional-label'></div>
{
"patient_gender": ""
}		{
"append_logic": [
{
"name": "APPEND_LOGIC-hideRes20JSep",
"actions": [
{
"name": "APPEND_LOGIC-hideRes20JSep",
"type": "property",
"state": true,
"property": {
"type": "boolean",
"label": "Hidden",
"value": "hidden"
}
}
],
"trigger": {
"type": "javascript",
"javascript": "result = moment(window.currentCase.created_at).isBefore('2022-10-05')"
}
}
]
}
26
4compliance_verificationComplianceVerified Patient DOBEDITRESHIDE19checkboxcompliance_verification_verified_patient_dob_41589
<span class='formio-main-label'>Verified Patient DOB &nbsp;<strong>{{component.patient_dob}}</strong></span> <span class='formio-required-dot'>*</span><div class='formio-optional-label'></div>
{"patient_dob": ""}{
"append_logic": [
{
"name": "APPEND_LOGIC-hideRes20JSep",
"actions": [
{
"name": "APPEND_LOGIC-hideRes20JSep",
"type": "property",
"state": true,
"property": {
"type": "boolean",
"label": "Hidden",
"value": "hidden"
}
}
],
"trigger": {
"type": "javascript",
"javascript": "result = moment(window.currentCase.created_at).isBefore('2022-10-05')"
}
},
{
"name": "APPEND_LOGIC_requiredMAAcount",
"actions": [
{
"name": "APPEND_LOGIC_requiredMAAcount",
"type": "property",
"state": true,
"property": {
"type": "boolean",
"label": "Required",
"value": "validate.required"
}
}
],
"trigger": {
"type": "javascript",
"javascript": "result = window.UserProfile.is_provider_ma == true;"
}
}
]
}
27
4compliance_verificationComplianceVerified Patient AddressEDITRESHIDE20checkboxcompliance_verification_verified_patient_state_41589
<span class='formio-main-label'>Verified Patient Address &nbsp;<strong>{{component.patient_address}}, {{component.patient_zip_code}}, {{component.patient_city}}, {{component.patient_state}}, {{component.patient_country }}</strong></span> <span class='formio-required-dot'>*</span><div class='formio-optional-label'></div>
{"patient_state": "", "patient_address": "","patient_city": "","patient_zip_code": "","patient_country": ""}{
"append_logic": [
{
"name": "APPEND_LOGIC-hideRes20JSep",
"actions": [
{
"name": "APPEND_LOGIC-hideRes20JSep",
"type": "property",
"state": true,
"property": {
"type": "boolean",
"label": "Hidden",
"value": "hidden"
}
}
],
"trigger": {
"type": "javascript",
"javascript": "result = moment(window.currentCase.created_at).isBefore('2022-10-05')"
}
}
]
}
28
4compliance_verificationComplianceChecked for SMS mobile numberEDITEDITHIDE21checkbox
compliance_verification_verified_patient_phone_49540
{
"append_logic": [
{
"name": "APPEND_LOGIC-hideRes20JSep",
"actions": [
{
"name": "APPEND_LOGIC-hideRes20JSep",
"type": "property",
"state": true,
"property": {
"type": "boolean",
"label": "Hidden",
"value": "hidden"
}
}
],
"trigger": {
"type": "javascript",
"javascript": "result = moment(window.currentCase.created_at).isBefore('2025-05-04')"
}
}
]
}
29
16compliance_advance_directiveAdvance DirectiveDo you have an advance directive (Also known as a living will)?HIDEEDITRES1radiocompliance_advance_directive_1Yes;No{
"append_logic": [
{
"name": "APPEND_LOGIC-hideSectionVital",
"actions": [
{
"name": "APPEND_LOGIC-hideSectionVital",
"type": "property",
"state": true,
"property": {
"type": "boolean",
"label": "Hidden",
"value": "hidden"
}
}
],
"trigger": {
"type": "javascript",
"javascript": "result = moment(window.currentCase.created_at).isBefore('2024-02-01')"
}
},
{
"name": "APPEND_LOGIC_requiredMAAcount",
"actions": [
{
"name": "APPEND_LOGIC_requiredMAAcount",
"type": "property",
"state": true,
"property": {
"type": "boolean",
"label": "Required",
"value": "validate.required"
}
}
],
"trigger": {
"type": "javascript",
"javascript": "result = window.UserProfile.is_provider_ma == true;"
}
}
]
}
30
16compliance_advance_directiveAdvance Directive<p>What is your code status? <a href="https://top-virginia-05112023.s3.amazonaws.com/medicalform/codectatusexplanations.pdf " target="_blank" > See More Code Status Explanations</a></p>HIDEEDITRES2radiocompliance_advance_directive_2
FULL CODE;LIMITED CODE;DNR;COMFORT CARE;UNKNOWN
{
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{
"name": "APPEND_LOGIC-hideSectionVital",
"actions": [
{
"name": "APPEND_LOGIC-hideSectionVital",
"type": "property",
"state": true,
"property": {
"type": "boolean",
"label": "Hidden",
"value": "hidden"
}
}
],
"trigger": {
"type": "javascript",
"javascript": "result = moment(window.currentCase.created_at).isBefore('2024-02-01')"
}
}
]
}
31
16compliance_advance_directiveAdvance DirectiveDo you have a medical power of attorney?HIDEEDITRES3radiocompliance_advance_directive_3Yes;No{
"append_logic": [
{
"name": "APPEND_LOGIC-hideSectionVital",
"actions": [
{
"name": "APPEND_LOGIC-hideSectionVital",
"type": "property",
"state": true,
"property": {
"type": "boolean",
"label": "Hidden",
"value": "hidden"
}
}
],
"trigger": {
"type": "javascript",
"javascript": "result = moment(window.currentCase.created_at).isBefore('2024-02-01')"
}
}
]
}
32
16compliance_advance_directiveAdvance DirectiveIs blood transfusion acceptable in an emergency?HIDEEDITRES4radiocompliance_advance_directive_4Yes;No{
"append_logic": [
{
"name": "APPEND_LOGIC-hideSectionVital",
"actions": [
{
"name": "APPEND_LOGIC-hideSectionVital",
"type": "property",
"state": true,
"property": {
"type": "boolean",
"label": "Hidden",
"value": "hidden"
}
}
],
"trigger": {
"type": "javascript",
"javascript": "result = moment(window.currentCase.created_at).isBefore('2024-02-01')"
}
}
]
}
33
16compliance_advance_directiveAdvance DirectiveDo you have a patient advocate?HIDEEDITRES5radiocompliance_advance_directive_5Yes;No{
"append_logic": [
{
"name": "APPEND_LOGIC-hideSectionVital",
"actions": [
{
"name": "APPEND_LOGIC-hideSectionVital",
"type": "property",
"state": true,
"property": {
"type": "boolean",
"label": "Hidden",
"value": "hidden"
}
}
],
"trigger": {
"type": "javascript",
"javascript": "result = moment(window.currentCase.created_at).isBefore('2024-02-01')"
}
}
]
}
34
16compliance_advance_directiveAdvance DirectiveWhat is your advocate's name?HIDEEDITEDIT6textfieldcompliance_advance_directive_6{
"append_logic": [
{
"name": "APPEND_LOGIC-hideSectionVital",
"actions": [
{
"name": "APPEND_LOGIC-hideSectionVital",
"type": "property",
"state": true,
"property": {
"type": "boolean",
"label": "Hidden",
"value": "hidden"
}
}
],
"trigger": {
"type": "javascript",
"javascript": "result = moment(window.currentCase.created_at).isBefore('2024-02-01')"
}
},
{
"name": "Res28June",
"actions": [
{
"name": "Res28June",
"type": "property",
"state": true,
"property": {
"type": "boolean",
"label": "Required",
"value": "validate.required"
}
}
],
"trigger": {
"type": "javascript",
"javascript": "result = data.compliance_advance_directive_5 == 'Yes' && window.role == 'doctor';"
}
},
{
"name": "requiredlabelRes28June",
"actions": [
{
"name": "requiredlabelRes28June",
"type": "property",
"property": {
"type": "string",
"label": "Label",
"value": "label"
},
"text": "<span class=\"formio-main-label\">What is your advocate's name?</span><span class=\"formio-required-dot\">*</span><div class=\"formio-optional-label\"></div> "
}
],
"trigger": {
"type": "javascript",
"javascript": "result = data.compliance_advance_directive_5 == 'Yes' && window.role == 'doctor';"
}
}
]
}
35
16compliance_advance_directiveAdvance DirectiveWhat is your relation to the advocate?HIDEEDITEDIT7textfieldcompliance_advance_directive_7{
"append_logic": [
{
"name": "APPEND_LOGIC-hideSectionVital",
"actions": [
{
"name": "APPEND_LOGIC-hideSectionVital",
"type": "property",
"state": true,
"property": {
"type": "boolean",
"label": "Hidden",
"value": "hidden"
}
}
],
"trigger": {
"type": "javascript",
"javascript": "result = moment(window.currentCase.created_at).isBefore('2024-02-01')"
}
},
{
"name": "Res28June",
"actions": [
{
"name": "Res28June",
"type": "property",
"state": true,
"property": {
"type": "boolean",
"label": "Required",
"value": "validate.required"
}
}
],
"trigger": {
"type": "javascript",
"javascript": "result = data.compliance_advance_directive_5 == 'Yes' && window.role == 'doctor';"
}
},
{
"name": "requiredlabelRes28June",
"actions": [
{
"name": "requiredlabelRes28June",
"type": "property",
"property": {
"type": "string",
"label": "Label",
"value": "label"
},
"text": "<span class=\"formio-main-label\">What is your relation to the advocate?</span><span class=\"formio-required-dot\">*</span><div class=\"formio-optional-label\"></div> "
}
],
"trigger": {
"type": "javascript",
"javascript": "result = data.compliance_advance_directive_5 == 'Yes' && window.role == 'doctor';"
}
}
]
}
36
1patient_informationPatient InformationSuggested for RPMHIDEHIDEHIDE1radioshowotherpatient_suggested_for_rpm1Yes;Nopatient_suggested_consult_schedule
37
1patient_informationPatient InformationSuggested RPM Consult ScheduleHIDEHIDEHIDE2datetimepatient_suggested_consult_schedule
38
1patient_informationPatient InformationTalking pointVIEWHIDEVIEW3contentpatient_talking_point_1
<p class="rf-alert rf-alert-info"><i>Instruction: MG Agent will state their name, MG name, and the patient they have on the line. They will provide a case ID to search for the patient in TMS software. They will state the patient is ready for transfer and the patient will be now active on the line with the PSS.</i></p>
39
1patient_informationPatient InformationPERSONAL INFORMATIONVIEWVIEWVIEW4contentpatient_header_1
<div class="d-flex align-items-center" style="min-height:40px;">
<b><h2 class="mb-0">PERSONAL INFORMATION</h2></b>
</div>
{"customClass": "bg-light"}
40
1patient_informationPatient InformationPatient's First Name RESRESRES5textfieldpatient_first_name{"tableView":true,"customClass": "formio-column-50"}
41
1patient_informationPatient InformationPatient's Last NameRESRESRES6textfieldpatient_last_name{"tableView":true,"customClass": "formio-column-50"}
42
1patient_informationPatient InformationM.IEDITEDITEDIT7textfieldpatient_mi{"tableView":true,"customClass": "formio-column-50"}
43
1patient_informationPatient InformationDate of BirthRESRESRES8datetime18pluspatient_dob{
"customClass": "formio-column-50",
"validate": {
"custom": "if(input){\r\n console.log('%cUntitled-1:2 input', 'color: #007acc;', input);\r\n var today = new Date();\r\n var birthDate = new Date(input);\r\n var age = today.getFullYear() - birthDate.getFullYear();\r\n var m = today.getMonth() - birthDate.getMonth();\r\n if (m < 0 || (m === 0 && today.getDate() < birthDate.getDate())) {\r\n age--;\r\n }\r\n var min_age = 18;\r\n var max_age = 81;\r\n\r\n try {\r\n if(window.marketingGroupOption && window.marketingGroupOption.metadata){\r\n if(window.marketingGroupOption.metadata.validate_age_dob.min_age >= 0){\r\n \tmin_age = window.marketingGroupOption.metadata.validate_age_dob.min_age;\r\n \t }\r\n \t if(window.marketingGroupOption.metadata.validate_age_dob.max_age >= 0 ){\r\n max_age = window.marketingGroupOption.metadata.validate_age_dob.max_age;\r\n }\r\n }\r\n } catch (error) {\r\n min_age = 18\r\n max_age = 81\r\n }\r\n if(age < min_age || age > max_age) {\r\n if(age < min_age) {\r\n text_valid = 'Patient must be > {{min_age}} years of age';\r\n valid = text_valid.replace(/{{min_age}}/g, min_age);\r\n }else{\r\n text_valid = 'Patient must be < {{max_age}} years of age';\r\n valid = text_valid.replace(/{{max_age}}/g, max_age);\r\n }\r\n }\r\n}",
"customMessage": "",
"customPrivate": false,
"json": "",
"multiple": false,
"required": true,
"strictDateValidation": false,
"unique": false
}
}
44
1patient_informationPatient InformationHome EnvironmentHIDEHIDEHIDE6checkboxPrivateHome_AssistedLiving_Other
45
1patient_informationPatient InformationGenderRESRESRES10radiopatient_gender1Male;Female
46
1patient_informationPatient InformationEthnicityRESRESRES11
selectboxshowother
patient_ethnicity_selectboxes
Asian;African American;Ashkenazi Jewish;Caucasian;French Canadian;Hispanic;Indian;Middle Eastern;Native American;Pacific Islander;Other
patient_ethnicity_other
47
1patient_informationPatient InformationOther EthnicityEDITEDITEDIT12textfieldpatient_ethnicity_other
48
1patient_informationPatient InformationMedicare #HIDEHIDEHIDE7textfieldpatient_medicare_id
49
1patient_informationPatient InformationPrimary Insurance TypeRESEDITRES8radiosetvaluepatient_primary_type1Medicarepatient_primary_name
50
1patient_informationPatient InformationPrimary InsuranceRESEDITRES9textfieldpatient_primary_name{
"calculateValue": "if(data.patient_primary_type ==\"Tricare\"){value=\"Tricare\"}\n"
}
51
1patient_informationPatient InformationPrimary Policy #RESEDITRES10textfieldpatient_primary_insurance_id{
"validate": {
"required": true,
"custom": "var reg_medicare = new RegExp(\"\\\\b[1-9][AC-HJKMNP-RT-Y][AC-HJKMNP-RT-Y0-9][0-9][AC-HJKMNP-RT-Y][AC-HJKMNP-RT-Y0-9][0-9][AC-HJKMNP-RT-Y]{2}\\\\d{2}\\\\b\"); \nvar reg_tricare = new RegExp(\"^[0-9]{11}$\")\nif((input!==\"\" || input!==null )&& data.patient_secondary_insurance_id != \"\" && input === data.patient_secondary_insurance_id){\n valid = \"Primary Insurance ID and Secondary Insurance ID must be different\"\n}else if(\"Medicare\" == data.patient_primary_type && !reg_medicare.test(input)){\n valid = \"Invalid Medicare#\"\n}else if(\"Tricare\" == data.patient_primary_type && reg_tricare.test(input)){\n valid = true\n}\nelse if(\"Tricare\" == data.patient_primary_type && !reg_tricare.test(input)){\n valid = \"The DoD Benefits Number is an 11-digit number on the back of the ID card.\"\n}else {\n valid = true\n}",
"validateOn": "blur"
},
"calculateValue": "if(data.patient_primary_insurance_id) {value = data.patient_primary_insurance_id.trim()}"
}
52
1patient_informationPatient InformationPrimary Group #EDITEDITEDIT11textfieldpatient_primary_group
53
1patient_informationPatient InformationSeparatorEDITEDITEDIT13separatorpatient_no_secondary_insurance_separator
54
1patient_informationPatient InformationNo Secondary InsuranceEDITEDITEDIT14
checkboxhideothers
patient_no_secondary_insurance
patient_secondary_type;patient_secondary_name;patient_secondary_insurance_id;patient_secondary_group;patient_secondary_card
55
1patient_informationPatient InformationSecondary Insurance TypeRESEDITRES15radiosetvaluepatient_secondary_type1
Commercial carrier/Private Insurance;Tricare
patient_secondary_nameCovid Test;RPM
56
1patient_informationPatient InformationSecondary InsuranceRESEDITRES16textfieldpatient_secondary_name
57
1patient_informationPatient InformationSecondary Policy #RESEDITRES17textfieldpatient_secondary_insurance_id{
"validate": {
"required": true,
"custom": "var reg_medicare = new RegExp(\"\\\\b[1-9][AC-HJKMNP-RT-Y][AC-HJKMNP-RT-Y0-9][0-9][AC-HJKMNP-RT-Y][AC-HJKMNP-RT-Y0-9][0-9][AC-HJKMNP-RT-Y]{2}\\\\d{2}\\\\b\"); \nvar reg_tricare = new RegExp(\"^[0-9]{11}$\")\nif((input!==\"\" || input!==null )&& data.patient_secondary_insurance_id != \"\" && input === data.patient_primary_insurance_id){\n valid = \"Primary Insurance ID and Secondary Insurance ID must be different\"\n}else if(\"Medicare\" == data.patient_secondary_type && !reg_medicare.test(input)){\n valid = \"Invalid Medicare#\"\n}else if(\"Tricare\" == data.patient_secondary_type && reg_tricare.test(input)){\n valid = true\n}\nelse if(\"Tricare\" == data.patient_secondary_type && !reg_tricare.test(input)){\n valid = \"The DoD Benefits Number is an 11-digit number on the back of the ID card.\"\n}else {\n valid = true\n}",
"validateOn": "blur"
},
"calculateValue": "if(data.patient_secondary_insurance_id) {value = data.patient_secondary_insurance_id.trim()}"
}
58
1patient_informationPatient InformationSecondary Group #EDITEDITEDIT18textfieldpatient_secondary_group
59
1patient_informationPatient InformationSocial Security NumberEDITEDITEDIT23textfieldpatient_social_security_number
60
1patient_informationPatient InformationTalking pointVIEWVIEWVIEW24contentpatient_talking_point_2
<p class='rf-alert rf-alert-info'>Ensure height and weight are inputted correctly or cases may be rejected.</p>
61
1patient_informationPatient InformationHeight (ft.in.)VIEWVIEWVIEW24contentpatient_height_weight_title
<div><span>Height (ft.in.)</span><span class="formio-required-dot">*</span></div>
{"customClass": "formio-custom-title"}
62
1patient_informationPatient InformationHeight (ft.)RESRESRES25numberpatient_height{"hideLabel": true,"placeholder": "ft.","tableView":true, "customClass": "formio-column-50"}{
"validate": {
"min": 1
}
}
63
1patient_informationPatient InformationHeight (in.)RESRESRES26textfieldpatient_height_in1{"hideLabel": true,
"placeholder": "in.",
"tableView":true,"customClass": "formio-column-50"}		{
"calculateValue": "if (value) {\n value = value.replace(/[^0-9]/g, '');\n}"
}
64
1patient_informationPatient InformationWeight (lb.)RESRESRES27numberpatient_weight{
"validate": {
"min": 1
}
}
65
1patient_informationPatient InformationBMIVIEWVIEWVIEW28textfieldpatient_bmi{"calculateValue": "\ntry {\n if (!isNaN(data.patient_weight) && !isNaN(data.patient_height) && !isNaN(data.patient_height_in) ) {\n let patient_weight = parseFloat(data.patient_weight);\n let patient_height = parseFloat(data.patient_height);\n let patient_height_in = parseFloat(data.patient_height_in);\n\n let h = (patient_height * 12) + patient_height_in;\n value = ((patient_weight / (h*h)) * 703).toFixed(2);\n}\nelse {\n value = \"\";\n}\n\n} catch (error) {\n value = \"N/a\";\n}\n"}
66
1patient_informationPatient InformationIncorrect Height / Weight compliance warningHIDEEDITEDIT29checkboxpatient_weight_warning_compliance
67
1patient_informationPatient InformationCONTACT INFORMATIONVIEWVIEWVIEW32contentpatient_header_2
<div class="d-flex align-items-center" style="min-height:40px;">
<b><h2 class="mb-0">CONTACT INFORMATION</h2></b>
</div>
{"customClass": "bg-light"}
68
1patient_informationPatient InformationPatient's Email AddressEDITEDITEDIT33emailpatient_email
69
1patient_informationPatient InformationPhone Number TypesRESRESRES34radiopatient_phone_number_type1
Cell Phone;Landline
70
1patient_informationPatient InformationPatient's Phone NumberRESRESRES35
phone_number_us
patient_phone
71
1patient_informationPatient InformationStreet AddressRESRESRES29textfieldpatient_address
72
1patient_informationPatient InformationApt, Suite, etc. (Optional)EDITEDITEDIT30textfieldpatient_apt_suite
73
1patient_informationPatient InformationZip CodeRESRESRES33textfieldpatient_zip_code
74
1patient_informationPatient InformationCityRESRESRES31textfieldpatient_city
75
1patient_informationPatient InformationStateRESRESRES32textfieldpatient_state1
AL;AK;AZ;AR;CA;CO;CT;DC;DE;FL;GA;HI;ID;IL;IN;IA;KS;KY;LA;ME;MD;MA;MI;MN;MS;MO;MT;NE;NV;NH;NJ;NM;NY;NC;ND;OH;OK;OR;PA;RI;SC;SD;TN;TX;UT;VT;VA;WA;WV;WI;WY
{
"case": "uppercase"
}
76
1patient_informationPatient InformationCountryRESRESRES34textfieldpatient_countryUSA
77
1patient_informationPatient InformationADDITIONAL INFORMATIONVIEWVIEWVIEW42contentpatient_header_4
<div class="d-flex align-items-center" style="min-height:40px;">
<b><h2 class="mb-0">ADDITIONAL INFORMATION</h2></b>
</div>
{"customClass": "bg-light"}
78
1patient_informationPatient InformationTexting Consent
May we send you text reminders for your follow-up appointment?
EDITEDITEDIT37radiopatient_information_texting_consent1YesNo;Yes{
"append_logic": [
{
"name": "APPEND_LOGIC-hideRes20JSep",
"actions": [
{
"name": "APPEND_LOGIC-hideRes20JSep",
"type": "property",
"state": true,
"property": {
"type": "boolean",
"label": "Hidden",
"value": "hidden"
}
}
],
"trigger": {
"type": "javascript",
"javascript": "result = moment(window.currentCase.created_at).isAfter('2025-10-09')"
}
}
]
}
79
1patient_informationPatient InformationReason of VisitEDITEDITEDIT39textfieldpatient_reason_of_visit{
"append_logic": [
{
"name": "APPEND_LOGIC-hideRes20JSep",
"actions": [
{
"name": "APPEND_LOGIC-hideRes20JSep",
"type": "property",
"state": true,
"property": {
"type": "boolean",
"label": "Hidden",
"value": "hidden"
}
}
],
"trigger": {
"type": "javascript",
"javascript": "result = moment(window.currentCase.created_at).isAfter('2025-04-15')"
}
}
]
}
80
1patient_informationPatient InformationReason of VisitRESRESRES40selectpatient_reason_of_visit_generic
Annual Wellness / Health Risk Assessment;Cancer Risk & CGx Consultation;Chronic Pain Management Consultation;Diabetes Risk & Management Consultation;Follow Up Visit;General Medical Consultation / Other;Immunology & Immune System Evaluation;Metabolic Disorder Evaluation;Neurological Diagnostic Evaluation;PGx / Medication Review Consultation;Remote Monitoring (RPM) Evaluation;Urinary Tract Infection (UTI) Evaluation
{
"append_logic": [
{
"name": "APPEND_LOGIC-hideRes20JSep",
"actions": [
{
"name": "APPEND_LOGIC-hideRes20JSep",
"type": "property",
"state": true,
"property": {
"type": "boolean",
"label": "Hidden",
"value": "hidden"
}
}
],
"trigger": {
"type": "javascript",
"javascript": "result = !moment(window.currentCase.created_at).isAfter('2025-04-15')"
}
}
]
}
81
1patient_informationPatient InformationSpecify RPM serviceEDITEDITVIEW41selectpatient_reason_of_visit_option_rpm
Continuous or Blood Glucose Monitoring (CGM or BGM);Blood Pressure monitoring;Heart Rate monitoring;Pulse rate monitoring;Weight management scale
{"conditional": {
"show": true,
"when": "patient_reason_of_visit_generic",
"eq": "Remote Monitoring (RPM) Evaluation"
}}		{
"append_logic": [
{
"name": "APPEND_LOGIC-hideRes20JSep",
"actions": [
{
"name": "APPEND_LOGIC-hideRes20JSep",
"type": "property",
"state": true,
"property": {
"type": "boolean",
"label": "Hidden",
"value": "hidden"
}
}
],
"trigger": {
"type": "javascript",
"javascript": "result = !moment(window.currentCase.created_at).isAfter('2025-04-15')"
}
},
{
"name": "APPEND_LOGIC-medical_history",
"actions": [
{
"name": "APPEND_LOGIC-medical_history",
"type": "property",
"state": true,
"property": {
"type": "boolean",
"label": "Required",
"value": "validate.required"
}
}
],
"trigger": {
"type": "javascript",
"javascript": "result = (data.patient_reason_of_visit_generic === 'Remote Monitoring (RPM) Evaluation')"
}
},
{
"name": "APPEND_LOGIC-requiredlabelmedical_history",
"actions": [
{
"name": "APPEND_LOGIC-requiredlabelmedical_history",
"type": "property",
"property": {
"type": "string",
"label": "Label",
"value": "label"
},
"text": "<span class=\"formio-main-label\">Specify RPM service? </span> <span class=\"formio-required-dot\">*</span><div class=\"formio-optional-label\"></div> "
}
],
"trigger": {
"type": "javascript",
"javascript": "result = (data.patient_reason_of_visit_generic === 'Remote Monitoring (RPM) Evaluation')"
}
}
]
}
82
1patient_informationPatient InformationMisc. FilesEDITEDITEDIT42filepatient_misc_files
83
23ordering_provider_informationOrdering ProviderProvider First NameHIDEVIEWVIEW1textfieldorder_first_name
84
23ordering_provider_informationOrdering ProviderProvider Last NameHIDEVIEWVIEW2textfieldorder_last_name
85
23ordering_provider_informationOrdering ProviderPhoneHIDEVIEWVIEW3phone_numberorder_phone
86
23ordering_provider_informationOrdering ProviderAddressHIDEVIEWVIEW4textfieldorder_address
87
23ordering_provider_informationOrdering ProviderFax numberHIDEVIEWVIEW5phone_numberorder_fax_number
88
23ordering_provider_informationOrdering ProviderEmail AddressHIDEVIEWVIEW6emailorder_email
89
23ordering_provider_informationOrdering ProviderNPI#HIDEVIEWVIEW7
textfield_npi_number
order_npi
90
27insurance_billingPatient's Insurance InformationPrimary Insurance TypeHIDEHIDEHIDE1radiosetvalueinsurance_billing_primary_type1Medicareinsurance_billing_primary_name
91
27insurance_billingPatient's Insurance InformationPrimary InsuranceHIDEHIDEHIDE1textfieldinsurance_billing_primary_name
92
27insurance_billingPatient's Insurance InformationPrimary Policy #HIDEHIDEHIDE2textfieldinsurance_billing_primary_insurance_id
93
27insurance_billingPatient's Insurance InformationPrimary Group #HIDEHIDEHIDE3textfieldinsurance_billing_primary_group
94
27insurance_billingPatient's Insurance InformationSeparatorHIDEHIDEHIDE1separatorinsurance_billing_no_secondary_insurance_separator
95
27insurance_billingPatient's Insurance InformationNo Secondary InsuranceHIDEHIDEHIDE1
checkboxhideothers
insurance_billing_no_secondary_insurance
insurance_billing_secondary_type;insurance_billing_secondary_name;insurance_billing_secondary_insurance_id;insurance_billing_secondary_group
96
27insurance_billingPatient's Insurance InformationSecondary Insurance TypeHIDEHIDEHIDE1radiosetvalueinsurance_billing_secondary_type1
Commercial carrier/Private Insurance;Tricare
insurance_billing_secondary_name
97
27insurance_billingPatient's Insurance InformationSecondary InsuranceHIDEHIDEHIDE4textfieldinsurance_billing_secondary_name
98
27insurance_billingPatient's Insurance InformationSecondary Policy #HIDEHIDEHIDE5textfieldinsurance_billing_secondary_insurance_id
99
27insurance_billingPatient's Insurance InformationSecondary Group #HIDEHIDEHIDE6textfieldinsurance_billing_secondary_group
100
5pcp_informationPrimary Care ProviderPrimary Care Provider (PCP) information unavailableEDITEDITHIDE0
checkboxhideothers
pcp_no_pcp_certification
pcp_first_name;pcp_last_name;pcp_phone;pcp_fax_number;pcp_email;pcp_npi;pcp_address;pcp_zip_code;pcp_city;pcp_state;pcp_postal_code;pcp_hospital_clinic_name;pcp_hospital_clinic_phone_number;pcp_secondary_phone;pcp_apt_suite_other
{"ADMIN_MEDICAL_QC": "EDIT", "ADMIN_MEDICAL_SALES_QC":"EDIT"}