{
  "resourceType" : "Task",
  "contained" : [{
    "resourceType" : "Patient",
    "id" : "patient",
    "identifier" : [{
      "use" : "usual",
      "type" : {
        "coding" : [{
          "system" : "http://terminology.hl7.org/CodeSystem/v2-0203",
          "code" : "MB",
          "display" : "Member Number"
        }],
        "text" : "Member Number"
      },
      "system" : "http://example.org/cdex/payer/member-ids",
      "value" : "Member123"
    },
    {
      "use" : "usual",
      "type" : {
        "coding" : [{
          "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType",
          "code" : "pat",
          "display" : "Patient Account Number"
        }],
        "text" : "Patient Account Number"
      },
      "system" : "http://example.org/cdex/provider/patient-ids",
      "value" : "PA-123"
    }],
    "name" : [{
      "family" : "Shaw",
      "given" : ["Amy"]
    }],
    "birthDate" : "1987-02-20"
  },
  {
    "resourceType" : "PractitionerRole",
    "id" : "practitionerrole",
    "practitioner" : {
      "identifier" : {
        "system" : "http://hl7.org/fhir/sid/us-npi",
        "value" : "9941339100"
      }
    },
    "organization" : {
      "identifier" : {
        "system" : "http://hl7.org/fhir/sid/us-npi",
        "value" : "1234567893"
      }
    }
  }],
  "identifier" : [{
    "type" : {
      "coding" : [{
        "system" : "http://hl7.org/fhir/us/davinci-cdex/CodeSystem/cdex-temp",
        "code" : "tracking-id",
        "display" : "Tracking Id"
      }],
      "text" : "Re-Association Tracking Control Number"
    },
    "system" : "http://example.org/payer",
    "value" : "trackingid1012"
  }],
  "status" : "requested",
  "intent" : "order",
  "code" : {
    "coding" : [{
      "system" : "http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes",
      "code" : "attachment-request-questionnaire"
    }],
    "text" : "Attachment Request Questionnaire"
  },
  "for" : {
    "reference" : "#patient"
  },
  "authoredOn" : "2022-06-17T16:16:06Z",
  "lastModified" : "2022-06-17T16:16:06Z",
  "requester" : {
    "identifier" : {
      "system" : "http://example.org/cdex/payer/payer-ids",
      "value" : "Payer123"
    }
  },
  "owner" : {
    "reference" : "#practitionerrole"
  },
  "reasonCode" : {
    "coding" : [{
      "system" : "http://hl7.org/fhir/claim-use",
      "code" : "preauthorization",
      "display" : "Preauthorization"
    }],
    "text" : "preauthorization"
  },
  "reasonReference" : {
    "identifier" : {
      "system" : "http://example.org/cdex/payer/claim-ids",
      "value" : "Preauth123"
    }
  },
  "restriction" : {
    "period" : {
      "end" : "2022-06-21"
    }
  },
  "input" : [{
    "extension" : [{
      "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-paLineNumber",
      "valueInteger" : 1
    }],
    "type" : {
      "coding" : [{
        "system" : "http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes",
        "code" : "questionnaire-context"
      }]
    },
    "valueCanonical" : "http://example.org/cdex-questionnaire-example1"
  },
  {
    "type" : {
      "coding" : [{
        "system" : "http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes",
        "code" : "payer-url"
      }]
    },
    "valueUrl" : "http://example.org/cdex/payer/$submit-attachment"
  },
  {
    "type" : {
      "coding" : [{
        "system" : "http://hl7.org/fhir/us/davinci-cdex/CodeSystem/cdex-temp",
        "code" : "purpose-of-use"
      }]
    },
    "valueCodeableConcept" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/v3-ActReason",
        "code" : "COVAUTH",
        "display" : "coverage authorization"
      }]
    }
  }]
}