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This page is part of the Da Vinci Payer Data Exchange (v2.2.0: STU2.2) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version. For a full list of available versions, see the Directory of published versions

: Treatment Attestation Form Example 2 - XML Representation

Page standards status: Informative

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<DocumentReference xmlns="http://hl7.org/fhir">
  <id value="treatment-attestation-form-002"/>
  <meta>
    <lastUpdated value="2024-12-16T10:00:00Z"/>
  </meta>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><p>Signed Treatment Relationship Attestation Form for Sarah Williams</p></div>
  </text>
  <status value="current"/>
  <docStatus value="final"/>
  <type>
    <coding>
      <system value="http://loinc.org"/>
      <code value="64292-6"/>
      <display value="Release of information consent Document"/>
    </coding>
  </type>
  <category>
    <coding>
      <system value="http://loinc.org"/>
      <code value="64292-6"/>
      <display value="Release of information consent Document"/>
    </coding>
  </category>
  <subject>🔗 
    <reference value="Patient/patient-prov-002"/>
    <display value="Sarah Elizabeth Williams"/>
  </subject>
  <date value="2024-12-16T09:45:00Z"/>
  <author>🔗 
    <reference value="Practitioner/provider-002"/>
    <display value="Dr. Mary Jones"/>
  </author>
  <custodian>🔗 
    <reference value="Organization/provider-org-002"/>
    <display value="Second Example Provider Organization"/>
  </custodian>
  <description
               value="Signed attestation form documenting active treatment relationship between Dr. Jones and patient Sarah Williams"/>
  <content>
    <attachment>
      <contentType value="application/pdf"/>
      <language value="en-US"/>
      <title value="Treatment Relationship Attestation Form"/>
      <creation value="2024-12-16T09:45:00Z"/>
    </attachment>
  </content>
  <context>
    <period>
      <start value="2024-02-15"/>
    </period>
  </context>
</DocumentReference>