# Use this for the HIPAA form questions
---
objects:
  - doc_type: DAList
  - studentattorney: Individual
  - client: Individual
  - parent: Individual
  - hospital: DAObject
  - court: DAObject
  - defender: DAObject
  - accelerator: DAObject
---
mandatory: True
code: |
  if not user_logged_in():
    require_login_screen
  ok_to_finish = True
  doc_select
  studentattorney.name.first
  client.name.first
  client.dob
  if "jdc" in doc_select.true_values():
    parent.name.first
  if "defenders" in doc_select.true_values():
    hospital.name
    court.name
    defender.disclose
  if "a2p"  in doc_select.true_values():
    hospital.name
    accelerator.beginning
    accelerator.permission
    client.event
    client.initials
  client.signature
  if "jdc" in doc_select.true_values():
    parent.signature
---
event: require_login_screen
question: |
  You need to log in to finish this interview.
buttons:
  - Log in: leave
    url: ${ url_of('login', next=interview_url()) }
---
question: |
  [BR]Welcome to the HIPAA Realese of Information App. You may fax the form to local hospitals indicated, or email a secure PDF to yourself.[BR]

    [BR]Signing this form hereby authorizes and permits the Suffolk Univerisity Law School Clinic student attorney, attorney, investigator, or expert defense witness to inspect and/or copy any and all documents pertaining to me which are in custody or control of the entity or institution named below. This includes the release of my complete medical, mental health, educational, employment, and other institutional records, including but not limited to any records of psychiatric examination, counseling, treatment for drug and/or alcohol abuse, or HIV/Aids treatment from any public or private entity at which the records are held.[BR]

  [BR]Pursuant to HIPAA Standards of April 14, 2003 (See 45 CFR 164.508(c))[BR]

field: welcome
---
question: |
  Which HIPAA form would you like to fill out?
fields:
  - no label: doc_select
    datatype: checkboxes
    choices:
      - JDC HIPAA: jdc
      - Defenders HIPAA: defenders
      - Accelerator to Practice HIPAA: a2p
    none of the above: False
---
question: |
  Student Attorney Information
fields:
  - First name: studentattorney.name.first
  - Last name: studentattorney.name.last
  - Email: studentattorney.email
---
question: |
  Client Information
fields:
  - First name: client.name.first
  - Last name: client.name.last
  - Birthday: client.dob
    datatype: date
---
question: |
  Parent/Guardian Information
fields:
  - First name: parent.name.first
  - Last name: parent.name.last
---
question: |
  What date/event will this HIPAA form expire?
fields:
  - Date / Event: client.event
---
question: |
  Hospital Information
fields:
  - Name of Hospital/Medical Institution: hospital.name
  - Street: hospital.street
  - City: hospital.city
  - Zip Code: hospital.zip
  - Hospital fax number: hospital.fax
    required: False
#defenders and accelarator
---
question: |
  Court Information
fields:
  - Name of Court with pending case: court.name
#defenders
---
question: |
  Disclosure Authorization
fields:
  - "I authorize disclosure of (check one)": defender.disclose
    datatype: checkboxes
    choices:
      - All Information: all.info
      - Records: records_def
    none of the above: False
    required: False
  - "If Records, please specify what the records relate to": relates_to
    required: False
#defenders, having some trouble with the "if, then" with this
---
question: |
  Permission Authorization
fields:
  - "I give permission to disclose the following information": accelerator.permission
    datatype: checkboxes
    choices:
      - "Records, opinions, reports, X-rays, lab test results, information relating to testing, diagnosis or treatment, and any other information or documents relating to services provided from dates provided": defender_records
      - "Psychotherapy records, reports, notes, and information relating to diagnosis and treatment. (Note, Permission to release psychotherapy notes must be on a separate form.)": defender_psych
      - "Any and all information and records about testing, diagnosis or treatment for HIV/ AIDS or sexually transmitted diseases it may contain.": defender_hiv
      - "Any and all information and records about drug or alcohol use, testing, diagnosis or treatment it may contain, which are protected by federal confidentiality rules 42 CFR Part 2 (FEDERAL RULES PROHIBIT ANY FURTHER DISCLOSURE OF THIS INFORMATION UNLESS FURTHER DISCLOSURE IS EXPRESSLY PERMITTED OR WRITTEN CONSENT OF THE PERSON TO WHOM IT PERTAINS OR AS OTHERWISE PERMITTED BY 42 CFR PART 2.)": defender_abuse
      - Other: defender_other
    none of the above: False
  - "If other, please specify": accel_other
    required: False
---
question: |
  If requesting Records, please provide the start date
fields:
  - Beginning date: accelerator.beginning
    datatype: date
#accelerator, having some trouble with the "if, then" with this
---
question: |
  Please sign your name below.
signature: client.signature
under: |
  ${ client }
---
question: |
  Please sign parent name below.
signature: parent.signature
under: |
  ${ parent }
---
question: |
  Please sign your initials.
signature: client.initials

under: |
  ${ client }
#accelarator
---
comment: |
  We can use reconsider here to make sure the selection is updated
  if the person uses the back button
reconsider: True
code: |
  # Docassemble stops running a code block after variable it's seeking is defined.
  # So we start with a temp variable, and don't define our real variable name
  # until we finish building it
  form_to_use_temp = []
  if "jdc" in doc_select.true_values():
    form_to_use_temp.append(JDCHIPAA)
  if "a2p" in doc_select.true_values():
    form_to_use_temp.append(A2PHIPAA)
  if "defenders" in doc_select.true_values():
    form_to_use_temp.append(DEFHIPAA)

  form_to_use = form_to_use_temp
---
question: |
  Here are your PDF forms
mandatory: True
attachment code: form_to_use
---
attachment:
  variable name: JDCHIPAA
  name: HIPAA JDC
  filename: HIPAA JDC
  pdf template file: JDC_HIPAA_Improved.pdf
  fields:
    - client.name: |
        ${ client.name }
    - studentattorney.name: |
        ${ studentattorney.name }
    - client.dob: |
        ${ client.dob }
    - todays.date: |
        ${ today() }
    - date_event: |
        ${ client.event }
    - client.signature: |
        ${ client.signature }
    - parent.name: |
        ${ parent.name }
    - parent.signature: |
        ${ parent.signature }
---
attachment:
  variable name: A2PHIPAA
  name: HIPAA Accelerator
  filename: HIPAA Accelerator
  pdf template file: A2P_HIPAA.pdf
  fields:
    - Name Organization: |
        ${ hospital.name }
    - Address: |
        ${ hospital.street } ${ hospital.city }, MA ${ hospital.zip }
    - client.name: |
        ${ client.name }
    - studentattorney.name: |
        ${ studentattorney.name }
    - client.dob: |
        ${ client.dob }
    - todays.date: |
        ${ today() }
    - records.date: |
        ${ accelerator.beginning }
    - date_event: |
        ${ client.event }
    - client.signature: |
        ${ client.signature }
    - client.initial.records: |
        if defender_records
          ${ client.initials }
    - client.initial.psych: |
        if defender_psych
          ${ client.initials }
    - client.initial.hiv: |
        if defender_hiv
          ${ client.initials }
    - client.initial.abuse: |
        if defender_abuse
          ${ client.initials }
    - client.other: |
        ${ accel_other }
---
attachment:
  variable name: DEFHIPAA
  name: HIPAA Defenders
  filename: HIPAA Defenders
  pdf template file: Defenders_HIPAA_Redone.pdf
  fields:
    - client.name: |
        ${ client.name }
    - studentattorney.name: |
        ${ studentattorney.name }
    - client.dob: |
        ${ client.dob }
    - todays.date: |
        ${ today() }
    - today.year: |
        ${ format_date( today() + date_interval(years=1) ) }.
    - court: |
        ${ court.name }
    - all.info: |
          ${yesno(defender.disclose['all.info'])}
    - records: |
          ${yesno(defender.disclose['records_def'])}
    - relates_to: |
          ${ relates_to }
    - client.signature: |
        ${ client.signature }
---
question: |
  What is your fax number?
fields:
  - Fax: fax_number
---
question: |
  What file would you like
  me to fax?
fields:
  - File: document
    datatype: file
---
code: |
  fax_result = send_fax(user, document)
---
mandatory: True
question: |
  % if fax_result.received():
  The fax was received.
  % else:
  The status of the fax is
  ${ fax_result.status() }.
  % endif
reload: True