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Sample PDF, Spec updates, PDF JSON, Upload/PDF Stamper logic
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46 changes: 46 additions & 0 deletions
46
modules/simple_forms_api/app/form_mappings/vha_10_7959a.json.erb
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| Original file line number | Diff line number | Diff line change |
|---|---|---|
| @@ -0,0 +1,46 @@ | ||
| { | ||
| "form1[0].#subform[0].Phone-ptnt[0]": "<%= form.data.dig('veteran', 'phone_number') %>", | ||
| "form1[0].#subform[0].ZIPCode-ptnt[0]": "<%= form.data.dig('veteran', 'address', 'postal_code') %>", | ||
| "form1[0].#subform[0].State-ptnt[0]": "<%= form.data.dig('veteran', 'address', 'state') %>", | ||
| "form1[0].#subform[0].City-ptnt[0]": "<%= form.data.dig('veteran', 'address', 'city') %>", | ||
| "form1[0].#subform[0].Date-Ptnt[0]": "<%= form.data.dig('veteran', 'date_of_birth') %>", | ||
| "form1[0].#subform[0].CheckIfNew[0]": "<%= form.data.dig('veteran', 'is_new_address') %>", | ||
| "form1[0].#subform[0].StreetAddrss-ptnt[0]": "<%= form.data.dig('veteran', 'address', 'street') %>", | ||
| "form1[0].#subform[0].SSN-ptnt[0]": "<%= form.data.dig('veteran', 'ssn_or_tin') %>", | ||
| "form1[0].#subform[0].MiddleInit-ptnt[0]": "<%= form.data.dig('veteran', 'full_name', 'middle') %>", | ||
| "form1[0].#subform[0].FirstNme-ptnt[0]": "<%= form.data.dig('veteran', 'full_name', 'first') %>", | ||
| "form1[0].#subform[0].LastNme-ptnt[0]": "<%= form.data.dig('veteran', 'full_name', 'last') %>", | ||
|
|
||
| "form1[0].#subform[0].#area[2].WorkRelatedTreat[0]": "", | ||
| "form1[0].#subform[0].#area[2]": "", | ||
| "form1[0].#subform[0].#area[0].OutsdWrkAccdnt[0]": "", | ||
| "form1[0].#subform[0].#area[0]": "", | ||
| "form1[0].#subform[0].PtntCverage[0]": "", | ||
| "form1[0].#subform[0].NameOHI-1[0]": "<%= form.data.dig('ohi_info', 'insurances')[0]&.dig('name') %>", | ||
| "form1[0].#subform[0].OHIPolicyNmbr-1[0]": "<%= form.data.dig('ohi_info', 'insurances')[0]&.dig('policy_number') %>", | ||
| "form1[0].#subform[0].Phone-OHI-1[0]": "<%= form.data.dig('ohi_info', 'insurances')[0]&.dig('phone_number') %>", | ||
| "form1[0].#subform[0].NameOHI-2[0]": "<%= form.data.dig('ohi_info', 'insurances')[1]&.dig('name') %>", | ||
| "form1[0].#subform[0].OHIPolicyNmbr-2[0]": "<%= form.data.dig('ohi_info', 'insurances')[1]&.dig('policy_number') %>", | ||
| "form1[0].#subform[0].Phone-OHI-2[0]": "<%= form.data.dig('ohi_info', 'insurances')[1]&.dig('phone_number') %>", | ||
| "form1[0].#subform[0].#area[1].RadioButtonList[0]": "", | ||
| "form1[0].#subform[0].#area[1].RadioButtonList[1]": "", | ||
| "form1[0].#subform[0].#area[1].RadioButtonList[2]": "", | ||
| "form1[0].#subform[0].#area[1].RadioButtonList[3]": "", | ||
| "form1[0].#subform[0].#area[1].SpecifyOtherPrimaryHealthInsurance[0]": "<%= form.data.dig('ohi_info', 'coverage_type_other') %>", | ||
|
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| "form1[0].#subform[0].LastNme-spnsr[0]": "<%= form.data.dig('sponsor', 'full_name', 'last') %>", | ||
| "form1[0].#subform[0].FirstNme-spnsr[0]": "<%= form.data.dig('sponsor', 'full_name', 'first') %>", | ||
| "form1[0].#subform[0].MiddleInit-spnsr[0]": "<%= form.data.dig('sponsor', 'full_name', 'middle') %>", | ||
|
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||
| "form1[0].#subform[0].SignatureTelephoneNumber[0]": "<%= form.data.dig('claimant', 'phone_number') %>", | ||
| "form1[0].#subform[0].SignatureZipCode[0]": "<%= form.data.dig('claimant', 'address', 'postal_code') %>", | ||
| "form1[0].#subform[0].SignatureState[0]": "<%= form.data.dig('claimant', 'address', 'state') %>", | ||
| "form1[0].#subform[0].SignatureCity[0]": "<%= form.data.dig('claimant', 'address', 'city') %>", | ||
| "form1[0].#subform[0].SignatureStreetAddress[0]": "<%= form.data.dig('claimant', 'address', 'street') %>", | ||
| "form1[0].#subform[0].SignatureField1[0]": "<%= form.data.dig('claimant', 'signature') %>", | ||
| "form1[0].#subform[0].SignatureMiddleInitial[0]": "<%= form.data.dig('claimant', 'full_name', 'middle') %>", | ||
| "form1[0].#subform[0].SignatureFirstName[0]": "<%= form.data.dig('claimant', 'full_name', 'first') %>", | ||
| "form1[0].#subform[0].SignatureLastName[0]": "<%= form.data.dig('claimant', 'full_name', 'last') %>", | ||
| "form1[0].#subform[0].relationshipToApplicant[0]": "<%= form.data.dig('claimant', 'relationship_to_patient') %>", | ||
| "form1[0].#subform[0].SignatureDateOfBirth2[0]": "<%= form.data.dig('claimant', 'date_of_birth') %>" | ||
| } |
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modules/simple_forms_api/app/models/simple_forms_api/vha_10_7959a.rb
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| Original file line number | Diff line number | Diff line change |
|---|---|---|
| @@ -0,0 +1,25 @@ | ||
| # frozen_string_literal: true | ||
|
|
||
| module SimpleFormsApi | ||
| class VHA107959a | ||
| include Virtus.model(nullify_blank: true) | ||
|
|
||
| attribute :data | ||
|
|
||
| def initialize(data) | ||
| @data = data | ||
| end | ||
|
|
||
| def metadata | ||
| { | ||
| 'veteranFirstName' => @data.dig('veteran', 'full_name', 'first'), | ||
| 'veteranLastName' => @data.dig('veteran', 'full_name', 'last'), | ||
| 'fileNumber' => @data.dig('veteran', 'va_file_number').presence || @data.dig('veteran', 'ssn'), | ||
| 'zipCode' => @data.dig('veteran', 'address', 'postal_code'), | ||
| 'source' => 'VA Platform Digital Forms', | ||
| 'docType' => @data['form_number'], | ||
| 'businessLine' => 'CMP' | ||
| } | ||
| end | ||
| end | ||
| end |
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66 changes: 66 additions & 0 deletions
66
modules/simple_forms_api/spec/fixtures/form_json/vha_10_7959a.json
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| Original file line number | Diff line number | Diff line change |
|---|---|---|
| @@ -0,0 +1,66 @@ | ||
| { | ||
| "form_number": "10-7959A", | ||
| "veteran": { | ||
| "date_of_birth": "1987-02-02", | ||
| "address": { | ||
| "country": "USA", | ||
| "street": "1 First Ln", | ||
| "city": "Place", | ||
| "state": "AL", | ||
| "postal_code": "12345" | ||
| }, | ||
| "full_name": { | ||
| "first": "Veteran", | ||
| "middle": "B", | ||
| "last": "Surname" | ||
| }, | ||
| "ssn_or_tin": "222554444", | ||
| "va_claim_number": "123456789", | ||
| "phone_number": "9876543213", | ||
| "is_new_address": true | ||
| }, | ||
| "sponsor": { | ||
| "full_name": { | ||
| "first": "Sponsor", | ||
| "middle": "P", | ||
| "last": "Sponsor_Surname" | ||
| } | ||
| }, | ||
| "ohi_info": { | ||
| "is_treatment_work_injury": false, | ||
| "is_treatement_non_work_injury": true, | ||
| "is_patient_covered": true, | ||
| "coverage_type": "other", | ||
| "coverage_type_other": "", | ||
| "insurances": [ | ||
| { | ||
| "name": "OHI LLC", | ||
| "policy_number": "7777", | ||
| "phone_number": "215-345-2424" | ||
| }, | ||
| { | ||
| "name": "OHI ORG", | ||
| "policy_number": "9999", | ||
| "phone_number": "668-123-4567" | ||
| } | ||
| ] | ||
| }, | ||
| "claimant": { | ||
| "date_of_birth": "1986-03-03", | ||
| "full_name": { | ||
| "first": "Claimant", | ||
| "middle": "L", | ||
| "last": "Claimant_Surname" | ||
| }, | ||
| "address": { | ||
| "country": "USA", | ||
| "street": "2 Second Ln", | ||
| "city": "Place Two", | ||
| "state": "PA", | ||
| "postal_code": "54321" | ||
| }, | ||
| "phone_number": "2153555555", | ||
| "relationship_to_patient": "Mother", | ||
| "signature": "Claimant Signature" | ||
| } | ||
| } |
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