department-of-veterans-affairs/vets-website

import React from 'react';
import { VaAdditionalInfo } from '@department-of-veterans-affairs/component-library/dist/react-bindings';
import { recordEventOnce } from 'platform/monitoring/record-event';
import { ANALYTICS_EVENTS, HELP_TEXT_CLICKED_EVENT } from '../constants';

const {
  openedPrivateRecordsAcknowledgment,
  openedPrivateChoiceHelp,
} = ANALYTICS_EVENTS;

export const privateRecordsChoiceHelp = (
  <div className="private-records-choice-help">
    <VaAdditionalInfo
      trigger="Which should I choose?"
      disableAnalytics
      onClick={() =>
        recordEventOnce(openedPrivateChoiceHelp, HELP_TEXT_CLICKED_EVENT)
      }
    >
      <h3 className="vads-u-font-size--h4">You upload your medical records</h3>
      <p>
        If you upload a digital copy of all your medical records, we can review
        your claim more quickly. Uploading a digital file works best if you have
        a computer with a fast Internet connection. The digital file can be
        uploaded as a .pdf or other photo file format, like a .jpeg or .png.
      </p>
      <h3 className="vads-u-font-size--h4">
        We get your medical records for you
      </h3>
      <p>
        If you tell us the name of the private doctor or hospital that treated
        you for your condition, we can get your medical records for you. Getting
        your records may take us some time, and this could mean that it’ll take
        us longer to make a decision on your claim.
      </p>
    </VaAdditionalInfo>
  </div>
);

export const patientAcknowledgmentTitle = (
  <h3 className="vads-u-margin-top--0">Request a disclosure</h3>
);

export const patientAcknowledgmentText = (
  <div className="patient-acknowldegment-help">
    <VaAdditionalInfo
      trigger="Read the full text."
      disableAnalytics
      onClick={() =>
        recordEventOnce(
          openedPrivateRecordsAcknowledgment,
          HELP_TEXT_CLICKED_EVENT,
        )
      }
    >
      <h4>Patient Authorization:</h4>
      <p>
        I voluntarily authorize and request disclosure (including paper, oral,
        and electronic interchange) of: All my medical records; including
        information related to my ability to perform tasks of daily living. This
        includes specific permission to release:
      </p>
      <ol>
        <li>
          All records and other information regarding my treatment,
          hospitalization, and outpatient care for my impairment(s) including,
          but not limited to:
        </li>
        <li>
          <ul>
            <li>
              Psychological, psychiatric, or other mental impairment(s)
              excluding "psychotherapy notes" as defined in 45 C.F.R. §164.501,
            </li>
            <li>Drug abuse, alcoholism, or other substance abuse,</li>
            <li>Sickle cell anemia,</li>
            <li>
              Records which may indicate the presence of a communicable or
              non-communicable disease; and tests for or records of HIV/AIDS,
            </li>
            <li>Gene-related impairments (including genetic test results)</li>
          </ul>
        </li>
        <li>
          Information about how my impairment(s) affects my ability to complete
          tasks and activities of daily living, and affects my ability to work.
        </li>
        <li>
          Information created within 12 months after the date this authorization
          is signed in Item 11, as well as past information.
        </li>
      </ol>
      <p>
        You should not complete this form unless you want the VA to obtain
        private treatment records on your behalf. If you have already provided
        these records or intend to obtain them yourself, there is no need to
        fill out this form. Doing so will lengthen your claim processing time.
      </p>
      <h4>Important:</h4>
      <p>
        In accordance with 38 C.F.R. §3.159(c), "VA will not pay any fees
        charged by a custodian to provide records requested."
      </p>
      <h4>Patient Acknowledgment:</h4>
      <p>
        I hereby authorize the sources listed in Section IV, to release any
        information that may have been obtained in connection with a physical,
        psychological or psychiatric examination or treatment, with the
        understanding that VA will use this information in determining my
        eligibility to veterans benefits I have claimed.
      </p>
      <p>
        I understand that the source being asked to provide the Veterans
        Benefits Administration with records under this authorization may not
        require me to execute this authorization before it provides me with
        treatment, payment for health care, enrollment in a health plan, or
        eligibility for benefits provided by it.
      </p>
      <p>
        I understand that once my source sends this information to VA under this
        authorization, the information will no longer be protected by the HIPAA
        Privacy Rule, but will be protected by the Federal Privacy Act, 5 USC
        552a, and VA may disclose this information as authorized by law.
      </p>
      <p>
        I also understand that I may revoke this authorization in writing, at
        any time except to the extent a source of information has already relied
        on it to take an action. To revoke, I must send a written statement to
        the VA Regional Office handling my claim or the Board of Veterans'
        Appeals (if my claim is related to an appeal) and also send a copy
        directly to any of my sources that I no longer wish to disclose
        information about me.
      </p>
      <p>
        I understand that VA may use information disclosed prior to revocation
        to decide my claim.
      </p>
      <p>
        Note: For additional information regarding VA Form 21-4142, refer to the
        following website:{' '}
        <a
          href="https://www.benefits.va.gov/privateproviders/"
          target="_blank"
          rel="noopener noreferrer"
        >
          https://www.benefits.va.gov/privateproviders/
        </a>
        .
      </p>
    </VaAdditionalInfo>
  </div>
);