department-of-veterans-affairs/vets-website

import React from 'react';
import fullSchema from 'vets-json-schema/dist/21-4142-schema.json';
import { schemaFields } from '../definitions/constants';

/** @type {PageSchema} */
export default {
  uiSchema: {
    'ui:title': (
      <h3 className="vads-u-color--gray-dark vads-u-margin-top--0">
        Provide your authorization to request the medical records
      </h3>
    ),
    'ui:description': (
      <>
        <h4 className="vads-u-color--gray-dark vads-u-margin-top--0">
          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 className="vads-u-margin-left--neg2">
          <li>
            All records and other information regarding my treatment,
            hospitalization, and outpatient care for my impairment(s) including,
            but not limited to:
            <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, 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 className="vads-u-color--gray-dark">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 className="vads-u-color--gray-dark">Acknowledgment</h4>
        <p>
          I hereby authorize the sources listed in this form, 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>
      </>
    ),
    [schemaFields.acknowledgeToReleaseInformation]: {
      'ui:title': 'I acknowledge and authorize this release of information',
      'ui:widget': 'checkbox',
      'ui:options': {
        hideLabelText: true,
      },
      'ui:errorMessages': {
        enum:
          'Please authorize the release so we can request your private medical records from your non-VA provider or hopsital.',
        required:
          'Please authorize the release so we can request your private medical records from your non-VA provider or hopsital.',
      },
    },
  },
  schema: {
    type: 'object',
    required: [schemaFields.acknowledgeToReleaseInformation],
    properties: {
      [schemaFields.acknowledgeToReleaseInformation]:
        fullSchema.properties[schemaFields.acknowledgeToReleaseInformation],
    },
  },
};