"{\n \"request\": {\n \"urgent\": \"false\",\n \"form_id\": \"\",\n \"state\": \"\",\n \"memo\": \"\",\n \"patient\": {\n \"first_name\": \"\",\n \"middle_name\": \"\",\n \"last_name\": \"\",\n \"date_of_birth\": \"\",\n \"gender\": \"\",\n \"email\": \"\",\n \"member_id\": \"\",\n \"phone_number\": \"\",\n \"address\": {\n \"street_1\": \"\",\n \"street_2\": \"\",\n \"city\": \"\",\n \"state\": \"\",\n \"zip\": \"\"\n }\n },\n \"payer\": {\n \"form_search_text\": \"\",\n \"bin\": \"\",\n \"pcn\": \"\",\n \"group_id\": \"\",\n \"medical_benefit_name\": \"\",\n \"drug_benefit_name\": \"\"\n },\n \"prescriber\": {\n \"npi\": \"\",\n \"first_name\": \"\",\n \"last_name\": \"\",\n \"clinic_name\": \"\",\n \"speciality\": \"\",\n \"address\": {\n \"street_1\": \"\",\n \"street_2\": \"\",\n \"city\": \"\",\n \"state\": \"\",\n \"zip\": \"\"\n },\n \"fax_number\": \"\",\n \"phone_number\": \"\"\n },\n \"prescription\": {\n \"drug_id\": \"\",\n \"strength\": \"\",\n \"frequency\": \"\",\n \"enumerated_fields\": \"\",\n \"refills\": \"\",\n \"dispense_as_written\": \"\",\n \"quantity\": \"\",\n \"days_supply\": \"\"\n },\n \"pharmacy\": {\n \"name\": \"\",\n \"address\": {\n \"street_1\": \"\",\n \"street_2\": \"\",\n \"city\": \"\",\n \"state\": \"\",\n \"zip\": \"\"\n },\n \"fax_number\": \"\",\n \"phone_number\": \"\"\n },\n \"enumerated_fields\": {\n \"icd9_0\": \"\",\n \"icd9_1\": \"\",\n \"icd9_2\": \"\",\n \"failed_med_0\": \"\",\n \"failed_med_1\": \"\",\n \"failed_med_2\": \"\",\n \"failed_med_3\": \"\",\n \"failed_med_4\": \"\",\n \"failed_med_5\": \"\",\n \"failed_med_6\": \"\",\n \"failed_med_7\": \"\",\n \"failed_med_8\": \"\",\n \"failed_med_9\": \"\"\n }\n }\n}\n"