This developer sample maps page 1 of the official CMS Medicare GLP-1 Bridge Prior Authorization Request Form to structured intake fields with source regions. The form contains only clearly fictional, privacy-safe demo values. It contains no PHI and does not represent a patient, prescription, payer decision, clinical determination, or coverage outcome.
The unchanged downloaded CMS source is preserved at
source/cms-glp-1-bridge-original.pdf with SHA-256
c223dc0f6acaf1d7b7e345bdf968ba2373ce94b39994b006a1e9915a07768fa0.
Its canonical publisher URL is https://www.cms.gov/glp-1-bridge.pdf.
Open this reviewed proof on GitHub Pages →
data/prior-authorization.pdf is a deterministic one-page derivative. It
keeps CMS page 1 as vector content, reserves a restrained provenance rail, and
adds only the eleven approved demo values in their printed fields and
checkboxes. It has no AcroForm tree or Widget annotations. The previous bespoke
fixture remains available as data/legacy-synthetic-prior-authorization.pdf.
From the repository root:
python3 demos/prior_authorization/build_public_form.py
python3 demos/prior_authorization/build_public_form.py --check
The builder verifies the approved original and derived hashes before writing.
--check compares the committed PDF byte-for-byte without modifying it.
python3 demos/prior_authorization/generate_demo.py --provisional
python3 demos/prior_authorization/check_expected.py --allow-provisional
Open demos/prior_authorization/provisional/output/index.html directly. The page is
self-contained. These commands do not read NUTRIENT_API_KEY, use a response
cache, call the network, or consume credits. A zero exit code means only that
the fixture-derived values and manually reviewed page-0 source boxes match the
independent oracle. Provisional evidence is not API-performance evidence. The
commands write only below provisional/ and never replace the committed
reviewed artifacts under output/.
--refresh is the only credential-reading and network-capable path. It consumes
Extract API credits and may run only through the separately approved live gate:
python3 demos/prior_authorization/generate_demo.py --refresh
python3 demos/prior_authorization/check_expected.py
python3 demos/prior_authorization/generate_demo.py --replay-live
The historical cache and receipt are preserved, but they are bound to the legacy synthetic input and cannot serve as evidence for this public-form fixture. Replays require an exact input/request match. Replays never fall back to provisional evidence.
After a replacement live response has received a recorded independent review, reproduce that reviewed state with:
python3 demos/prior_authorization/generate_demo.py --replay-reviewed
python3 demos/prior_authorization/check_expected.py --reviewed-live
These commands replay receipt-bound evidence and its recorded review. They do not perform a new review or themselves approve publication.
This is intake and source review only. It does not decide patient care, medical necessity, coverage, payer action, or compliance. It is not an accuracy, compliance, security, or performance benchmark. Source regions make results reviewable; the independent oracle determines whether this single form matches.
Generated provisional artifacts are provisional/evidence.json,
provisional/output/source-page.png, provisional/output/comparison.json, and
provisional/output/index.html.