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<ClinicalDocument xmlns="urn:hl7-org:v3" xmlns:voc="urn:hl7-org:v3/voc" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xmlns:ex="urn:hl7-PGB-Ext:v1" xsi:schemaLocation="urn:hl7-org:v3 ../../schemas/CDA.xsd">
	<!-- 
********************************************************
  CDA Header
********************************************************
	-->
	<typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/>
	<templateId root="2.16.840.1.113883.3.27.1776"  />
	<id extension="c266" root="2.16.840.1.113883.19.4"/>
	<code code="VER1" codeSystem="2.16.840.1.113883.2.4.3.21.3" codeSystemName="LOINC" displayName="Verantwoording"/>
	<title>PGB Verantwoordingsformulier</title>
	<effectiveTime value="20060322221056"/>
	<confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/>
	<languageCode code="nl-NL"/>
	<!--<setId extension="BB35" root="2.16.840.1.113883.19.7"/>
-->
	<!--<versionNumber value="2"/>
-->
	<recordTarget>
		<patientRole>
			<id extension="12345" root="2.16.840.1.113883.2.4.3.21.1"/>
			<addr>
				<city>Amsterdam</city>
				<streetAddressLine>Waterpoort 447</streetAddressLine>
			</addr>
			
			<!--<telecom use="HP" value="tel:+981 555 3472"/>
			<telecom use="WP" value="tel:+981 538 9766"/>
-->
			<patient>
				<name>
					<given>Gregory</given>
					<family>Thumbstone</family>
				</name>
			<!--	<administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1"/>
				<birthTime value="19320924"/>
-->
			</patient>
			<!--<providerOrganization>
				<id root="2.16.840.1.113883.19.5"/>
			</providerOrganization>
-->
		</patientRole>
	</recordTarget>
	<author>
		<time value="2006040714"/>
		<assignedAuthor>
			<id extension="1" root="2.16.840.1.113883.19.5"/>
			
			<assignedAuthoringDevice>
				<softwareName>ePGB Digitale verantwoording</softwareName>
			</assignedAuthoringDevice>
			<representedOrganization>
				<id extension="30228887" root="2.16.840.1.113883.19.5"/>
				<name>ePGB</name>
				<telecom  value="tel:020 77 288 26"></telecom>
				<addr>
				<city>Utrecht</city>
				<streetAddressLine>Churchillaan 11</streetAddressLine>
				</addr>

			</representedOrganization>
		</assignedAuthor>
	</author>
	<custodian>
		<assignedCustodian>
			<representedCustodianOrganization>
				<id extension="30228887" root="2.16.840.1.113883.19.5"/>
				<name>ePGB</name>
			</representedCustodianOrganization>
		</assignedCustodian>
	</custodian>

	<legalAuthenticator>
		<time value="20050329224512"/>
		<signatureCode code="S"/>
		<assignedEntity>
			<id extension="1" root="2.16.840.1.113883.19.5"/>
			<addr>
				<city>Amsterdam</city>
				<streetAddressLine>Waterpoort 447</streetAddressLine>
			</addr>
			<assignedPerson>
				<name>
					<given>William</given>
					<family>Robertson</family>
				</name>
			</assignedPerson>
		</assignedEntity>
	</legalAuthenticator>
	<!--<relatedDocument typeCode="RPLC">
		<parentDocument>
			<id extension="a123" root="2.16.840.1.113883.19.4"/>
			<setId extension="BB35" root="2.16.840.1.113883.19.7"/>
			<versionNumber value="1"/>
		</parentDocument>
	</relatedDocument>
-->
	<!--<componentOf>
		<encompassingEncounter>
			<id extension="KPENC1332" root="2.16.840.1.113883.19.6"/>
			<effectiveTime value="20060407"/>
			<encounterParticipant typeCode="CON">
				<time value="20060407"/>
				<assignedEntity>
					<id extension="600355" root="2.16.840.1.113883.19.5"/>
					<assignedPerson>
						<name>
							<given>Giesbert</given>
							<family>Nij</family>
							<suffix>MD</suffix>
						</name>
					</assignedPerson>
					<representedOrganization>
						<id root="2.16.840.1.113883.19.5"/>
					</representedOrganization>
				</assignedEntity>
			</encounterParticipant>
			<location>
				<healthCareFacility classCode="DSDLOC">
					<code code="GIM" codeSystem="2.16.840.1.113883.5.10588" displayName="General internal medicine clinic"/>
				</healthCareFacility>
			</location>
		</encompassingEncounter>
	</componentOf>
-->
	<!-- 
********************************************************
  CDA Body
********************************************************
-->
	<component>
		<structuredBody>
			<component>
				<section>
					<!-- <code code="10153-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
					Human readable part of the CDA. Only used for 'opmerking'. Transformations are done by xsl.-->
					<text>
						<list>
							<item>
								<content ID="opmerking">Dit is een opmerking</content>
							</item>
						</list>
					</text>
					<ex:entry xsi:schemaLocation="urn:hl7-PGB-Ext:v1 Verantwoording-Extension.xsd">
						<!-- EPGB Extensie -->
						<ex:totaalverantwoording>
							<ex:effectiveTime>
								<ex:low value="20060901"/>
								<ex:high value="20061001"/>
							</ex:effectiveTime>
							<ex:amt value="2000" currency="EUR"/>
							<!-- START : Ziek geweest  -->
							<ex:component1>
								<ex:doorbetaling>
									<ex:amt value="600"/>
									<ex:reason>
										<ex:vervangendeActiviteit>
											<ex:subjectOf>
												<ex:observationEvent>
													<ex:code code="gemeld" codeSystem="2.16.840.1.113883.2.4.3.21.5"/>
													<ex:value code="1" codeSystem="2.16.840.1.113883.2.4.3.21.2"/>
												</ex:observationEvent>
											</ex:subjectOf>
										</ex:vervangendeActiviteit>
									</ex:reason>
								</ex:doorbetaling>
							</ex:component1>
							<!-- END : Ziek geweest  -->
							<ex:component2>
								<!-- START : FOR EACH ZORGVERLENER -->
				
								<ex:financialTransaction>
									<ex:amt value="4.43" currency="EUR"/>
									<ex:reason>
										<ex:activiteitenSet>
											<ex:performer>
												<ex:assignedEntity>
												       <!-- Persoon of organization actief -->
												       <!--  <ex:assignedPerson>
														<ex:id extension="1234" root="2.16.840.1.13883.2.4.6.3" assigningAuthorityName="BSN"/>
														<ex:name>
																		<ex:given>Persoon 1</ex:given>
																		<ex:familiy>Persoon 1</ex:familiy>
														</ex:name>
													</ex:assignedPerson>  
-->
													<ex:representedOrganization>
														<ex:id extension="1234" root="1.3.106" assigningAuthorityName="KVK"/>
														<ex:name></ex:name>
													</ex:representedOrganization>
												</ex:assignedEntity>
											</ex:performer>
											<ex:component>
												<ex:activiteit>
													<!-- START : FOR EACH ACTIVITEIT -->
													<ex:code code="BM" codeSystem="2.16.840.1.113883.2.4.3.21.1"/>
													<ex:code code="OB-U" codeSystem="2.16.840.1.113883.2.4.3.21.1"/>
													<!-- END : FOR EACH ACTIVITEIT -->
												</ex:activiteit>
											</ex:component>
										</ex:activiteitenSet>
									</ex:reason>
								</ex:financialTransaction>
								<!-- END : FOR EACH ZORGVERLENER -->
							</ex:component2>
						</ex:totaalverantwoording>
					</ex:entry>
				</section>
			</component>
		</structuredBody>
	</component>
</ClinicalDocument>
