Form 17 One Time Query for an Individual

Non-visible Questions
Label

PDF Name
(step)

Location

Response Visibility
Input
Trigger
Item

Organization
Description

One Time
Query for an
Individual (1)

Below
Organization
Type

Text Entry The field is
displayed if
the user
selects an
organization
type that
requires a
description.

Name of
Occupation

One Time
Query for an
Individual (1)

Beside
Profession or
Field of
Licensure

Text entry The field is
displayed if
the user
selects a
profession or
field of
licensure that
requires a
description.

“Specialty” is
displayed in place
of “Name of
Occupation” if the
selected profession
or field of licensure
requires specialty
information.

Specialty

One Time
Query for an
Individual (1)

Beside
Profession or
Field of
Licensure

Drop List

“Name of
Occupation” is
displayed in place
of “Specialty” if the
selected profession
or field of licensure
does not require
information for a
specialty.

The field is
displayed if
the user
selects a
profession or
field of
licensure that
requires
information
for specialty.

Other

FEIN (Federal
Employer
Identification
Number)

One Time
Query for an
Individual (1)

Below
Text Entry
checkbox
"Does the
subject have
an FEIN, or
UPIN
identification
number?"

The field is
displayed if
the user
selects the
checkbox
for "Does the
subject have
an FEIN, or
UPIN
identification
number?"

Selecting the
checkbox displays
FEIN and UPIN text
entry fields.

UPIN (Unique
Physician
Identification
Numbers)

One Time
Query for an
Individual (1)

Below FEIN
text entry

Text Entry The field is
displayed if
the user
selects the
checkbox
for "Does the
subject have
an FEIN, or
UPIN
identification
number?"

Selecting the
checkbox displays
FEIN and UPIN text
entry fields.

Entity
Selection

One Time
Query for an
Individual (2)

After step 1
Subject
Information

Check
boxes

All entities are
listed for which the
user is authorized
to query.

The Entity
Selection
section is only
displayed if
the user is
authorized to
act as an
agent to
query on
behalf of
other
entities.

State Changes
Label
Public
Burden
Statement

PDF Name
One Time
Query for an
Individual

Item Type
Modal

Trigger
When the user selects the Public
Burden Statement link the modal
is displayed.

Select a
One Time
Profession or Query for an
Field of
Individual
Licensure

Modal

When the user sets focus on the
Profession or Field of Licensure
text entry, the modal to select a
profession is displayed and focus
is set on the Search text
entry. The user can enter text in
the Search text box to find a
specific profession or select a
profession from the list without
searching. The modal is hidden
once the user selects a profession
from the list. The user's selection
populates the Profession or Field
of Licensure text entry.

Name of
Occupation

One Time
Query for an
Individual

Text Entry

The field is disabled if the user
does not select a profession or
field of licensure requiring a
description.

License
Number

One Time
Query for an
Individual

Text Entry

The field is disabled if the user
selects the "No/ Not sure" option
for "Does the subject have a
license for your selected
profession or field of licensure?"