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pdf Non-visible Questions
Label
PDF Name
(step)
Location
Response
Input
Item
Visibility
Trigger
Other
Name of your
federal agency
Entity
Registration
Renewal –
Select the
best option
for your
organization
Below “Federal
government
agency or
entity” radio
button
Drop List
The field is
displayed if the
user the option
“Federal
government
agency or
entity” for
“Who owns
your
organization?”
Is your
organization also
a health plan?
Entity
Registration
Renewal –
Select the
best option
for your
organization
Below “Best
category for
your
organization”
Radio
buttons
The fields are
displayed if the
user selects a
category that
has a
secondary
category for
registration.
Radio buttons
are “Yes” and
“No.”
The label for the
secondary
category is
dynamic and is
dependent on the
user’s selection for
the primary
category (i.e., the
“Best category for
your organization.”
Select up to 4
additional
functions or
services
Entity
Registration
Renewal –
Select the
best option
for your
organization.
Below drop list
“Select your
organization’s
primary health
care-related
function or
service
Check
Boxes
The fields are
displayed if
user selects the
link “Add a
function”
Selecting the link
displays all
relevant functions
that apply to the
registration
category and
secondary
category selected
by the user.
Label
PDF Name
(step)
Location
Response
Input
Item
Visibility
Trigger
Description
Entity
Registration
Renewal –
Select the
best option
for your
organization.
Below checkbox Text Entry
for relevant
checkbox
selection
The field is
displayed if the
user selects a
function that
requires a
description.
NPI (National
Provider
Identifier)
Entity
Registration
Renewal –
Organization
Information
Below
Identification
Numbers
Text Entry The field is
displayed if the
user selects a
registration
category or
secondary
category that
has an NPI.
CCN (CMS
Certification
Number)
Entity
Registration
Renewal –
Organization
Information
Below
Identification
Numbers
Text Entry The field is
displayed if the
user selects a
registration
category or
secondary
category that
has a CCN
ORI (Originating
Entity
Agency Identifier) Registration
Renewal –
Organization
Information
Below
Identification
Numbers
Text Entry The field is
displayed if the
user selects a
registration
category or
secondary
category that
has an ORI.
Other
Label
PDF Name
(step)
Location
Response
Input
Item
Visibility
Trigger
Other
Name of person
or office
Entity
Registration
Renewal –
Your Point of
Contact on
NPDB
Reports
Below the radio Text Entry
button “I will
assign a specific
person or office
to contact”
The field is
displayed if the
user selects the
radio button
for “I will
assign a
specific person
or office to
contact.”
Selecting the
checkbox displays
Name of person or
office, Title or
department,
Phone, and
Extension text
entry fields.
Title or
department
Entity
Below “Name of Text Entry
Registration person or
Renewal –
office”
Your Point of
Contact on
NPDB
Reports
The field is
displayed if the
user selects the
radio button
for “I will
assign a
specific person
or office to
contact.”
Selecting the
checkbox displays
Name of person or
office, Title or
department,
Phone, and
Extension text
entry fields.
Phone
Entity
Below “Title or
Registration department”
Renewal –
Your Point of
Contact on
NPDB
Reports
Text Entry The field is
displayed if the
user selects the
radio button
for “I will
assign a
specific person
or office to
contact.”
Selecting the
checkbox displays
Name of person or
office, Title or
department,
Phone, and
Extension text
entry fields.
Extension
(optional)
Entity
Beside “Phone”
Registration
Renewal –
Your Point of
Contact on
NPDB
Reports
Text Entry The field is
displayed if the
user selects the
radio button
for “I will
assign a
specific person
or office to
contact.”
Selecting the
checkbox displays
Name of person or
office, Title or
department,
Phone, and
Extension text
entry fields.
Label
PDF Name
(step)
Description
Entity
Registration
Renewal
Location
Response
Input
Item
Below Select up Text
to 5 actions
Entry
Visibility
Trigger
The field is
displayed if the
user selects an
adverse action
that requires a
description.
Other
State Changes
Label
PDF Name
OMB Number: 09150126 Expiration Date:
mm/dd/yyyy
Entity
Registration
Renewal
I am authorized by my Entity
organization to serve Registration
as the certifying
Renewal
official
Item Type
Modal
Trigger
When the user selects the link the modal
is displayed with the public burden
statement content.
Check Box Selecting the checkbox hides the fields for
the Certifying Official’s Information (First
Name, Middle Name, Last Name, Suffix,
Title, Phone, Extension, Email Address,
Employee ID).
| File Type | application/pdf |
| File Title | Entity Registration (Renewal Update) |
| Subject | NPDB forms |
| Author | Health Resources and Services Administration |
| File Modified | 2020-11-19 |
| File Created | 2020-08-26 |