Form 34 Authorized Agent Designation_0915-0126

Non-visible Questions
Label

PDF Name
(step)

Location

Response
Input
Item

Visibility Trigger

Other

One-Time
Query

Authorized
Agent
Designation
(1)

2nd section
of the form
to select
functions

Checkbox If the entity is
authorized and elects
to query the NPDB

Continuous
Query
Enrollment

Authorized
Agent
Designation
(1)

2nd section
of the form
to select
functions

Checkbox If the entity is
authorized and elects
to query the NPDB and
has activated
Continuous Query

I authorize
my agent to
resolve
compliance
actions for
professions
in a
compliance
review

Authorized Below the
Agent
report
Designation checkbox
(1)

Is the agent
authorized to
use your EFT
account to
pay for query
transactions
submitted on
your behalf?

Authorized
Agent
Designation
(1)

Below the
Radio
group of
buttons
checkboxes
to select
functions
the user is
authorizing
the agent to
perform

The field is displayed
if the user selects the
One-Time Query or
Continuous Query
Enrollment checkbox

The options
displayed are Yes and
No

Where
should we
send your
responses?

Authorized
Agent
Designation
(1)

Below the
Radio
radio button buttons
group of
who should
receive the
responses

The field is displayed if
the user selects the My
organization radio
button or Both of us
radio button

The options
displayed are IQRS,
the NPDB system and
QRXS

Checkbox The field is displayed
if the user selects the
Report checkbox and is
a state licensure entity

State Changes
Label

PDF Name

Item Type

Trigger

OMB Number:
0915-0126
Expiration Date:
mm/dd/yyyy

Authorized
Agent
Designation
(1)

Modal

When the user selects the link the
modal is displayed with the public
burden statement content.