31 Agent Registration (Initial)_0915-0126

National Practitioner Data Bank for Adverse Information on Physicians and Other Health Care Practitioners: 45 CFR Part 60 Regulations and Forms

Agent Registration (Initial)_0915-0126

OMB: 0915-0126

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Non-visible Questions
Label

PDF Name
(step)

Location

Response
Input
Item

Visibility
Trigger

Other

Register for a new Agent
NPDB account for Registration
my organization

Below “Register
my
organization”

Radio
Button

The field is
displayed if the
user selects the
option
“Register my
organization.”

Selecting the radio
button “Register
my organization”
displays three
options: “Register
for a new NPDB
account for my
organization,”
“Renew or update
my organization’s
NPDB registration,”
and “Request
another DBID for
my organization’s
NPDB account.”

Renew or update Agent
my organization’s Registration
NPDB registration

Below “Register
my
organization”

Radio
Button

The field is
displayed if the
user selects the
option
“Register my
organization.”

Selecting the radio
button “Register
my organization”
displays three
options: “Register
for a new NPDB
account for my
organization,”
“Renew or update
my organization’s
NPDB registration,”
and “Request
another DBID for
my organization’s
NPDB account.”

Label

PDF Name
(step)

Location

Request another
DBID for my
organization’s
NPDB account

Agent
Below “Register
Registration – my
(What do you organization”
need to do?)

DBID Number

Agent
Registration–
(Select the
best option
for your
organization)

Response
Input
Item
Radio
Button

Below “Do you Text Entry
know the
current DBID for
your
organization?”

Visibility
Trigger

Other

The field is
displayed if the
user selects the
option
“Register my
organization.”

Selecting the radio
button “Register
my organization”
displays three
options: “Register
for a new NPDB
account for my
organization,”
“Renew or update
my organization’s
NPDB registration,”
and “Request
another DBID for
my organization’s
NPDB account.”

The field is
displayed if the
user selects the
“Yes” option.

State Changes
Label

PDF Name

OMB Number: 09150126 Expiration Date:
mm/dd/yyyy

Agent
Registration

Modal

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

Is your organization
already registered
with the NPDB?

Agent
Registration

Modal

When the user selects “Request another
DBID my organization’s NPDB account” for
“Register my organization”

An agent may only
Agent
access the NPDB if
Registration
they are designated by
a registered health
care entity to act on
their behalf

Modal

When the user submits their selection for a
category and the radio button “An agent
registering to query and/or report on
behalf of another organization” is selected,
then the modal is displayed with a Yes and
No button. If the user selects Yes, they
continue to register as an agent. If no, then
the modal closes.

I am authorized by my Agent
organization to serve Registration
as the certifying
official

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).

Password
Requirements

Info box

Agent
Registration

Item Type

Trigger

When the user sets focus on the "Create a
new password" text entry, the info box is
displayed. The state of each rule changes
to indicate whether or the rule is met as
the user enters their text.


File Typeapplication/pdf
File TitleAgent Registration (Initial)
SubjectNPDB registration forms
AuthorHealth Resources and Services Administration
File Modified2020-11-19
File Created2020-08-03

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