Download:
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pdf 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 Type | application/pdf |
| File Title | Agent Registration (Initial) |
| Subject | NPDB registration forms |
| Author | Health Resources and Services Administration |
| File Modified | 2020-11-19 |
| File Created | 2020-08-03 |