26 Authorized Agent Attestation_0915-0126

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

Authorized Agent Attestation_0915-0126

OMB: 0915-0126

Document [pdf]
Download: pdf | pdf
Non-visible Questions
Label
Why
not?

PDF Name
(step)

Location

Authorized
Agent
Attestation (1)

Response
Input Item

Below the Yes Text Entry
and No radio
buttons

Visibility Trigger

Other

The field is displayed
if the user selects the
No radio button

State Changes
Label

PDF Name

Item Type

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

Authorized Modal
Agent
Attestation

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


File Typeapplication/pdf
File TitleAuthorized Agent Attestation
SubjectNPDB attestation
AuthorHealth Resources and Services Administration
File Modified2020-11-19
File Created2020-07-29

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