Form 44 Other Eligible Entity Attestation_0915-0126

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

Other Eligible Entity Attestation_0915-0126

Other Eligible Entity Attestation

OMB: 0915-0126

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

PDF Name
(step)
Other Eligible
Entity
Attestation (1)

Location

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

Trigger

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

Other Eligible
Entity
Attestation

Modal

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


File Typeapplication/pdf
File TitleOther Eligible Entity Attestation
SubjectNPDB attestation
AuthorHealth Resources and Services Administration
File Modified2020-11-19
File Created2020-07-29

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