2 Medical Malpractice Payment

Medical Malpractice Payment Form and Instruction

Non-visible Questions
Label

PDF Name
(step)

Location

Response
Input
Item

Visibility Trigger

Other

Date of Death

Medical
Below "Is this
Malpractice person deceased?"
Payment (1)

Text
Entry

The field is displayed
if the user selects
the "Yes" radio
button for "Is this
person deceased?"

Organization
Description

Medical
Below Organization
Malpractice Type
Payment (1)

Text
Entry

The field is displayed
if the user selects an
organization type
that requires a
description.

Specialty

Medical
Beside Profession or Text
Malpractice Field of Licensure
entry
Payment (1)

The field is displayed
if the user selects a
profession or field of
licensure that
requires a
description.

“Specialty” is
displayed in place
of “Name of
Occupation” if
the selected
profession or
field of
licensure requires
specialty
information.

Description

Medical
Beside Profession or Drop List The field is displayed
Malpractice Field of Licensure
if the user selects a
Payment (1)
profession or field of
licensure that
requires information
for specialty.

“Description” is
displayed in place
of “Specialty” if
the selected
profession or
field of licensure
does not require
information for a
specialty.

FEIN (Federal
Employer
Identification
Number)

Medical
Below checkbox
Malpractice "Does the subject
Payment (1) have an FEIN, or
UPIN identification
number?"

Selecting the
checkbox
displays FEIN and
UPIN text entry
fields.

Text
Entry

The field is displayed
if the user selects
the checkbox
for "Does the
subject have an
FEIN, or UPIN
identification
number?"

Label

PDF Name
(step)

Location

Response
Input
Item
Text
Entry

Visibility Trigger

Other

The field is displayed
if the user selects
the checkbox for
"Does the subject
have an FEIN, or
UPIN identification
number?"

Selecting the
checkbox
displays FEIN and
UPIN text entry
fields.

UPIN (Unique
Physician
Identification
Numbers)

Medical
Below FEIN text
Malpractice entry
Payment (1)

Unknown

Medical
Beside Total Amount Checkbox The field is displayed
Malpractice Paid (to be Paid)
if the user selects
Payment (2)
“One of multiple
payments” for “This
payment
represents.”

Date of Judgment

Medical
Below This payment Text
Malpractice was a result of:
Entry
Payment (2)

The field is displayed
if the user selects
“Judgment” from
the “This payment
was a result of:”
drop list.

If the user selects
“Judgment” then
the Date of
Judgment,
Adjudicative
Body Name, Case
Number, and
Court File
Number fields
are displayed.

Adjudicative Body
Name

Medical
Below Date of the
Malpractice Judgment
Payment (2)

The field is displayed
if the user selects
“Judgment” from
the “This payment
was a result of:”
drop list.

If the user selects
“Judgment” then
the Date of
Judgment,
Adjudicative
Body Name, Case
Number, and
Court File
Number fields
are displayed.

Text
Entry

Label

PDF Name
(step)

Location

Response
Input
Item

Visibility Trigger

Other

Case Number

Medical
Beside Adjudicative
Malpractice Body Name
Payment (2)

Text
Entry

The field is displayed
if the user selects
“Judgment” from
the “This payment
was a result of:”
drop list.

If the user selects
“Judgment” then
the Date of
Judgment,
Adjudicative
Body Name, Case
Number, and
Court File
Number fields
are displayed.

Court File Number

Medical
Below Adjudicative
Malpractice Body Name
Payment (2)

Text
Entry

The field is displayed
if the user selects
“Judgment” from
the “This payment
was a result of:”
drop list.

If the user selects
“Judgment” then
the Date of
Judgment,
Adjudicative
Body Name, Case
Number, and
Court File
Number fields
are displayed.

Date of Settlement

Medical
Below This payment Text
Malpractice was a result of:
Entry
Payment (2)

The field is displayed
if the user selects
“Settlement” from
the “This payment
was a result of:”
drop list.

If the user selects
“Settlement”
then the Date of
Settlement and
“This is a global
settlement for
multiple
claimants”
checkbox fields
are displayed.

Label

PDF Name
(step)

Location

Response
Input
Item

Visibility Trigger

This is a global
settlement for
multiple claimants

Medical
Below Date of
Malpractice Settlement
Payment (2)

Checkbox The field is displayed
if the user selects
“Settlement” from
the “This payment
was a result of:”
drop list.

Total number of
claimants included
in this settlement

Medical
Below “This is a
Text
Malpractice global settlement
Entry
Payment (2) for multiple
claimants” checkbox

The field is displayed
if the user selects
“This is a global
settlement for
multiple claimants”
checkbox.

Total number of
practitioners

Medical
Below “Are other
Malpractice practitioners
Payment (2) included in this
case?”

The field is displayed
if the user selects
the “Yes” radio
button for “Are
other practitioners
included in this
case?”

Text
Entry

Other

If the user selects
“Settlement”
then the Date of
Settlement and
“This is a global
settlement for
multiple
claimants”
checkbox fields
are displayed.

If the user selects
the “Yes” radio
button for “Are
other
practitioners
included in this
case?” then
“Total number of
practitioners”
and “Total
amount paid (or
to be paid) for all
practitioners in
this case fields”
are displayed.

Label

PDF Name
(step)

Location

Response
Input
Item

Visibility Trigger

Other

If the user selects
the “Yes” radio
button for “Are
other
practitioners
included in this
case?” then
“Total number of
practitioners”
and “Total
amount paid (or
to be paid) for all
practitioners in
this case fields”
are displayed.

Total amount paid
Medical
Below “Total
(or to be paid) for all Malpractice number of
practitioners in this Payment (2) practitioners”
case

Text
Entry

The field is displayed
if the user selects
the “Yes” radio
button for “Are
other practitioners
included in this
case?”

Has a state guaranty Medical
Below “Your
fund or state excess Malpractice organization’s
judgement fund
Payment (2) relationship with
made a payment for
this practitioner”
this practitioner in
this case (or is such
payment expected
to be made)?

Text
Entry

The field is displayed
if the user selects an
applicable option for
“Your organization’s
relationship with
this practitioner”

Medical
Below radio button Text
Malpractice for “Has a state
Entry
Payment (2) guaranty fund or
state excess
judgement fund
made a payment for
this practitioner in
this case (or is such
payment expected
to be made)?”

The field is displayed
if the user selects
the “Yes” radio
button for “Has a
state guaranty fund
or state excess
judgement fund
made a payment for
this practitioner in
this case (or is such
payment expected
to be made)?”

Total amount paid
(to be paid)

Label

PDF Name
(step)

Location

Has a self-insured
Medical
Below “Your
organization and/or Malpractice organization’s
other insurance
Payment (2) relationship with
company/companies
this practitioner”
made payments for
this practitioner in
this case (or is such
payment expected
to be made)?

Response
Input
Item

Visibility Trigger

Text
Entry

The field is displayed
if the user selects an
applicable option for
“Your organization’s
relationship with
this practitioner”

Total amount paid
(to be paid)

Medical
Below radio button Text
Malpractice for “Has a selfEntry
Payment (2) insured organization
and/or other
insurance
company/companies
made payments for
this practitioner in
this case (or is such
payment expected
to be made)?”

The field is displayed
if the user selects
the “Yes” radio
button for “Has a
self-insured
organization and/or
other insurance
company/companies
made payments for
this practitioner in
this case (or is such
payment expected
to be made)?”

Description

Medical
Below “Specific
Malpractice Allegation”
Payment (2)

The field is displayed
if the user selects an
allegation that
requires a
description.

Text
Entry

Other

State Changes
Label

PDF Name

Item Type

Trigger

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

Medical
Malpractice
Payment

Modal

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

Select a
Profession or
Field of
Licensure

Medical
Malpractice
Payment

Modal

When the user sets focus on the Profession or Field of
Licensure text entry, the modal to select a profession
is displayed and focus is set on the Search text
entry. The user can enter text in the Search text box
to find a specific profession or select a profession
from the list without searching. The modal is hidden
once the user selects a profession from the list. The
user's selection populates the Profession or Field of
Licensure text entry.

Name of
Occupation

Medical
Malpractice
Payment

Text Entry

Text entry is disabled if the user does not select a
profession or field of licensure requiring a
description.

License
Number

Medical
Malpractice
Payment

Text Entry

Text entry is disabled if the user selects the "No/ Not
sure" option for "Does the subject have a license for
the selected profession or field of licensure?"

Select an
Allegation

Medical
Malpractice
Payment

Modal

When the user sets focus on the Specific Allegation
text entry, the modal to select an act is displayed and
focus is set on the Search text entry. The user can
enter text in the Search text box to find a specific act
or select an act from the list without searching. The
modal is hidden once the user selects an act from the
list. The user's selection populates the Specific
Allegation text entry.