22 Subject Statement and Dispute

Subject Statement and Dispute Form and Instruction

State Changes
Label

PDF Name

Item Type

Trigger

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

Subject Statement
and Dispute

Modal

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

Add, edit, or
withdraw a
statement or
dispute

Subject Statement
and Dispute

link

When the user selects the link, display the Report
Summary page.

Withdraw

Subject Statement
and Dispute

link

When the user selects the link, display the Withdraw
Request For Dispute Resolution page

Update

Subject Statement
and Dispute

link

When the user selects the link, display the Account
Profile page

Additional Functionality Changes
Label

PDF Name
(step)

Response
Input Item

Trigger

First Name

Subject
Statement and
Dispute –
(Practitioner
Identification)

Text entry

If additional identity verification functionality is
available, then this field will be presented.

Middle Name

Subject
Statement and
Dispute –
(Practitioner
Identification)

Text entry

If additional identity verification functionality is
available, then this field will be presented.

Last Name

Subject
Statement and
Dispute –
(Practitioner
Identification)

Text entry

If additional identity verification functionality is
available, then this field will be presented.

Suffix (Jr, III)

Subject
Statement and
Dispute –
(Practitioner
Identification)

Text entry

If additional identity verification functionality is
available, then this field will be presented.

Agree to Terms and
Conditions

Subject
Statement and
Dispute –
(Practitioner
Identification)

Checkbox

If additional identity verification functionality is
available, then this field will be presented.

Experian Questions

Subject
Statement and
Dispute –
(Practitioner
Identification)

Radio
Button

If additional identity verification functionality is
available, then Experian questions will be
presented. Question and answer content is
determined by Experian. User will be shown four
questions, at least one of which contains financial
information. The questions are customized based
on the user's information.

User ID

Subject
Text entry
Statement and
Dispute –
(Account Profile)

If additional account functionality is available and a
User ID is required as a unique identifier, then this
field will be presented.

Label

PDF Name
(step)

Response
Input Item

Trigger

Mobile Phone
(Optional)

Subject
Text entry
Statement and
Dispute
(Account Profile)

If 3rd factor authentication is active, mobile phone
will be collected and used.

Question

Subject
Drop list
Statement and
Dispute
(Account Profile)

If account recovery functionality is available,
challenge questions will be presented. The user will
select a question from the list. Five challenge
questions will be presented. The user must select
different questions for each.

Answer

Subject
Text entry
Statement and
Dispute
(Account Profile)

If account recovery functionality is available, and
the challenge questions are displayed, the user
must provide an answer for each question they
selected.

Select notification
service

Subject
Checkbox
Statement and
Dispute
(Account Profile)

If additional services are available, the user will
have an option to select the service.

Profession or Field of
Licensure

Subject
Text Entry
Statement and
Dispute
(Account Profile)

If additional functionality is implemented, the user
will focus on the text entry to display the modal to
select their profession

Select an Occupation
or Field of Licensure

Subject
Modal
Statement and
Dispute
(Account Profile)

If Profession or Field of Licensure is implemented,
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.

Specific Name of
Occupation

Subject
Text Entry
Statement and
Dispute
(Account Profile)

If Profession or Field of Licensure is implemented,
the field is displayed if the user selects a profession
or field of licensure that requires a description.

Label

PDF Name
(step)

Response
Input Item

Trigger

License Number

Subject
Text Entry
Statement and
Dispute
(Account Profile)

If Profession or Field of Licensure is implemented,
the field is displayed and an entry is required.

State

Subject
Drop List
Statement and
Dispute
(Account Profile)

If Profession or Field of Licensure is implemented,
the field is displayed and a selection is required.

Name of School or
Institution

Subject
Text Entry
Statement and
Dispute
(Account Profile)

If additional functionality is implemented to collect
school information, the field is displayed.

Completion Year

Subject
Text Entry
Statement and
Dispute
(Account Profile)

If additional functionality is implemented to collect
school information, the field is displayed.

SSN or ITIN

Subject
Text Entry
Statement and
Dispute
(Account Profile)

If additional functionality is implemented to collect
SSN, the field is displayed.

NPI (National Provider Subject
Text Entry
Identifier)
Statement and
Dispute
(Account Profile)

If additional functionality is implemented to collect
NPI, the field is displayed.

Do you have a DEA,
Subject
Checkbox
FEIN or UPIN
Statement and
identification number? Dispute
(Account Profile)

If additional functionality is implemented to collect
DEA, FEIN or UPIN, the checkbox is displayed.

DEA (Drug
Enforcement
Administration)

Subject
Text Entry
Statement and
Dispute
(Account Profile)

If additional functionality is implemented to collect
DEA, FEIN or UPIN and the checkbox is selected,
DEA, FEIN and UPIN text entry fields are displayed.

FEIN (Federal
Subject
Text Entry
Employer
Statement and
Identification Number) Dispute
(Account Profile)

If additional functionality is implemented to collect
DEA, FEIN or UPIN and the checkbox is selected,
DEA, FEIN and UPIN text entry fields are displayed.

Label

PDF Name
(step)

Response
Input Item

UPIN (Unique
Subject
Text Entry
Physician
Statement and
Identification Number) Dispute
(Account Profile)

Trigger
If additional functionality is implemented to collect
DEA, FEIN or UPIN and the checkbox is selected,
DEA, FEIN and UPIN text entry fields are displayed.