Form 31 Agent Registration (Initial)

Agent Registration (Renewal & Update) Form and Instruction

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”

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”

Label

PDF Name
(step)

Location

Response
Input
Item

Visibility
Trigger

Other

Request another
DBID for my
organization

Agent
Below “Register
Registration – my
(What do you organization”
need to do?)

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”

Other

Agent
Beside “Other”
Registration
(What do you
need to do?)

Text Entry The field is
displayed if the
user select the
“Other” option
for “Why is
your
organization
requesting
another DBID?”

This field is
required if the
radio button
“Other” is selected.

DBID Number

Agent
Registration–
(Select the
best option
for your
organization)

Below “Do you Text Entry
know the
current DBID for
your
organization?”

The field is
displayed if the
user selects the
“Yes” option.

This field is only
required if the
“Yes” option is
selected.

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” 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.