Correction Revision to Action Void Notice of Appeal

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Correction, Revision-to-Action, Void, Notice of Appeal Forms and Instructions

Non-visible Questions
For Correction and Revision-to-Action the Non-visible questions will be the same as the nonvisible questions for the initial report.
Label
Please explain:

PDF Name
(step)

Location

Correction, Below the
Revision-to- selected radio
Action,
button
Void, Notice
of Appeal
(Void
Report)

Response
Input Item

Visibility Trigger

Other

Text entry The text entry is
This is displayed on
displayed below the the Void report.
selected radio
Only one text entry
button:
is displayed. It is
cleared if a different
• The report
radio button is
was
selected.
erroneously
submitted
(e.g., wrong
practitioner
named,
duplicate
report,
payment not
delivered,
action never
finalized)
• The report
was not
required to be
filed because
the action
does not
meet the legal
reporting
criteria
• The action
was reversed
because the
original action
should never
have been
taken (e.g.,
overturned on
appeal)

State Changes
For Correction and Revision-to-Action the state changes will be the same as the state
changes for the initial report.
Label

PDF Name

OMB Number:
0906-0081
Expiration Date:
mm/dd/yyyy

Correction, Modal
Revision-toAction,
Void,
Notice of
Appeal

Item Type

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