Medical Malpractice Payment

Status: Original and derived artifacts are available for this document.

Download: pdf

Medical Malpractice Payment Form and Instruction

Non-visible Questions
Label

PDF Name
(step)

Location

Date of Death

Medical
Malpractice
Payment (1)

Below "Is this
person deceased?"

Text
Entry

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

Organization
Description

Medical
Malpractice
Payment (1)

Below Organization
Type

Text
Entry

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

Description

Medical
Malpractice
Payment (1)

Beside Profession or Text
Field of Licensure
Entry

The field is
displayed if the user
selects a profession
or field of licensure
that does not have
a specialty.

“Description is
displayed in place
of “Specialty” if
the profession or
field of licensure
does not have a
specialty. The
label is
“Description” if
the selected
profession or
field of licensure
requires a
description.
Otherwise, the
label is
“Description
(Optional)”

Specialty

Medical
Malpractice
Payment (1)

Beside Profession or Drop List The field is
Field of Licensure
displayed if the user
selects a profession
or field of licensure
that has a specialty.

“Specialty” is
displayed in place
of “Description”
if the selected
profession or
field of licensure
has a specialty.

Response
Input
Item

Visibility Trigger

Other

Label

PDF Name
(step)

Location

Description

Medical
Malpractice
Payment (2)

Below the “This
payment was a
result of” drop list

Text
Entry

This is a Global
Settlement for
Multiple
Claimants

Medical
Malpractice
Payment (2)

Below Date of
Settlement

Response
Input
Item

Visibility Trigger

Other

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

The field is
hidden if the user
makes a selection
from the “This
payment was a
result of” drop
list that is not
“Other.”

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

The checkbox is
unselected by
default. If the
user selects it,
then “Total
Number of
Claimants
Included in The
Settlement” is
displayed. If the
user makes a
different
selection for
“This payment
was a result of”,
then “This is a
Global
Settlement for
Multiple
Claimants” and
“Total Number of
Claimants
Included in The
Settlement” are
hidden.

Label

PDF Name
(step)

Location

Total Number of
Claimants
Included in The
Settlement

Medical
Malpractice
Payment (2)

Below “This is a
Global Settlement
for Multiple
Claimants”
checkbox

Number of
practitioner for
whom this payer
has paid or will
pay in this case

Medical
Malpractice
Payment (2)

Total amount paid Medical
(to be paid) by this Malpractice
payer for all
Payment (2)
practitioners

Response
Input
Item

Visibility Trigger

Other

Text
Entry

The field is
displayed if the user
selects “This is a
Global Settlement
for Multiple
Claimants”
checkbox.

This field is
hidden if the user
deselects the
“This is a Global
Settlement for
Multiple
Claimants”
checkbox or
makes a different
drop list selection
other than
“Settlement” for
“This payment
was a result of”

Below “Are other
practitioners
included in this
case?”

Text
Entry

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

This field is
hidden if the user
selects the “No”
radio button for
“Are other
practitioners
included in this
case?

Below “Number of
practitioner for
whom this payer
has paid or will pay
in this case”

Text
Entry

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

This field is
hidden if the user
selects the “No”
radio button for
“Are other
practitioners
included in this
case?

Label

PDF Name
(step)

Location

Response
Input
Item

Visibility Trigger

Other

Did (or will) a
Medical
state guaranty or Malpractice
excess fund make Payment (2)
a payment for this
practitioner in this
case?

Below “Your
organization’s
relationship with
this practitioner”

Radio
Buttons

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

Selections are
“Yes,” “No” and
“Unknown.” On
selection of
“Yes,” the text
box entry for
“Total amount
paid (or to be
paid)” is
displayed. On
selection of “No”
or “Unknown,”
the text box
entry for “Total
amount paid (or
to be paid)” is
hidden.

Did (or will) a self- Medical
insured
Malpractice
organization
Payment (2)
and/or other
insurance
company make a
payment for this
practitioner in this
case?

Below “Your
organization’s
relationship with
this practitioner”

Radio
Buttons

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

Selections are
“Yes,” “No” and
“Unknown.” On
selection of
“Yes,” the text
box entry for
“Total amount
paid (or to be
paid)” is
displayed.
On selection of
“No” or
“Unknown,” the
text box entry for
“Total amount
paid (or to be
paid)” is hidden.

Label

PDF Name
(step)

Location

Response
Input
Item

Visibility Trigger

Other

On selection of
“No” or
“Unknown,” the
text box entry for
“Total amount
paid (or to be
paid)” is hidden.

Total amount paid Medical
(or to be paid)
Malpractice
Payment (2)

Below the radio
Text
buttons displayed if Entry
the user selects an
applicable option
for “Your
organization’s
relationship with
this practitioner”

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

Description

Below “Specific
Allegation”

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

Medical
Malpractice
Payment (2)

Text
Entry

State Changes
Label

PDF Name

Item Type

Trigger

OMB Number:
0906-0081
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.

Description
(Optional)

Medical
Malpractice
Payment

Text Entry

Text entry is disabled until the user selects a
profession or field of licensure that allows or requires
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?"

Name of
School or
Institution

Medical
Malpractice
Payment

Text Entry

Names of School or Institution and Completion Year
text entries are disabled by default. When the user
selects a health care-related Profession or Field of
Licensure, the Name of School or Institution and
Completion Year are enabled. If the user selects a
profession that is not related to health care, entries
for the Name of School or Institution and Completion
Year are not allowed, so Name of School or
Institution and Completion Year are cleared and
hidden. Subsequent selection of a health care-related
profession redisplays both fields.

Label

PDF Name

Item Type

Trigger

Completion
Year

Medical
Malpractice
Payment

Text Entry

Names of School or Institution and Completion Year
text entries are disabled by default. When the user
selects a health care-related Profession or Field of
Licensure, the Name of School or Institution and
Completion Year are enabled. If the user selects a
profession that is not related to health care, entries
for the Name of School or Institution and Completion
Year are not allowed, so Name of School or
Institution and Completion Year are cleared and
hidden. Subsequent selection of a health care-related
profession redisplays both fields.

Date of the
Settlement

Medical
Malpractice
Payment

Text Entry

This field is dynamic, depending on the selection in
the drop list “The payment was a result of” If the
user selects “Judgment”, the label is changed to
“Date of the Judgment.” Otherwise, the label is “Date
of the Settlement.”

Describe the
settlement
including any
conditions or
terms of
payment

Medical
Malpractice
Payment

Text Entry

This field is dynamic, depending on the selection in
the drop list “The payment was a result of” If the
user selects Judgment, then the label is “Describe the
judgement including any conditions or terms of
payment.” Otherwise, the label is “Describe the
settlement including any conditions or terms of
payment.”

Select a
Specific
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.

Label

PDF Name

I agree to allow Medical
the NPDB to
Malpractice
send an
Payment
electronic
report notice
to (STATE
BOARD NAME).
I attest that
this is the
correct state
board to notify
based on
where the
medical
malpractice
claim arose.

Item Type
Radio
button

Trigger
This radio button is displayed if the user selected a
profession or field of licensure and state for which a
state licensing or certification authority is registered
with the NPDB, regulates the profession for the state
and has enabled report forwarding. The registered
entity name is displayed as the STATE BOARD NAME.
The radio button is displayed above the radio button
“I attest that I will provide a copy of this report to the
appropriate state board.” This is above the final
Certification section of the form.