Self-Query for an Organization

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

Download: pdf

Self-Query on an Organization Form and Instruction

Non-visible Questions
Label

PDF Name
(step)

Location

Response Visibility Trigger
Input Item

Other

Organization
Description

Self-Query
Below
Text Entry
on an
Organization
Organization Type
(1)

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

Country

Self-Query
Below "the
on an
location
Organization address"
(1)
and "a
different
address"
options for
Delivery
Address

Drop List

The field is
displayed if the
user selects the
radio button "a
different
address."

Selecting "a different
address" displays
Country, Address,
Address Line 2, City,
State and ZIP
entries. United States is
the default selection.

Address

Self-Query
Below
on an
Country
Organization
(1)

Text Entry

The field is
displayed if the
user selects the
radio button "a
different
address."

Selecting "a different
address" displays
Country, Address,
Address Line 2, City,
State and ZIP
entries. United States is
the default selection.

Address Line
2

Self-Query
Below
on an
Address
Organization
(1)

Text Entry

The field is
displayed if the
user selects the
radio button "a
different
address."

Selecting "a different
address" displays
Country, Address,
Address Line 2, City,
State and ZIP
entries. United States is
the default selection.

Label

PDF Name
(step)

Location

Response Visibility Trigger
Input Item

Other

City

Self-Query
Below
Text Entry
on an
Address Line
Organization 2
(1)

The field is
displayed if the
user selects the
radio button "a
different
address."

Selecting "a different
address" displays
Country, Address,
Address Line 2, City,
State and ZIP
entries. United States is
the default selection.

State

Self-Query
Beside City
on an
Organization
(1)

Drop List

The field is
displayed if the
user selects the
radio button "a
different
address."

Selecting "a different
address" displays
Country, Address,
Address Line 2, City,
State and ZIP
entries. United States is
the default selection.

ZIP

Self-Query
Below State
on an
Organization
(1)

Text Entry

The field is
displayed if the
user selects the
radio button "a
different
address."

Selecting "a different
address" displays
Country, Address,
Address Line 2, City,
State and ZIP
entries. United States is
the default selection.

MPN/MSN
Self-Query
Below
(Medicare
on an
checkbox
Provider/Sup Organization "Do you
plier
(1)
have a DEA,
Number)
FEIN, or
UPIN
identificatio
n number?"

Text Entry

The field is
displayed if the
user selects the
checkbox for
"Do you have a
MPN/MSN, FDA
or CLIA
Identification
number?"

Selecting the checkbox
displays MPN/MSN,
FDA, and CLIA text entry
fields.

Label

PDF Name
(step)

Location

Response Visibility Trigger
Input Item

Other

FDA (Federal
Food and
Drug
Administratio
n)

Self-Query
Below
on an
MPN/MSN
Organization text entry.
(1)

Text Entry

The field is
displayed if the
user selects the
checkbox for
"Do you have a
MPN/MSN, FDA
or CLIA
Identification
number?"

Selecting the checkbox
displays MPN/MSN,
FDA, and CLIA text entry
fields.

CLIA (Clinical
Laboratory
Improvement
Act)

Self-Query
Below FDA
on an
text entry
Organization
(1)

Text Entry

The field is
displayed if the
user selects the
checkbox for
"Do you have a
MPN/MSN, FDA
or CLIA
Identification
number?"

Selecting the checkbox
displays MPN/MSN,
FDA, and CLIA text entry
fields.

Country

Self-Query
Below "the
on an
location
Organization address"
(2)
and "a
different
address"
options
for Billing
Address

Drop List

The field is
displayed if the
user selects the
radio button "a
different
address."

Selecting "a different
address" displays
Country, Address,
Address Line 2, City,
State and ZIP
entries. United States is
the default selection.

Address

Self-Query
Below
on an
Country
Organization
(2)

Text Entry

The field is
displayed if the
user selects the
radio button "A
different
address."

Selecting "A different
address" displays
Country, Address,
Address Line 2, City,
State and ZIP entries.

Label

PDF Name
(step)

Location

Response Visibility Trigger
Input Item

Other

Address Line
2

Self-Query
Below
on an
Address
Organization
(2)

Text Entry

The field is
displayed if the
user selects the
radio button "A
different
address."

Selecting "A different
address" displays
Country, Address,
Address Line 2, City,
State and ZIP entries.

City

Self-Query
Below
Text Entry
on an
Address Line
Organization 2
(2)

The field is
displayed if the
user selects the
radio button "A
different
address."

Selecting "A different
address" displays
Country, Address,
Address Line 2, City,
State and ZIP entries.

State

Self-Query
Beside City
on an
Organization
(2)

Drop List

The field is
displayed if the
user selects the
radio button "A
different
address."

Selecting "A different
address" displays
Country, Address,
Address Line 2, City,
State and ZIP entries.

ZIP

Self-Query
Below State
on an
Organization
(2)

Text Entry

The field is
displayed if the
user selects the
radio button "A
different
address"

Selecting "A different
address" displays
Country, Address,
Address Line 2, City,
State and ZIP entries.

Radio
Buttons

The section
Selecting “Yes, I need a
including the
paper copy” will return
radio buttons
the user back to the
“Yes, I need a
Payment page to select
paper copy” and the option to receive
“No, I do not
one.
needed it is only
displayed if the
user did not
elect to have a
paper copy
mailed to them.

Paper Copies Self-Query
Below
Question
on an
Payment
Organization
(2)

State Changes
Label

PDF Name

Item Type

Trigger

Place a Self-Query Self-Query on
Order
an
Organization

Modal

When user starts a Self-Query, the
modal is displayed.

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

Self-Query on
an
Organization

Modal

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

Confidentiality
Statement

Self-Query on
an
Organization

Modal

When the user selects the
Confidentiality link the modal is
displayed.

Are you
authorized to act
on behalf of the
organization?

Self-Query on
an
Organization

Modal

When the user selects Organization for
"Which type of NPDB search do you
need?

License Number

Self-Query on
an
Organization

Text Entry

Text entry is disabled if the user selects
the "No/ Not sure" option for "Does
your organization have a license?"

Password
Requirements

Self-Query on
an
Organization

Info box

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.