Entity Registration (Initial)

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Entity Registration (Initial) Form and Instruction

Non-visible Questions
Label

PDF Name
(step)

Location

Response
Input
Item

Visibility
Trigger

Other

Register for a new Entity
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 Entity
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
Radio
Button

Visibility
Trigger

Other

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”

Request another
DBID for my
organization

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

Other

Entity
Registration
(Is your
organization
already
registered
with the
NPDB?)

Beside the radio Text Entry This field is
button “Other”
displayed if the
user selects the
“Other” option
for “Why is
your
organization
requesting
another DBID?”

This field is
required if the
radio button
“Other” is selected
on the modal “Is
your organization
already registered
with the NPDB?”

DBID Number

Entity
Registration –
(Is your
organization
already
registered
with the
NPDB?)

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

This field is only
required if the
“Yes” radio button
for “Do you know
the current DBID
for your
organization?” on
the modal “Is your
organization
already registered
with the NPDB?”

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

Label

PDF Name
(step)

Location

Response
Input
Item

Visibility
Trigger

Name of your
federal agency

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

Below “Federal
government
agency or
entity” radio
button

Drop List

The field is
displayed if the
user selects the
option “Federal
government
agency or
entity” for
“Who owns
your
organization?”

Does your
organization
follow a formal
peer review
process?

Entity
Modal display
Registration
(Select the
best option
for your
organization)

Radio
buttons

The modal with
the fields is
displayed when
the user selects
“Other Health
Care Entity”
and Continue

Is your
organization also
a health plan,
health network or
health system?

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

Radio
buttons

The fields are
The label for the
displayed if the secondary category
user selected
is dynamic and is
“A private
dependent on the
sector
user’s selection for
organization”
the primary
as ownership
category (i.e., the
and selects a
“Best category for
category that
your organization.”
has a secondary
category for
registration.
Radio buttons
are “Yes” and
“No.”

Below “Best
category for
your
organization”

Other

If the user selects
“Yes” a Continue
button is displayed.
If they select “No”
and Exit button is
displayed.

Label

PDF Name
(step)

Location

Response
Input
Item

Which of the
following also
describes your
organization?

Entity
Registration
(Select the
best option
for your
organization)

Below “Best
category for
your
organization”

Radio
buttons

The fields are
The label is
displayed if the dynamic and is
user selected
dependent on the
“Local
user’s selection of
government
the primary
agency or
category (i.e., “Best
entity” as
category for your
ownership for organization”)
their
organization
and selects a
category that
has a secondary
category for
registration.
Radio buttons
are “Health
Plan”, “Acting
on Behalf of the
State to
Administer or
Supervise the
Administration
of a State
Health Care
Program” and
“Neither of
These”

Select up to 4
additional
functions or
services

Entity
Below drop list
Registration – “Select your
(Select the
organization’s
best option
primary health
for your
care-related
organization.) function or
service

Check
Boxes

The fields are
displayed if
user selects the
link “Add a
function”

Visibility
Trigger

Other

Selecting the link
displays all relevant
functions that
apply to the
registration
category and
secondary category
selected by the
user.

Label

PDF Name
(step)

Description

Entity
Registration –
(Select the
best option
for your
organization).

NPI (National
Provider
Identifier)

Entity
Below
Registration – Identification
(Organization Numbers
Information)

Text Entry The field is
displayed if the
user selects a
registration
category or
secondary
category that
has an NPI.

CCN (CMS
Certification
Number)

Entity
Below
Registration – Identification
(Organization Numbers
Information)

Text Entry The field is
displayed if the
user selects a
registration
category or
secondary
category that
has a CCN

ORI (Originating
Entity
Below
Agency Identifier) Registration – Identification
(Organization Numbers
Information)

Text Entry The field is
displayed if the
user selects a
registration
category or
secondary
category that
has an ORI.

Location

Response
Input
Item

Below checkbox Text Entry
for relevant
checkbox
selection

Visibility
Trigger
The field is
displayed if the
user selects a
function that
requires a
description.

Other

Label

PDF Name
(step)

Location

Response
Input
Item

Visibility
Trigger

Other

Name of person
or office

Entity
Below the radio
Registration – button “I will
(Your Point of assign a specific
Contact on
person or office
NPDB
to contact”
Reports)

Text Entry The field is
Selecting the
displayed if the checkbox displays
user selects the Name of person or
radio button
office, Title or
for “I will assign department,
a specific
Phone, and
person or office Extension text
to contact.”
entry fields.

Title or
department

Entity
Below “Name of Text Entry
Registration – person or office”
(Your Point of
Contact on
NPDB
Reports)

Phone

Entity
Below “Title or
Registration – department”
(Your Point of
Contact on
NPDB
Reports)

Text Entry The field is
Selecting the
displayed if the checkbox displays
user selects the Name of person or
radio button
office, Title or
for “I will assign department,
a specific
Phone, and
person or office Extension text
to contact.”
entry fields.

Extension
(optional)

Entity
Beside “Phone”
Registration –
(Your Point of
Contact on
NPDB
Reports)

Text Entry The field is
Selecting the
displayed if the checkbox displays
user selects the Name of person or
radio button
office, Title or
for “I will assign department,
a specific
Phone, and
person or office Extension text
to contact.”
entry fields.

The field is
Selecting the
displayed if the checkbox displays
user selects the Name of person or
radio button
office, Title or
for “I will assign department,
a specific
Phone, and
person or office Extension text
to contact.”
entry fields.

State Changes
Label

PDF Name

Item Type

OMB Number: 09060081 Expiration Date:
mm/dd/yyyy

Entity
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?

Entity
Registration

Modal

When the user selects “Request another
DBID my organization’s NPDB account” for
“Register my organization” the modal is
displayed.

Your organization
must follow a formal
peer review process

Entity
Registration

Modal

When the user selects “Other Health Care
Entity” for “Which category best fits your
organization?”

Trigger

I am authorized by my Entity
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

Entity
Registration

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.