Entity Registration (Renewal Update)

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Entity Registration Renewal Form and Instruction

Non-visible Questions
Label

PDF Name
(step)

Location

Response
Input
Item

Name of your
federal agency

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

Below “Federal
government
agency or
entity” radio
button

Drop List

The field is
This is only
displayed if the displayed if the
user selects the user choose to edit
option “Federal the Organization
Description.
government
agency or
entity” for
“Who owns
your
organization?”

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

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

Below “Best
category for
your
organization”

Radio
buttons

The fields are
displayed if the
user selects a
category that
has a
secondary
category for
registration.
Radio buttons
are “Yes” and
“No.”

Visibility
Trigger

Other

This is only
displayed if the
user choose to edit
the Organization
Description.
The label for the
secondary
category is
dynamic and is
dependent on the
user’s selection for
the primary
category (i.e., the
“Best category for
your organization.”

Label

PDF Name
(step)

Location

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

Below drop list
“Select your
organization’s
primary health
care-related
function or
service

Description

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

Below checkbox Text Entry The field is
for relevant
displayed if the
checkbox
user selects a
selection
function that
requires a
description.

This is only
displayed if the
user choose to edit
the Organization
Description.

NPI (National
Provider
Identifier)

Entity
Registration
(Renewal
Update) –
Organization
Information

Below
Identification
Numbers

This is only
displayed if the
user choose to edit
the Organization
Description.

Select up to 4
additional
functions or
services

Response
Input
Item
Check
Boxes

Visibility
Trigger

Other

The fields are
This is only
displayed if
displayed if the
user selects the user choose to edit
link “Add a
the Organization
function”
Description.
Selecting the link
displays all
relevant functions
that apply to the
registration
category and
secondary
category selected
by the user.

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

Label

PDF Name
(step)

Location

CCN (CMS
Certification
Number)

Entity
Registration
(Renewal
Update) –
Organization
Information

Below
Identification
Numbers

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

This is only
displayed if the
user choose to edit
the Organization
Description.

ORI (Originating
Entity
Agency Identifier) Registration
(Renewal
Update) –
Organization
Information

Below
Identification
Numbers

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

This is only
displayed if the
user choose to edit
the Organization
Description.

Name of person
or office

Below the radio Text Entry The field is
This is only
button “I will
displayed if the displayed if the
assign a specific
user selects the user choose to
person or office
radio button
change the
to contact”
for “I will
description for
assign a
their organization
specific person or selected the Edit
or office to
link in the
contact.”
Certifying Official
section on the
Review Your
Information page.

Entity
Registration
(Renewal
Update) –
Your Point of
Contact on
NPDB
Reports

Response
Input
Item

Visibility
Trigger

Other

Selecting the
checkbox displays
Name of person or
office, Title or
department,
Phone, and
Extension text
entry fields.

Label

Title or
department

PDF Name
(step)

Location

Response
Input
Item

Visibility
Trigger

Other

Entity
Below “Name of Text Entry The field is
This is only
Registration person or
displayed if the displayed if the
(Renewal
office”
user selects the user choose to
Update) –
radio button
change the
Your Point of
for “I will
description for
Contact on
assign a
their organization
NPDB
specific person or selected the Edit
Reports
or office to
link in the
contact.”
Certifying Official
section on the
Review Your
Information page.
Selecting the
checkbox displays
Name of person or
office, Title or
department,
Phone, and
Extension text
entry fields.

Label

Phone

PDF Name
(step)

Location

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

Response
Input
Item

Visibility
Trigger

Other

Text Entry The field is
This is only
displayed if the displayed if the
user selects the user choose to
radio button
change the
for “I will
description for
assign a
their organization
specific person or selected the Edit
or office to
link in the
contact.”
Certifying Official
section on the
Review Your
Information page.
Selecting the
checkbox displays
Name of person or
office, Title or
department,
Phone, and
Extension text
entry fields.

Label

Extension
(optional)

PDF Name
(step)

Location

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

Response
Input
Item

Visibility
Trigger

Other

Text Entry The field is
This is only
displayed if the displayed if the
user selects the user choose to
radio button
change the
for “I will
description for
assign a
their organization
specific person or selected the Edit
or office to
link in the
contact.”
Certifying Official
section on the
Review Your
Information page.
Selecting the
checkbox displays
Name of person or
office, Title or
department,
Phone, and
Extension text
entry fields.

State Changes
Label

PDF Name

Item Type

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

Entity
Registration
(Renewal
Update)

Modal

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

Caution: You Are
Changing Your
Organization’s
Description

Entity
Registration
(Renewal
Update)

Modal

This modal is displayed when the user
selects the Edit link on the Review Your
Information page under Organization
Description. If the user selects the Yes
button, the page “Select the best option
for your organization” is displayed and the
radio button is preselected.

Edit

Entity
Registration
(Renewal
Update)

Link

On the Review Your Information page
under Organization Information, when the
user selects the “Edit” link, the form for
Organization Information page is displayed
and prefilled. Form fields are Department,
Country, Street Address, Street Address
Line 2, City, State, ZIP, Phone Number, EIN
(Employer Identification Number) and
Company or Organization Website
Address. The user can change the
information.

Edit

Entity
Registration
(Renewal
Update)

Link

On the Review Your Information page
under Certifying Official, when the user
selects the “Edit” link, the form for
Certifying Official page is displayed and
prefilled. Form fields are First Name, MI,
Last Name, Title, Phone, Extension, Email
Address and Employee ID. The user can
change the information for Title, Phone,
Extension, Email Address and Employee
ID.

Trigger

Label

PDF Name

Item Type

I need to change the
certifying official
information

Entity
Registration
(Renewal
Update)

Check Box On the Certifying Official page, selecting
the checkbox displays radio button
selections.
• Enter a new certifying official
• Make myself the certifying official
• Make administrator (name and
User ID of another administrator
user account) the certifying official

Trigger

If the user is currently the certifying
official, then Make myself the certifying
official is preselected.
If the user is the only administrator for the
organization’s account, then “Make admin
Make administrator (name and User ID of
another administrator user account) the
certifying official” is not displayed.
Otherwise, a radio button is displayed for
all administrator accounts for the
organization, except the user’s account.
First Name

Entity
Registration
(Renewal
Update)

Text Entry Selecting the radio button “Enter a new
certifying official” displays the form with
First Name, MI, Last Name, Title, Phone,
Extension, Email Address and Employee
ID.

MI

Entity
Registration
(Renewal
Update)

Text Entry Selecting the radio button “Enter a new
certifying official” displays the form with
First Name, MI, Last Name, Title, Phone,
Extension, Email Address and Employee
ID.

Last Name

Entity
Registration
(Renewal
Update)

Text Entry Selecting the radio button “Enter a new
certifying official” displays the form with
First Name, MI, Last Name, Title, Phone,
Extension, Email Address and Employee
ID.

Label

PDF Name

Item Type

Title

Entity
Registration
(Renewal
Update)

Text Entry Selecting the radio button “Enter a new
certifying official” displays the form with
First Name, MI, Last Name, Title, Phone,
Extension, Email Address and Employee
ID.

Phone

Entity
Registration
(Renewal
Update)

Text Entry Selecting the radio button “Enter a new
certifying official” displays the form with
First Name, MI, Last Name, Title, Phone,
Extension, Email Address and Employee
ID.

Extension

Entity
Registration
(Renewal
Update)

Text Entry Selecting the radio button “Enter a new
certifying official” displays the form with
First Name, MI, Last Name, Title, Phone,
Extension, Email Address and Employee
ID.

Email Address

Entity
Registration
(Renewal
Update)

Text Entry Selecting the radio button “Enter a new
certifying official” displays the form with
First Name, MI, Last Name, Title, Phone,
Extension, Email Address and Employee
ID.

Employer ID

Entity
Registration
(Renewal
Update)

Text Entry Selecting the radio button “Enter a new
certifying official” displays the form with
First Name, MI, Last Name, Title, Phone,
Extension, Email Address and Employee
ID.

Make myself the
certifying official

Entity
Registration
(Renewal
Update)

Radio
Button

Selecting the radio button “Make myself
the certifying official” hides the form with
First Name, MI, Last Name, Title, Phone,
Extension, Email Address and Employee
ID.

Make administrator
(name and User ID of
another administrator
user account) the
certifying official

Entity
Registration
(Renewal
Update)

Radio
Button

Selecting the radio button “Make
administrator (name and User ID of
another administrator user account) the
certifying official” hides the form with First
Name, MI, Last Name, Title, Phone,
Extension, Email Address and Employee
ID.

Trigger

Label

PDF Name

Item Type

Edit

Entity
Registration
(Renewal
Update)

Link

The User Accounts section on the Review
Your Information page is only displayed
for Renewal. When the user selects the
Edit link, the page to Update User
Accounts is displayed with list user
accounts for the organization. The user
can select accounts to delete if applicable.
On selection of Exit or Continue, the user
is returned to the Review Your
Information page with any accounts
selected for deletion noted on the table.

Your organization
must follow a formal
peer review process

Entity
Registration
(Renewal
Update)

Modal

This modal is displayed if the user selected
the Edit link for Organization Description
and selects “Other Health Care Entity” for
“Which category best fits your
organization?” on the page “Select the
best option for your organization.”

Trigger