Agent Registration (initial)

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Agent Registration (Initial) Form and Instruction

NPDB
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REGISTER YOUR ORGANIZATION

0MB Number: 0906-0081 Expiration Date: mm/dd/yyyy

Registration Checklist
1. Have you identified the person who will serve as the certifying official for your organization?
As the person registering for your organization, you will serve as the administrator. The NPDB also requires someone from your
organization to serve as the certifying official, the individual responsible for verifying that your organization is legitimate and eligible to
register with the NPDB.
• The administrator and certifying official can be the same person.
• The certifying official can be someone other than the administrator who is in a management or executive role. The certifying official
will not have access to the NPDB until the administrator creates a user account for them.
If you will not be the certifying official, you will need to know how that person's name is listed on their government-issued ID, such as their
driver's license. This is important because you and the certifying official must complete a paper form in front of a notary public and show
them the ID The paper form will show the name you enter online. and the notary must verify that it matches the name on their ID.

2. Do you know the tax identification number for your organization?
You will need to know the Employer Identification Number (EIN} assigned to your organization by the IRS. If your organization is not required
to have an EIN (e.g., a sole proprietorship), enter your Social Security Number (SSN} or Individual Tax Identification Number (ITIN} instead.
3. Are there other identification numbers assigned to your organization?
If your organization has a National Provider Identification (NPI}, you will need to provide it. Hospitals should also add their CMS Certification
Number (CCN}, the provider number assigned for Medicare.
If you do not have this information, please Exit and return to registration later.

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Non-visible Questions
Label

PDF Name
(step)

Location

Response
Input
Item

Visibility
Trigger

Other

Register for a new Agent
NPDB account for Registration
my organization

Below “Register Radio
my
Button
organization”

The field is
Selecting the radio
displayed if the button “Register
user selects the my organization”
option
displays three
“Register my
options: “Register
organization.” 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 Agent
my organization’s Registration
NPDB registration

Below “Register Radio
my
Button
organization”

The field is
Selecting the radio
displayed if the button “Register
user selects the my organization”
option
displays three
“Register my
options: “Register
organization.” 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

Visibility
Trigger

Other

Request another
DBID for my
organization

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

The field is
Selecting the radio
displayed if the button “Register
user selects the my organization”
option
displays three
“Register my
options: “Register
organization.” for a new NPDB
account for my
organization,”
“Renew or update
my organization’s
NPDB
registration,” and
“Request another
DBID for my
organization”

Other

Agent
Beside the radio Text Entry This field is
This field is
Registration button “Other”
displayed if the required if the
(What do you
user selects the radio button
need to do?)
“Other” option “Other” is selected
for “Why is
on the modal “Is
your
your organization
organization
already registered
requesting
with the NPDB?”
another DBID?”

DBID Number

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

Below the Yes
Text Entry The field is
This field is only
radio button for
displayed if the required if the
“Do you know
user selects the “Yes” radio button
the current
“Yes” option.
for “Do you know
DBID for your
the current DBID
organization?”
for your
organization?” on
the modal “Is your
organization
already registered
with the NPDB?”

State Changes
Label

PDF Name

Item Type

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

Agent
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?

Agent
Registration

Modal

When the user selects “Request another
DBID my organization” for “Register my
organization”

An agent may only
Agent
access the NPDB if
Registration
they are designated
by a registered health
care entity to act on
their behalf

Modal

When the user submits their selection for
a category and the radio button “An agent
registering to query and/or report on
behalf of another organization” is
selected, then the modal is displayed with
a Yes and No button. If the user selects
Yes, they continue to register as an agent.
If no, then the modal closes.

I am authorized by my Agent
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

Agent
Registration

Trigger

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.