Document
Medical Malpractice Payer Attestation
ICR 202610-0906-006 · OMB 0906-0081 · Object 174170500.
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Document Metadata
| File Type | application/pdf |
|---|---|
| File Title | Medical Malpractice Payer Attestation |
| Author | Jo Anne Wright |
| Last Modified By | Adobe Acrobat (64-bit) 26.1.21431 |
| File Modified | 2026-06-29 |
| File Created | 2026-04-28 |
| Conversion State | complete |
Extracted Text
Medical Malpractice Attestation Form and Instruction
Non-visible Questions
Label
PDF Name
(step)
Location
Response
Input Item
Visibility Trigger
Why
not?
Medical
Malpractice
Payer
Attestation (1)
Below the
Yes and No
radio
buttons
Text Entry
The field is displayed
if the user selects the
No radio button
Item Type
Trigger
Modal
When the user selects the link the modal
is displayed with the public burden
statement content.
Other
State Changes
Label
PDF Name
OMB Number: 0906- Medical
0081 Expiration Date: Malpractice
mm/dd/yyyy
Payer
Attestation