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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
on an
Organization
(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.
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.
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.
Below "the
Drop List
location
address" and
"a different
address"
options for
Delivery
Address
Label
PDF Name
(step)
Location
Response Visibility Trigger
Input Item
Other
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
(Medicare
Provider/Sup
plier Number)
Self-Query
on an
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.
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.
Below
checkbox
"Do you
have a DEA,
FEIN, or
UPIN
identificatio
n number?"
FDA (Federal Self-Query
Below
Food and
on an
MPN/MSN
Drug
Organization text entry.
Administratio (1)
n)
Label
PDF Name
(step)
Location
CLIA (Clinical Self-Query
Below FDA
Laboratory
on an
text entry
Improvement Organization
Act)
(1)
Response Visibility Trigger
Input Item
Text Entry
Below "the
Drop List
location
address" and
"a different
address"
options
for Billing
Address
Other
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.
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.
Country
Self-Query
on an
Organization
(2)
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.
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.
Label
PDF Name
(step)
Location
Response Visibility Trigger
Input Item
Other
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.
State Changes
Label
PDF Name
Item Type
Trigger
Place a Self-Query
Order
Self-Query on
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 Self-Query on
to act on behalf of an
the organization? 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.
| File Type | application/pdf |
| File Title | Self-Query on an Organizatoin |
| Subject | NPDB forms |
| Author | Health Resources and Services Administration |
| File Modified | 2020-11-18 |
| File Created | 2020-08-06 |