Form 19 Self-Query on an Individual

Self-Query on an Individual Form and Instruction

Non-visible Questions
Label

PDF Name
(step)

Location

Response
Input Item

Visibility Trigger
The field is
displayed if the user
selects Work radio
button for Type of
Address.

Other

Organization
Name

Self-Query
on an
Individual
(1)

Below Home
and Work
radio buttons
for Type of
Address

Text Entry

Organization
Type

Self-Query
on an
Individual
(1)

Below
Organization
Name text
entry

Drop list

Organization
Description

Self-Query
on an
Individual
(1)

Below
Organization
Type

Text Entry

The field is
displayed if the user
selects an
organization type
that requires a
description.

Specialty

Self-Query
on an
Individual
(1)

Beside
Profession or
Field of
Licensure

Text Entry

The field is
displayed if the user
selects a profession
or field of licensure
that requires a
description.

“Specialty” is
displayed in place of
“Specific Name of
Occupation” if the
selected profession
or field of
licensure requires
specialty
information.

Specific Name Self-Query
of Occupation on an
Individual
(1)

Beside
Profession or
Field of
Licensure

Drop List

The field is
displayed if the user
selects a profession
or field of licensure
that requires
information for
specialty.

“Specific Name of
Occupation” is
displayed in place of
“Specialty” if the
selected profession
or field of licensure
does not require
information for
specialty.

Label

PDF Name
(step)

Location

Response
Input Item

Visibility Trigger

Other

DEA (Drug
Enforcement
Agency)

Self-Query
on an
Individual
(1)

Below
checkbox "Do
you have a
DEA, FEIN, or
UPIN
identification
number?"

Text Entry

Field is displayed if
user selects the
checkbox for "Do
you have a DEA,
FEIN, or UPIN
identification
number?"

Selecting the
checkbox displays
DEA, FEIN and UPIN
text entry fields.

FEIN (Federal
Employer
Identification
Number)

Self-Query
on an
Individual
(1)

Below DEA
text entry.

Text Entry

The field is
displayed if the user
selects the
checkbox for "Do
you have a DEA,
FEIN, or UPIN
identification
number?"

Selecting the
checkbox displays
DEA, FEIN and UPIN
text entry fields.

UPIN (Unique
Physician
Identification
Numbers)

Self-Query
on an
Individual
(1)

Below FEIN
text entry

Text Entry

The field is
displayed if the user
selects the
checkbox for "Do
you have a DEA,
FEIN, or UPIN
identification
number?"

Selecting the
checkbox displays
DEA, FEIN and UPIN
text entry fields.

Below “Do
Text Entry
you want a
sealed
envelope with
a paper copy
of your
response
mailed to
you?

The field is
displayed if the user
selects the radio
button “Yes” that
they want a paper
copy mailed to
them.

Selecting the radio
button “Yes”
displays the text
entry and “No" hides
it.

Sealed
Self-Query
Envelope with on an
a paper copy Individual
(2)

Label

PDF Name
(step)

Location

Response
Input Item

Visibility Trigger

Other

Country

Self-Query
on an
Individual
(2)

Below "Use
Drop List
the address I
entered" and
"Use a
different
address"
options for
Billing Address

The field is
displayed if the user
selects the radio
button "Use a
different address"

Selecting "Use a
different address"
displays Country,
Address, Address
Line 2, City, State
and ZIP
entries. United
States is the default
selection.

Address

Self-Query
on an
Individual
(2)

Below Country Text Entry

The field is
displayed if the user
selects the radio
button " Use a
different address"

Selecting " Use a
different address"
displays Country,
Address, Address
Line 2, City, State
and ZIP entries.

Address Line 2 Self-Query
on an
Individual
(2)

Below Address Text Entry

The field is
displayed if the user
selects the radio
button " Use a
different address"

Selecting " Use a
different address"
displays Country,
Address, Address
Line 2, City, State
and ZIP entries.

City

Self-Query
on an
Individual
(2)

Below Address Text Entry
Line 2

The field is
displayed if the user
selects the radio
button " Use a
different address"

Selecting " Use a
different address"
displays Country,
Address, Address
Line 2, City, State
and ZIP entries.

State

Self-Query
on an
Individual
(2)

Beside City

The field is
displayed if the user
selects the radio
button " Use a
different address"

Selecting " Use a
different address"
displays Country,
Address, Address
Line 2, City, State
and ZIP entries.

Drop List

Label

PDF Name
(step)

Location

Response
Input Item

Visibility Trigger

Other

ZIP

Self-Query
on an
Individual
(2)

Below State

Text Entry

The field is
displayed if the user
selects the radio
button " Use a
different address"

Selecting " Use a
different address"
displays Country,
Address, Address
Line 2, City, State
and ZIP entries.

Paper Copies
Question

Self-Query
on an
Individual
(3)

Below
Payment

Radio
Buttons

The section
including the radio
buttons “Yes, I need
a paper copy” and
“No, I do not
needed it is only
displayed if the user
did not elect to
have a paper copy
mailed to them.

Selecting “Yes, I
need a paper copy”
will return the user
back to the Payment
page to select the
option to receive
one.

Experian
Questions

Self-Query
on an
Individual
(4)

After Step (3) - Radio
Review
button
Information

Question and
answer content is
determined by
Experian. User will
be shown four
questions, at least
one of which
contains financial
information. The
questions are
customized based on
the user's
information. The
user may be shown
questions other than
those pictured in the
PDF.

State Changes
Label

PDF Name

Item Type

Trigger

Place a SelfQuery Order

Self-Query on
an Individual

Modal

When user starts a Self-Query, the modal is
displayed.

OMB Number:
0915-0126
Expiration Date:
mm/dd/yyyy

Self-Query on
an Individual

Modal

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

Confidentiality
Statement

Self-Query on
an Individual

Modal

When the user selects the Confidentiality link
the modal is displayed.

Select an
Occupation or
Field of
Licensure

Self-Query on
an Individual

Modal

When the user sets focus on the Profession
or Field of Licensure text entry, the modal to
select a profession is displayed and focus is
set on the Search text entry. The user can
enter text in the Search text box to find a
specific profession or select a profession
from the list without searching. The modal is
hidden once the user selects a profession
from the list. The user's selection populates
the Profession or Field of Licensure text
entry.

Other Name for
Occupation

Self-Query on
an Individual

Text Entry

Text entry is disabled if the user does not
select a profession or field of licensure
requiring a description.

License Number

Self-Query on
an Individual

Text Entry

Text entry is disabled if the user selects the
"No/ Not sure" option for "Do you have a
license for your selected profession or field
of licensure?"

Password
Requirements

Self-Query on
an Individual

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.