Form 24 Entity Registration (Initial)

Entity Registration (Initial) Form and Instruction

Non-visible Questions
Label

PDF Name
(step)

Location

Response
Input
Item

Visibility
Trigger

Other

Register for a new Entity
NPDB account for Registration
my organization

Below “Register
my
organization”

Radio
Button

The field is
displayed if the
user selects the
option
“Register my
organization.”

Selecting the radio
button “Register
my organization”
displays three
options: “Register
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 Entity
my organization’s Registration
NPDB registration

Below “Register
my
organization”

Radio
Button

The field is
displayed if the
user selects the
option
“Register my
organization.”

Selecting the radio
button “Register
my organization”
displays three
options: “Register
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

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

Radio
Button

The field is
displayed if the
user selects the
option
“Register my
organization.”

Selecting the radio
button “Register
my organization”
displays three
options: “Register
for a new NPDB
account for my
organization,”
“Renew or update
my organization’s
NPDB registration,”
and “Request
another DBID for
my organization”

Other

Entity
Beside “Other”
Registration
(What do you
need to do?)

Text Entry This field is
displayed if the
user selects the
“Other” option
for “Why is
your
organization
requesting
another DBID?”

This field is
required if the
radio button
“Other” is selected.

DBID Number

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

Below “Do you Text Entry
know the
current DBID for
your
organization?”

The field is
displayed if the
user selects the
“Yes” option.

This field is only
required if the
“Yes” option is
selected.

Label

PDF Name
(step)

Name of your
federal agency

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

Does your
organization
follow a formal
peer review
process?

Is your
organization also
a health plan?

Location

Below “Federal
government
agency or
entity” radio
button

Response
Input
Item

Visibility
Trigger

Other

Drop List

The field is
displayed if the
user the option
“Federal
government
agency or
entity” for
“Who owns
your
organization?”

Entity
Modal display
Registration
(Select the
best option
for your
organization)

Radio
buttons

The modal with
the fields is
displayed when
the user selects
“Other Health
Care Entity”
and Continue

If the user selects
“Yes” a Continue
button is displayed.
If they select “No”
and Exit button is
displayed.

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

Radio
buttons

The fields are
displayed if the
user selected
“A private
sector
organization”
as ownership
and selects a
category that
has a secondary
category for
registration.
Radio buttons
are “Yes” and
“No.”

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.”

Below “Best
category for
your
organization”

Label

PDF Name
(step)

Location

Response
Input
Item

Visibility
Trigger

Other

Which of the
following also
describes your
organization?

Entity
Registration
(Select the
best option
for your
organization)

Below “Best
category for
your
organization”

Radio
buttons

The fields are
displayed if the
user selected
“Local
government
agency or
entity” as
ownership for
their
organization
and selects a
category that
has a secondary
category for
registration.
Radio buttons
are “Health
Plan”, “Acting
on Behalf of the
State to
Administer or
Supervise the
Administration
of a State
Health Care
Program” and
“Neither of
These”

The label is
dynamic and is
dependent on the
user’s selection of
the primary
category (i.e., “Best
category for your
organization”)

Select up to 4
additional
functions or
services

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

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

Check
Boxes

The fields are
displayed if
user selects the
link “Add a
function”

Selecting the link
displays all relevant
functions that
apply to the
registration
category and
secondary category
selected by the
user.

Label

PDF Name
(step)

Location

Response
Input
Item

Below checkbox Text Entry
for relevant
checkbox
selection

Visibility
Trigger

Description

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

The field is
displayed if the
user selects a
function that
requires a
description.

NPI (National
Provider
Identifier)

Entity
Below
Registration – Identification
(Organization Numbers
Information)

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

CCN (CMS
Certification
Number)

Entity
Below
Registration – Identification
(Organization Numbers
Information)

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

ORI (Originating
Entity
Below
Agency Identifier) Registration – Identification
(Organization Numbers
Information)

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

Other

Label

PDF Name
(step)

Location

Response
Input
Item

Name of person
or office

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

Below the radio
button “I will
assign a specific
person or office
to contact”

Title or
department

Entity
Below “Name of Text Entry
Registration – person or office”
(Your Point of
Contact on
NPDB
Reports)

Phone

Extension
(optional)

Visibility
Trigger

Text Entry The field is
displayed if the
user selects the
radio button
for “I will assign
a specific
person or office
to contact.”

Other

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

The field is
displayed if the
user selects the
radio button
for “I will assign
a specific
person or office
to contact.”

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

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

Text Entry The field is
displayed if the
user selects the
radio button
for “I will assign
a specific
person or office
to contact.”

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

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

Text Entry The field is
displayed if the
user selects the
radio button
for “I will assign
a specific
person or office
to contact.”

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

Trigger

OMB Number: 09150126 Expiration Date:
mm/dd/yyyy

Entity
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?

Entity
Registration

Modal

When the user selects “Request another
DBID my organization’s NPDB account” for
“Register my organization”

Your organization
must follow a formal
peer review process

Entity
Registration

Modal

When the user selects “Other Health Care
Entity” for “Which category best fits your
organization?”

I am authorized by my Entity
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

Entity
Registration

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.