Form 43 Medical Malpractice Payer Attestation

Medical Malpractice Payer Attestation Form and Instruction

Non-visible Questions
Label
Why
not?

PDF Name
(step)

Location

Medical
Malpractice
Payer
Attestation (1)

Below the
Yes and No
radio
buttons

Response
Input Item
Text Entry

Visibility Trigger

Other

The field is displayed
if the user selects the
No radio button

State Changes
Label

PDF Name

Item Type

Trigger

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

Medical
Malpractice
Payer
Attestation

Modal

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