Form 25 Entity Registration (Renewal & Update)

Entity Registration (Renewal & Update) Forms and Instructions

Non-visible Questions
Label

PDF Name
(step)

Location

Response
Input
Item

Visibility
Trigger

Other

Name of your
federal agency

Entity
Registration
Renewal –
Select the
best option
for your
organization

Below “Federal
government
agency or
entity” radio
button

Drop List

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

Is your
organization also
a health plan?

Entity
Registration
Renewal –
Select the
best option
for your
organization

Below “Best
category for
your
organization”

Radio
buttons

The fields are
displayed if the
user 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.”

Select up to 4
additional
functions or
services

Entity
Registration
Renewal –
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

Visibility
Trigger

Description

Entity
Registration
Renewal –
Select the
best option
for your
organization.

Below checkbox Text Entry
for relevant
checkbox
selection

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

NPI (National
Provider
Identifier)

Entity
Registration
Renewal –
Organization
Information

Below
Identification
Numbers

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
Registration
Renewal –
Organization
Information

Below
Identification
Numbers

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

ORI (Originating
Entity
Agency Identifier) Registration
Renewal –
Organization
Information

Below
Identification
Numbers

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

Visibility
Trigger

Other

Name of person
or office

Entity
Registration
Renewal –
Your Point of
Contact on
NPDB
Reports

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

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.

Title or
department

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

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.

Phone

Entity
Below “Title or
Registration department”
Renewal –
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.

Extension
(optional)

Entity
Beside “Phone”
Registration
Renewal –
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.

Label

PDF Name
(step)

Description

Entity
Registration
Renewal

Location

Response
Input
Item

Below Select up Text
to 5 actions
Entry

Visibility
Trigger
The field is
displayed if the
user selects an
adverse action
that requires a
description.

Other

State Changes
Label

PDF Name

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

Entity
Registration
Renewal

I am authorized by my Entity
organization to serve Registration
as the certifying
Renewal
official

Item Type
Modal

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

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).