Form 20 Self-Query on an Organization

Self-Query on an Organization Form and Instruction

Non-visible Questions
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)

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.

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.

Below "the
location
address"
and "a
different
address"
options for
Delivery
Address

Label

PDF Name
(step)

Location

Response Visibility Trigger
Input Item

Other

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.

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.

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.

MPN/MSN
Self-Query
(Medicare
on an
Provider/Sup Organization
plier
(1)
Number)

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

Label

PDF Name
(step)

Location

Response Visibility Trigger
Input Item

Other

FDA (Federal
Food and
Drug
Administratio
n)

Self-Query
Below
on an
MPN/MSN
Organization text entry.
(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.

CLIA (Clinical
Laboratory
Improvement
Act)

Self-Query
Below FDA
on an
text entry
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.

Country

Self-Query
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. United States is
the default selection.

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.

Below "the
location
address"
and "a
different
address"
options
for Billing
Address

Label

PDF Name
(step)

Location

Response Visibility Trigger
Input Item

Other

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.

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.

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.

Paper Copies Self-Query
Below
Question
on an
Payment
Organization
(2)

State Changes
Label

PDF Name

Item Type

Trigger

Place a Self-Query Self-Query on
Order
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 to act
on behalf of the
organization?

Self-Query on
an
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.