Form npdb1

National Practitioner Data Bank: Section 1921 of the Social Security Act

npdb info1

National Practitioner Data Bank, Section 1921

OMB: 0915-0331

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National Practitioner Data Bank
Healthcare Integrity and Protection Data Bank

ENTITY REGISTRATION

Complete this form to register your entity with the NPDB, HIPDB, or both Data Banks, and
click Continue. If you are actively registered and need to update your current entity
registration, log into the IQRS as the entity's administrator and select Update Registration Profile from
the Administrator Options menu. If you have been locked out of the IQRS because your password has
expired or if you have been deactivated, do not complete this form. You must call the Customer Service
Center and request a new password. If you need to renew your entity registration, log into the IQRS as
the entity's administrator and follow the instructions provided after you log in.
After completing this form, you will be instructed to print the Entity Registration, provide an original
signature, and mail the form to the Data Banks. Once the signed form has been processed, the Data
Banks will send you a confirmation notice, which provides your Data Bank Identification Number (DBID)
and other important information. Only entities authorized by law may register with the Data Banks.
OMB # 0915-0239 expiration date 10/31/10
OMB # 0915-0126 expiration date 07/31/10
OMB # 0915-xxxx expiration date xx/xx/xx
Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to
respond to, a collection of information unless it displays a currently valid OMB control number. The OMB
control numbers for this project are 0915-0239 (HIPDB), 0915-0126 (NPDB) and 0915-xxxx (NPDB).
Public reporting burden for this collection of information is estimated to average 1 hour to complete this
form, including the time for reviewing instructions, searching existing data sources, and completing and
reviewing the collection of information. Send comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports
Clearance Officer, 5600 Fishers Lane, Room 14-22, Rockville, Maryland, 20857.

ENTITY IDENTIFICATION INFORMATION
Name of Entity:
Department or Office to Which Mail
Should be Addressed:
Street Address:
Address Line 2:
City:
State:
ZIP Code:

CHOOSE ONE FROM LIST

Country (if U.S., leave blank):
Department Fax Number:
Taxpayer Identification Number (TIN):
National Crime Information Center
Originating Agency Identifier (ORI)
(For law enforcement only):
Ownership of the Entity:
If Federal, Specify Department:

CHOOSE ONE FROM LIST
CHOOSE ONE FROM LIST

6
6

EXISTING DBID
Complete this section if you already have a Data Bank Identification Number (DBID). Leave this
section blank if you are registering for the first time. If you have a DBID and your password has
expired, or if your account has been deactivated, do not complete this form. Call the Customer Service
Center to request a new password.
If you received a notice to renew your registration, do not complete this form. Your Entity Data
Bank Administrator must log in to the IQRS to renew your entity's registration.
Existing DBID:
Reason for this Registration:

CHOOSE ONE FROM LIST

6
5

Additional Comments:
6

ELIGIBILITY/STATUTORY AUTHORITY
For each of the three statutes below, entities must select the most appropriate function/service category
based on their primary function or service. Review each of these statutes and regulations prior to
submitting your entity registration.
1. Title IV of Public Law 99-660, the Health Care Quality Improvement Act of 1986, as amended;
2. Public Law 100-93, Section 5[b] of the Medicare and Medicaid Patient and Program Protection Act
of 1987, [Section 1921 of the Social Security Act]; and
3. Section 221[a], Public Law 104-191, the Health Insurance Portability and Accountability Act of
1996, more commonly referred to as Section 1128E of the Social Security Act.
Each entity is responsible for determining its legal obligation or eligibility under the applicable laws and
regulations, and must register accordingly. For a complete description of the requirements and penalties
of each authority, follow the links at the top of each authority selection list. You may wish to seek advice
from legal counsel before specifying your statutory authority(ies). If no function/service applies to you
in the block, select "None of These."
If you are registering under Section 1921 of the Social Security Act, please be aware that this legislation
has not been implemented. Therefore, reports and queries are not accepted under this authority at this
time. You will be notified when final regulations to implement Section 1921 have been established. Until
that time, your certification election for this statute will be stored but will remain inactive.
Title IV Statutory Authority Selections
National Practitioner Data Bank - Title IV Statutory
Function/Service Categories
Statutory Requirements
More information about Title IV querying eligibility
and reporting requirements
Function/Service (select one)
Querying
Reporting
j Board
k
l
m
n

of Medical/Dental Examiners*

Optional

Mandatory

j Other
k
l
m
n

State Practitioner Licensing Board

Optional

No Requirement

Mandatory

n Hospital**
j
k
l
m

j Professional
k
l
m
n
j Other
k
l
m
n

Health Care Entity**

j Medical
k
l
m
n

j None
k
l
m
n

Society**

Malpractice Payer

of These

Optional

Mandatory

Optional

Mandatory

Prohibited

Mandatory

Prohibited

* Includes Composite Boards for physicians or dentists and other health care practitioners.
** Must provide health care services directly or indirectly and must follow a formal peer
review process for the furthering of quality health care.

Section 1921 Statutory Authority Selections
National Practitioner Data Bank - Section 1921
Statutory Function/Service Categories
More information about Section 1921 querying
eligibility and reporting requirements
Function/Service (select one)

Statutory Requirements
Querying

Reporting

j State
k
l
m
n

Health Care Practitioner Licensing Board

Optional

Mandatory

j State
k
l
m
n

Health Care Entity Licensing Board

Optional

Mandatory

j Quality
k
l
m
n

Improvement Organization under Contract
with the Centers for Medicare & Medicaid
Optional
Services (CMS)

j Peer
k
l
m
n

Review Organization

j Private
k
l
m
n

Accreditation Organization

j Hospital*
k
l
m
n

Prohibited

Mandatory

Prohibited

Mandatory

Optional

No Requirement

n Other
j
k
l
m

Health Care Entity, including Professional
Optional
Society*
j Agency Administering a Federal Health Care
k
l
m
n
Optional
Program, including Private Entities Under Contract
j State Agency Administering or Supervising the
k
l
m
n
Optional
Administration of a State Health Care Program
j State
k
l
m
n

Medicaid Fraud Control Unit

j Attorney
k
l
m
n
j None
k
l
m
n

No Requirement

No Requirement
No Requirement
No Requirement

Optional

No Requirement

General/Other Law Enforcement Agency Optional

No Requirement

of These

Prohibited

* Must provide health care services directly or indirectly and must follow a formal peer
review process for the furthering of quality health care.

Section 1128E Statutory Authority Selections
Healthcare Integrity and Protection Data Bank Section 1128e Statutory Function/Service
Categories
More information about Section 1128e querying
eligibility and reporting requirements
Function/Service (select one)
n Federal
j
k
l
m

n State
j
k
l
m

Government Agency

Statutory Requirements

Querying

Reporting

Optional

Mandatory

Optional

Mandatory

j Health
k
l
m
n
j None
k
l
m
n

Plan

of These

Optional

Mandatory

Prohibited

PRIMARY FUNCTION
Select the category that best describes the primary function that your organization performs. Make
only one selection from this list. If the code says "specify," describe the function. Entities that provide
health care services and are self-insured for malpractice liability should register as health care service
providers, not as malpractice payers.
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n

Hospitals [100-109]
Other Health Care Service Providers [120-169]
Health Plans or Health Insurance Companies [200-259]
Licensing Agencies [300-349]
Survey and Certification Agencies [350]
Professional Societies [400-409]
Malpractice Payers [500-519]
Law Enforcement Agencies [600-629]
Government Health Care Program Administration [650-689]
Utilization and Quality Control Peer Review Organizations [700-710]
Private Accreditation Organizations [800]

QUERY OPTIONS FOR ENTITIES AUTHORIZED BY LAW TO QUERY
BOTH THE NPDB AND THE HIPDB
Select the Data Bank(s) you elect to query. Fees are assessed for each Data Bank you choose to query
(except for Federal agencies, which, by law, are exempt from HIPDB query fees). Hospitals MUST
query the NPDB under Title IV.
Query the NPDB and the HIPDB for each query submitted.
j Query only the NPDB for each query submitted.
k
l
m
n
j Query only the HIPDB for each query submitted.
k
l
m
n
j Do not query either the NPDB or the HIPDB.
k
l
m
n
j
k
l
m
n

c I have elected not to query the NPDB but I wish to query the NPDB after the publication of final
d
e
f
g
regulations implementing Section 1921 of the Social Security Act.

POINT OF CONTACT FOR REPORTS
A report point of contact is applicable only if the entity is eligible under law to submit reports. You may
designate an individual or office to be the point of contact to be included on all reports submitted by your
organization to the NPDB and/or the HIPDB. If your entity does not designate a point of contact, the
submitter of each individual report will be listed as the point of contact for that report.
Name or Office:
Title or Department:
Telephone:

Ext.

ENTITY ADMINISTRATOR
The entity administrator is the person who is responsible for overseeing the use of the IQRS at your
entity, establishing individual user accounts, and updating entity profile information. Enter the entity
administrator's Name, Title, Telephone, and E-mail Address information below.
Name:
Title:
Telephone:
E-mail Address to Which
Correspondence Should be Sent:

Ext.

CERTIFICATION
I certify that the entity identified above qualifies under law as specified in the ELIGIBILITY/STATUTORY
AUTHORITY section and is eligible to perform the querying and/or reporting functions. I understand that
the entity may be subject to sanctions under Federal statute for failure to report final adverse actions as
required in the statutes and regulations or for the use of information obtained from the NPDB or the
HIPDB other than the purposes for which it was provided. I further certify that I am authorized to submit
this registration information to the NPDB-HIPDB and that the information provided is true, correct, and
complete. If I become aware that any information in this form is not true, correct, or complete, I agree to
notify the NPDB-HIPDB of this fact immediately. I understand that any omission, misrepresentation, or
falsification of any information contained in this form or contained in any communication supplying
information to the NPDB-HIPDB to complete or clarify this form may be punishable by criminal, civil, or
other administrative actions including fines, penalties, and/or imprisonment under Federal law.
Name of Certifying Official:
Title of Certifying Official:
Telephone:
Certification Date (MMDDYYYY):

Ext.
07162009

Complete this form to register as an authorized agent to query and/or report to the NPDB,
the HIPDB, or both, on behalf of eligible, registered entities. In most cases, an authorized
agent is an independent contractor used for centralized credentialing (e.g., a county medical society or
State hospital association). Complete this form only if you are an authorized agent. If you are actively
registered and need to update your current agent registration, log into the IQRS as the administrator and
select Update Registration Profile from the Administrator Options menu. If you have been locked out
of the IQRS because your password has expired or you have been deactivated, do not complete this
form. You must call the Customer Service Center and request a new password. If you need to renew
your agent registration, log into the IQRS as the administrator and follow the instructions provided after
you log in. Entities that are authorized by law to query, report, or both on their own behalf must register
using the Entity Registration form.
After completing this form, you must click Continue and print the Agent Registration, provide an original
signature, and mail the form to the Data Banks. Once the signed form has been processed, the Data
Banks will send you a confirmation notice, which provides your Data Bank Identification Number (DBID)
and other important information.
All agents must review and sign this registration form to ensure knowledge of and compliance with the
confidentiality requirements of Public Law 99-660, the Health Care Quality Improvement Act of 1986, as
amended; Public Law 100-93, Section 5[b] of the Medicare and Medicaid Patient and Program
Protection Act of 1987, as amended by Public Law 101-508, Omnibus Budget Reconciliation Act of
1990; and/or Public Law 104-191, the Health Insurance Portability and Accountability Act of 1996, as
amended; that applies to information submitted to the NPDB-HIPDB. Review each of these statutes and
regulations prior to submitting your agent registration.
OMB # 0915-0239 expiration date 10/31/10
OMB # 0915-0126 expiration date 07/31/10
Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to
respond to, a collection of information unless it displays a currently valid OMB control number. The OMB
control numbers for this project are 0915-0239 (HIPDB) and 0915-0126 (NPDB). Public reporting burden
for this collection of information is estimated to average 15 minutes to complete this form, including the
time for reviewing instructions, searching existing data sources, and completing and reviewing the
collection of information. Send comments regarding this burden estimate or any other aspect of this
collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance
Officer, 5600 Fishers Lane, Room 14-22, Rockville, Maryland, 20857.
AUTHORIZED AGENT IDENTIFICATION INFORMATION
Agent Organization Name:
Department or Office to Which Mail
Should be Addressed:
Street Address:
Address Line 2:
City:
State:
ZIP Code:
Country (if U.S., leave blank):

CHOOSE ONE FROM LIST

Department Fax Number:
Taxpayer Identification Number (TIN):

Ext.

(To ensure your entity is able to receive Data Bank e-mail, add
the sra.com and npdb-hipdb.hrsa.gov domains to your Safe
Sender list. For assistance, call the Customer Service Center
at 1-800-767-6732.)
AUTHORIZED AGENT REQUIREMENTS
As an agent authorized to report and query the NPDB-HIPDB on behalf of an eligible entity, I certify that
the organization has read and understands the provisions of Public Law 99-660, as amended; the NPDB
regulation (45 CFR Part 60); Public Law 100-93, as amended by Public Law 101-508; and/or the HIPDB
regulation (45 CFR Part 61), Public Law 104-191, as amended; and that I will meet and comply with the
following requirements:
z

I am authorized to conduct business in my State.

My facilities are secure to ensure the confidentiality of NPDB-HIPDB information.

I understand and can comply with the technical requirements for electronically reporting to and
querying the NPDB-HIPDB, as provided by the NPDB-HIPDB and/or guidance distributed by the
NPDB-HIPDB.

I will use my own password and DBID to report and query on behalf of my NPDB-HIPDB client.

I understand that I must query the NPDB and/or the HIPDB separately for each entity on whose
behalf I am authorized to query. My agreement(s) with the entity(ies) I represent explicitly prohibits
me from using information obtained from the NPDB-HIPDB other than the purpose for which the
disclosure was made.

I will not use a single query response for a particular practitioner, provider, or supplier on behalf of
more than one entity.

To my knowledge, the information I am submitting is accurate and truthful.

I will keep registration information concerning my organization in the NPDB-HIPDB up-to-date; and
I will delete NPDB-HIPDB query and report information from my organization’s database that I
provided or obtained on behalf of any entity for whom I am no longer acting as agent.

My activities as an agent are subject to the provisions of Public Law 104-191, as amended;
Public Law 100-93, as amended by Public Law 101-508; and Public Law 104-191, as amended
and regulations codified at 45 CFR Parts 60 and 61.

CERTIFICATION
Notice: 18 U.S.C. §1001 authorizes criminal penalties against whomever in any matter within the
jurisdiction of the executive, legislative, or judicial branch of the Government, knowingly and willfully
falsifies, conceals, or covers-up by any trick, scheme, or writing or document knowing the same to
contain any materially false, fictitious, or fraudulent statement or entry. Individual offenders are
subject to fines of up to $250,000 and imprisonment for up to 5 years. Offenders that are
organizations are subject to fines of up to $500,000. 18 U.S.C.§3571, Section 3571 (d) also
authorizes fines of up to the greater of twice the gross gain derived by the offender or twice the
gross loss sustained by another as a result of the offense. By signing this document, I certify that I
satisfy the requirements as specified above. I understand that if I do not comply with the stated
requirements, my status as an authorized agent with the NPDB-HIPDB may be suspended or revoked
by the Government. I further understand that any omission, misrepresentation, or falsification of any
information contained in this form or in any communication supplying information to the NPDB-HIPDB to
complete or clarify this form may be punishable by criminal, civil, or other administrative actions
including fines, penalties, and/or imprisonment under Federal law.
Name of Certifying Official:
Title of Certifying Official:
Telephone:
Certification Date (MMDDYYYY):

Ext.
01042008

National Practitioner Data Bank
Healthcare Integrity and Protection Data Bank

UPDATE ENTITY PROFILE
Entity: TEST ENTITY (FAIRFAX, VA)

To update entity registration information, complete the fields that require a change, then
click Submit to Data Bank(s). Some changes will require that a signed copy be mailed to
the NPDB-HIPDB; please follow any instructions provided after submitting in order to
process your registration update.
OMB # 0915-0239 expiration date 10/31/10
OMB # 0915-0126 expiration date 07/31/10
OMB # 0915-xxxx expiration date xx/xx/xx
Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to
respond to, a collection of information unless it displays a currently valid OMB control number. The OMB
control numbers for this project are 0915-0239 (HIPDB), 0915-0126 (NPDB) and 0915-xxxx (NPDB).
Public reporting burden for this collection of information is estimated to average 5 minutes to complete
this form, including the time for reviewing instructions, searching existing data sources, and completing
and reviewing the collection of information. Send comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports
Clearance Officer, 5600 Fishers Lane, Room 14-22, Rockville, Maryland, 20857.
ENTITY IDENTIFICATION INFORMATION
Name of Entity:
Department or Office to Which Mail
Should be Addressed:
Street Address:

TEST ENTITY

Address Line 2:

SUITE 4001

City:

FAIRFAX

State:

VA Virginia

ZIP Code:

22033

4350 FAIR LAKES COURT

- 4435

777777772
VA3254345
Federal Government Agency
Centers for Medicare & Medicaid Services

1. Title IV of Public Law 99-660, the Health Care Quality Improvement Act of 1986, as amended;
2. Public Law 100-93, Section 5[b] of the Medicare and Medicaid Patient and Program Protection Act
of 1987, [Section 1921 of the Social Security Act]; and
3. Section 221[a], Public Law 104-191, the Health Insurance Portability and Accountability Act of
1996, more commonly referred to as Section 1128E of the Social Security Act.
Each entity is responsible for determining its legal obligation or eligibility under the applicable laws and
regulations, and must register accordingly. For a complete description of the requirements and
penalties of each authority, follow the links at the top of each authority selection list. You may wish to
seek advice from legal counsel before specifying your statutory authority(ies). If no function/service
applies to you in the block, select "None of These."
If you are registering under Section 1921 of the Social Security Act, please be aware that this legislation
has not been implemented. Therefore, reports and queries are not accepted under this authority at this
time. You will be notified when final regulations to implement Section 1921 have been established. Until
that time, your certification election for this statute will be stored but will remain inactive.
Title IV Statutory Authority Selections
National Practitioner Data Bank - Title IV Statutory
Function/Service Categories
More information about Title IV querying
eligibility and reporting requirements
Function/Service (select one)

Statutory Requirements
Querying

Reporting

Board of Medical/Dental Examiners*

Optional

Mandatory

Other State Practitioner Licensing Board

Optional

No Requirement

Hospital**

Mandatory

Professional Society**

Optional

Mandatory

Other Health Care Entity**

Optional

Mandatory

Medical Malpractice Payer

Prohibited

Mandatory

None of These

Prohibited

Statutory Requirements
Querying

Reporting

State Health Care Practitioner Licensing Board

Optional

Mandatory

State Health Care Entity Licensing Board

Optional

Mandatory

Quality Improvement Organization under Contract
with the Centers for Medicare & Medicaid
Optional
Services (CMS)

No Requirement

Peer Review Organization

Prohibited

Mandatory

Private Accreditation Organization

Prohibited

Mandatory

Hospital*

Optional

No Requirement

Other Health Care Entity, including Professional
Society*

Optional

No Requirement

Agency Administering a Federal Health Care
Optional
Program, including Private Entities Under Contract

No Requirement

State Agency Administering or Supervising the
Administration of a State Health Care Program

Optional

No Requirement

State Medicaid Fraud Control Unit

Optional

No Requirement

Attorney General/Other Law Enforcement Agency Optional

No Requirement

None of These

Prohibited

* Must provide health care services directly or indirectly and must follow a formal peer
review process for the furthering of quality health care.

Statutory Requirements

Querying

Reporting

Federal Government Agency

Optional

Mandatory

State Government Agency

Optional

Mandatory

Health Plan

Optional

Mandatory

None of These

Prohibited

Hospitals [100-109]
General/Acute Care Hospital (100)
Children's Hospital (101)
Psychiatric Hospital (102)
Rehabilitation Hospital (103)
Long Term Care Hospital (104)
Specialty Hospital (105)
Critical Access Hospital (106)

Other Hospital, Specify (109)

Other Health Care Service Providers [120-169]
Health Plans or Health Insurance Companies [200-259]
Licensing Agencies [300-349]
Survey and Certification Agencies [350]
Professional Societies [400-409]
Malpractice Payers [500-519]
Law Enforcement Agencies [600-629]
Government Health Care Program Administration [650-689]
Utilization and Quality Control Peer Review Organizations [700-710]
Private Accreditation Organizations [800]
QUERY OPTIONS FOR ENTITIES AUTHORIZED BY LAW TO QUERY
BOTH THE NPDB AND THE HIPDB
Select the Data Bank(s) you elect to query. Fees are assessed for each Data Bank you choose to
query (except for Federal agencies, which, by law, are exempt from HIPDB query fees). Hospitals
MUST query the NPDB under Title IV.
Query the NPDB and the HIPDB for each query submitted.
Query only the NPDB for each query submitted.
Query only the HIPDB for each query submitted.
Do not query either the NPDB or the HIPDB.
I have elected not to query the NPDB but I wish to query the NPDB after the publication of final
regulations implementing Section 1921 of the Social Security Act.
POINT OF CONTACT FOR REPORTS
A report point of contact is applicable only if the entity is eligible under law to submit reports. You may
designate an individual or office to be the point of contact to be included on all reports submitted by your
organization to the NPDB and/or the HIPDB. If your entity does not designate a point of contact, the
submitter of each individual report will be listed as the point of contact for that report.
Name or Office:

JACK SMITH

Title or Department:

DIRECTOR

Telephone:

7035552323

Ext.

JANE SMITH

Title:

ADMINISTRATOR

Telephone:
E-mail Address to Which
Correspondence Should be Sent:

7035554545

Ext. 111

Test_001@deve-npdb-hipdb.sra.com
(To ensure your entity is able to receive Data Bank e-mail, add
the sra.com and npdb-hipdb.hrsa.gov domains to your Safe
Sender list. For assistance, call the Customer Service Center
at 1-800-767-6732.)

TEST

Title of Certifying Official:

TEST

Telephone:

239872948274928

Certification Date (MMDDYYYY):

07132009

Ext.

Entity: HR TEST, INC (ARLINGTON, VA)
To update agent registration information, complete the fields that require a change, then
click Submit to Data Bank(s).
OMB # 0915-0239 expiration date 10/31/10
OMB # 0915-0126 expiration date 07/31/10
Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to
respond to, a collection of information unless it displays a currently valid OMB control number. The OMB
control numbers for this project are 0915-0239 (HIPDB) and 0915-0126 (NPDB). Public reporting burden
for this collection of information is estimated to average 5 minutes to complete this form, including the
time for reviewing instructions, searching existing data sources, and completing and reviewing the
collection of information. Send comments regarding this burden estimate or any other aspect of this
collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance
Officer, 5600 Fishers Lane, Room 14-22, Rockville, Maryland, 20857.
AGENT IDENTIFICATION INFORMATION
Agent Organization Name:
Department or Office to Which Mail
Should be Addressed:
Street Address:

HR TEST, INC

123 WEST OX DR

Address Line 2:
City:
State:
ZIP Code:

ARLINGTON
VA Virginia

22011

Country (if U.S., leave blank):
Department Fax Number:
Taxpayer Identification Number (TIN):

123456789

SIMON TEST2

Title:

ACCOUNT ASSISTANT

Telephone:
E-mail Address to Which
Correspondence Should be Sent:

7032222222

Ext.

test123@sra.com
(To ensure your entity is able to receive Data Bank e-mail, add
the sra.com and npdb-hipdb.hrsa.gov domains to your Safe
Sender list. For assistance, call the Customer Service Center
at 1-800-767-6732.)

AUTHORIZED AGENT REQUIREMENTS
As an agent authorized to report and query the NPDB-HIPDB on behalf of an eligible entity, I certify that
the organization has read and understands the provisions of Public Law 99-660, as amended; the NPDB
regulation (45 CFR Part 60); Public Law 100-93, as amended by Public Law 101-508; and/or the HIPDB
regulation (45 CFR Part 61), Public Law 104-191, as amended; and that I will meet and comply with the
following requirements:
z

I am authorized to conduct business in my State.

My facilities are secure to ensure the confidentiality of NPDB-HIPDB information.

I understand and can comply with the technical requirements for electronically reporting to and
querying the NPDB-HIPDB, as provided by the NPDB-HIPDB and/or guidance distributed by the
NPDB-HIPDB.

I will use my own password and DBID to report and query on behalf of my NPDB-HIPDB client.

I will not use a single query response for a particular practitioner, provider, or supplier on behalf of
more than one entity.

To my knowledge, the information I am submitting is accurate and truthful.

Telephone:
Certification Date (MMDDYYYY):

Ext.
01042008

Entity: TEST ENTITY (FAIRFAX, VA)
Complete this form to renew your registration, and click Submit to Data Bank(s). After
completing this form, you must print the Entity Registration Renewal, provide an original
signature, and mail the form to the Data Banks. Once the signed form has been
processed, the Data Banks will send you correspondence confirming your registration
renewal via the Data Bank Correspondence screen, accessible through the Administrator
Options menu.
OMB # 0915-0239 expiration date 10/31/10
OMB # 0915-0126 expiration date 07/31/10
Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to
respond to, a collection of information unless it displays a currently valid OMB control number. The OMB
control numbers for this project are 0915-0239 (HIPDB) and 0915-0126 (NPDB). Public reporting burden
for this collection of information is estimated to average 1 hour to complete this form, including the time
for reviewing instructions, searching existing data sources, and completing and reviewing the collection
of information. Send comments regarding this burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600
Fishers Lane, Room 14-22, Rockville, Maryland, 20857.
ENTITY IDENTIFICATION INFORMATION
Name of Entity:
Department or Office to Which Mail
Should be Addressed:
Street Address:

TEST ENTITY

4350 FAIRLAKES COURT

Address Line 2:
City:
State:
ZIP Code:

FAIRFAX
VA Virginia

22033

234123451

State Government Agency
CHOOSE ONE FROM LIST

ELIGIBILITY/STATUTORY AUTHORITY

For each of the three statutes below, entities must select the most appropriate function/service category
based on their primary function or service. Review each of these statutes and regulations prior to
submitting your entity registration.
1. Title IV of Public Law 99-660, the Health Care Quality Improvement Act of 1986, as amended;

2. Public Law 100-93, Section 5[b] of the Medicare and Medicaid Patient and Program Protection Act
of 1987, [Section 1921 of the Social Security Act]; and
3. Section 221[a], Public Law 104-191, the Health Insurance Portability and Accountability Act of
1996, more commonly referred to as Section 1128E of the Social Security Act.
Each entity is responsible for determining its legal obligation or eligibility under the applicable laws and
regulations, and must register accordingly. For a complete description of the requirements and
penalties of each authority, follow the links at the top of each authority selection list. You may wish to
seek advice from legal counsel before specifying your statutory authority(ies). If no function/service
applies to you in the block, select "None of These."
If you are registering under Section 1921 of the Social Security Act, please be aware that this legislation
has not been implemented. Therefore, reports and queries are not accepted under this authority at this
time. You will be notified when final regulations to implement Section 1921 have been established.
Until that time, your certification election for this statute will be stored but will remain inactive.
Title IV Statutory Authority Selections
National Practitioner Data Bank - Title IV Statutory
Function/Service Categories
Statutory Requirements
More information about Title IV querying eligibility
and reporting requirements
Function/Service (select one)
Querying
Reporting
j Board
k
l
m
n

of Medical/Dental Examiners*

Optional

Mandatory

n Other
j
k
l
m

State Practitioner Licensing Board

Optional

No Requirement

Mandatory

Optional

Mandatory

Optional

Mandatory

Prohibited

Mandatory

Prohibited

n Hospital**
i
j
k
l
m
n Professional
j
k
l
m
j Other
k
l
m
n

Health Care Entity**

j Medical
k
l
m
n
j None
k
l
m
n

Society**

Malpractice Payer

of These

Statutory Requirements
Querying

Reporting

j State
k
l
m
n

Health Care Practitioner Licensing Board

Optional

Mandatory

j State
k
l
m
n

Health Care Entity Licensing Board

Optional

Mandatory

n Quality
j
k
l
m

Improvement Organization under Contract
with the Centers for Medicare & Medicaid
Optional
Services (CMS)

j Peer
k
l
m
n

Review Organization

j Private
k
l
m
n

Accreditation Organization

No Requirement

Prohibited

Mandatory

Prohibited

Mandatory

i Hospital*
j
k
l
m
n

Optional

j Other
k
l
m
n

Medicaid Fraud Control Unit

j Attorney
k
l
m
n
j None
k
l
m
n

No Requirement
No Requirement
No Requirement
No Requirement

Optional

No Requirement

General/Other Law Enforcement Agency Optional

No Requirement

of These

Prohibited

* Must provide health care services directly or indirectly and must follow a formal peer
review process for the furthering of quality health care.

Government Agency

j Health
k
l
m
n
j None
k
l
m
n

Government Agency

Plan

of These

Statutory Requirements

Querying

Reporting

Optional

Mandatory

Optional

Mandatory

Optional

Mandatory

Prohibited

PRIMARY FUNCTION OF ENTITY
Select the category that best describes the primary function that your organization performs. Make
only one selection from this list. If the code says "specify," describe the function. Entities that provide
health care services and are self-insured for malpractice liability should register as health care service
providers, not as malpractice payers.
Primary Function of Entity:
If Other, Specify:

44 Hospital

QUERY OPTIONS FOR ENTITIES AUTHORIZED BY LAW TO QUERY
BOTH THE NPDB AND THE HIPDB
Select the Data Bank(s) you elect to query. Fees are assessed for each Data Bank you choose to query
(except for Federal agencies, which, by law, are exempt from HIPDB query fees). Complete this section
only if you are eligible to query both the NPDB and the HIPDB, based on the selections made in the
ELIGIBILITY/STATUTORY AUTHORITY section. Hospitals MUST query the NPDB under Title IV.
Query the NPDB and the HIPDB for each query submitted.
j Query only the NPDB for each query submitted.
k
l
m
n
j Query only the HIPDB for each query submitted.
k
l
m
n
j Do not query either the NPDB or the HIPDB.
k
l
m
n
i
j
k
l
m
n

I have elected not to query the NPDB but I wish to query the NPDB after the publication of final
regulations implementing Section 1921 of the Social Security Act.
c
d
e
f
g

POC NAME

Title or Department:

POC TITLE

Telephone:

2341234123

Ext.

ADMIN NAME

Title:

ADMINISTRATOR

Telephone:
E-mail Address to Which
Correspondence Should be Sent:

2412341243

Ext.

admin@test.com
(To ensure your entity is able to receive Data Bank e-mail, add
the sra.com and npdb-hipdb.hrsa.gov domains to your Safe
Sender list. For assistance, call the Customer Service Center
at 1-800-767-6732.)

Ext.
01072008

Entity: TEST AGENT (FAIRFAX, VA)
Complete this form to renew your registration as an authorized agent to query and/or
report to the NPDB, the HIPDB, or both, on behalf of eligible, registered entities.
After completing this form, you must print the Agent Registration Renewal, provide an original signature,
and mail the form to the Data Banks. Once the signed form has been processed, the Data Banks will
send you correspondence confirming your registration renewal via the Data Bank Correspondence
screen, accessible through the Administrator Options menu.
All agents must review and sign this registration form to ensure knowledge of and compliance with the
confidentiality requirements of Public Law 99-660, the Health Care Quality Improvement Act of 1986, as
amended; Public Law 100-93, Section 5[b] of the Medicare and Medicaid Patient and Program
Protection Act of 1987, as amended by Public Law 101-508, Omnibus Budget Reconciliation Act of
1990; and/or Public Law 104-191, the Health Insurance Portability and Accountability Act of 1996, as
amended; that applies to information submitted to the NPDB-HIPDB. Review each of these statutes and
regulations prior to submitting your agent registration renewal.
OMB # 0915-0239 expiration date 10/31/10
OMB # 0915-0126 expiration date 07/31/10
Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to
respond to, a collection of information unless it displays a currently valid OMB control number. The OMB
control numbers for this project are 0915-0239 (HIPDB) and 0915-0126 (NPDB). Public reporting burden
for this collection of information is estimated to average 15 minutes to complete this form, including the
time for reviewing instructions, searching existing data sources, and completing and reviewing the
collection of information. Send comments regarding this burden estimate or any other aspect of this
collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance
Officer, 5600 Fishers Lane, Room 14-22, Rockville, Maryland, 20857.
AGENT IDENTIFICATION INFORMATION
Agent Organization Name:
Department or Office to Which Mail
Should be Addressed:
Street Address:

TEST AGENT

4350 FAIRLAKES CT

Address Line 2:
City:
State:
ZIP Code:

FAIRFAX
VA Virginia

22033

Country (if U.S., leave blank):
Department Fax Number:
Taxpayer Identification Number (TIN):

324124124

ENTITY ADMINISTRATOR

The entity administrator is the person who is responsible for overseeing the use of the IQRS at your

entity, establishing individual user accounts, and updating entity profile information. Enter the entity
administrator's Name, Title, Telephone, and E-mail Address information below.
Name:

ADMIN NAME

Title:

ADMINISTRATOR

Telephone:
E-mail Address to Which
Correspondence Should be Sent:

2341234123

Ext.

admin@agent.com
(To ensure your entity is able to receive Data Bank e-mail, add
the sra.com and npdb-hipdb.hrsa.gov domains to your Safe
Sender list. For assistance, call the Customer Service Center
at 1-800-767-6732.)

I am authorized to conduct business in my State.

My facilities are secure to ensure the confidentiality of NPDB-HIPDB information.

I understand and can comply with the technical requirements for electronically reporting to and
querying the NPDB-HIPDB, as provided by the NPDB-HIPDB and/or guidance distributed by the
NPDB-HIPDB.

I will use my own password and DBID to report and query on behalf of my NPDB-HIPDB client.

I will not use a single query response for a particular practitioner, provider, or supplier on behalf of
more than one entity.

To my knowledge, the information I am submitting is accurate and truthful.

contain any materially false, fictitious, or fraudulent statement or entry. Individual offenders are
subject to fines of up to $250,000 and imprisonment for up to 5 years. Offenders that are
organizations are subject to fines of up to $500,000. 18 U.S.C.§3571, Section 3571 (d) also
authorizes fines of up to the greater of twice the gross gain derived by the offender or twice the
gross loss sustained by another as a result of the offense. By signing this document, I certify that I
satisfy the requirements as specified above. I understand that if I do not comply with the stated
requirements, my status as an authorized agent with the NPDB-HIPDB may be suspended or revoked
by the Government. I further understand that any omission, misrepresentation, or falsification of any
information contained in this form or in any communication supplying information to the NPDB-HIPDB to
complete or clarify this form may be punishable by criminal, civil, or other administrative actions
including fines, penalties, and/or imprisonment under Federal law.
Name of Certifying Official:
Title of Certifying Official:
Telephone:
Certification Date (MMDDYYYY):

Ext.
01072008

STATE LICENSURE

Individual Subject: Initial Report

Please provide as much of the following information as possible. Failure to provide sufficient
information to permit identification of a single subject will result in the report being rejected,
necessitating resubmission.
Do not print this page. A printable copy of your report submission will be provided after submission.
OMB # 0915-0239 expiration date 10/31/10
OMB # 0915-0126 expiration date 07/31/10
Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to
respond to, a collection of information unless it displays a currently valid OMB control number. The
OMB control numbers for this project are 0915-0239 (HIPDB) and 0915-0126 (NPDB). Public reporting
burden for this collection of information is estimated to average 45 minutes to complete the forms,
including the time for reviewing instructions, searching existing data sources, and completing and
reviewing the collection of information. Send comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports
Clearance Officer, 5600 Fishers Lane, Room 14-22, Rockville, Maryland, 20857.

SUBJECT INFORMATION
Subject Name:
Last Name

First Name

Middle Name

Suffix (e.g., Jr, III)

Other Names Used (Last Name and First Name Required):
Last Name
First Name
Middle Name

Suffix (e.g., Jr, III)

1.
2.
3.
4.
5.

Gender:
 Male




Birth Date
(MMDDYYYY):
Work
Organization
Name:

 Female





 Unknown





Organization
Type:

CHOOSE ONE FROM LIST



Description (if 'Other' was selected above):

ADDRESSES
Click

for information on filling out non-U.S. and military addresses.

Work Address
Street Address:
Address Line 2:
City:
CHOOSE ONE FROM LIST

State:
ZIP Code:



Country (if U.S., leave
blank):
Home Address/Address of
Record
Street Address:
Address Line 2:
City:
CHOOSE ONE FROM LIST

State:
ZIP Code:



Country (if U.S., leave
blank):
Is Subject Deceased?

 No





 Unknown





 Yes--Deceased





Date (MMDDYYYY)

SOCIAL SECURITY NUMBERS (SSN) (FORMAT NNNNNNNNN)
1.

INDIVIDUAL TAXPAYER IDENTIFICATION NUMBERS (ITIN) (FORMAT 9NNNNNNNN)
1.

FEDERAL EMPLOYER IDENTIFICATION NUMBERS (FEIN)
1.

NATIONAL PROVIDER IDENTIFIERS (NPI)
1.

DRUG ENFORCEMENT ADMINISTRATION (DEA) NUMBERS
1.

UNIQUE PHYSICIAN IDENTIFICATION NUMBERS (UPIN)
1.

PROFESSIONAL SCHOOLS ATTENDED
The form will suggest medical schools as you type. Please choose the matching school
or enter the complete school name.
School Name:

Year of
Graduation
(Format YYYY):

1.
2.
3.
4.
5.

OCCUPATION AND STATE LICENSURE INFORMATION
(Provide at least one license. Check 'No License' if the subject does not have a State License Number.
Use the Add Additional License/Occupation button to provide more than one license. Up to 60
licenses may be provided.)

1. State License Number:

State of Licensure:

CHOOSE ONE FROM LIST

Occupation/Field of
Licensure:

010 Physician (MD)







No License




Description (complete only if 'Other' is selected above):

Specialty:

CHOOSE ONE FROM LIST



HEALTH CARE ENTITIES WITH WHICH THE SUBJECT IS AFFILIATED OR ASSOCIATED
Inclusion of an affiliated/associated health care entity in this report does not imply complicity in the reported
action.
Click
1.

for information on filling out non-U.S. and military addresses.
Name of Affiliated/Associated
Health Care Entity:
Street Address:
Address Line 2:
City:
State:

CHOOSE ONE FROM LIST

ZIP Code:
Country (if U.S., leave
blank):
Nature of Subject's
Relationship to Affiliate:



CHOOSE ONE FROM LIST



Other Description (complete only if 'Other' is selected above):

Add Additional Affiliate

ADVERSE ACTION INFORMATION
BASIS FOR ACTION
Select a category and then choose a basis for action code that best describes the reason for the action.
Click Add Additional Basis For Action to provide up to 5 basis for action selections. View a complete
basis for action list.
1. 
 Non-Compliance With Requirements












































Criminal Conviction or Adjudication
Confidentiality, Consent or Disclosure Violations
Misconduct or Abuse
Fraud, Deception, or Misrepresentation
Unsafe Practice or Substandard Care
Improper Supervision or Allowing Unlicensed Practice
Improper Prescribing, Dispensing, Administering Medication/Drug Violation
Other

Name of Agency or Program
that Took the Adverse Action
Specified in This Report:
Date Action Was Taken
(MMDDYYYY):
Date Action Became
Effective (MMDDYYYY):
Length of Action:
 Permanent




 Indefinite/Unspecified




 Specific Period




Years:
Months:
Days:
Is Reinstatement Automatic
at Completion of Adverse
Action Period?

 Yes




 Yes, with conditions (requires a Revision to Action Report when status




changes)
 No





Total Amount of Monetary Penalty, Assessment and/or Restitution or fine (Format NNNNN.NN):
Note: If no amount, leave this field blank.
$
Is the Adverse Action Specified in This Report Based on the Subject's Professional
Competence or Conduct, Which Adversely Affected, or Could Have Adversely Affected, the
 Yes 



Health or Welfare of the Patient? 
 No



Description of Subject's Act(s) or Omission(s) or Other Reasons for Action(s) Taken and
Description of Action(s) Taken by Reporting Entity
Note: Do not reference any personal identification information
(e.g., names) of anyone other than the subject of this report.
The description must include sufficient specificity to enable a
knowledgeable reviewer to determine clearly the
circumstances of the action(s) or surrender. Refer to the Fact
Sheet on Submitting a Factually Sufficient Narrative
Description for detailed information.




There are 4000 characters remaining for the description.
Is the Action on Appeal?

 Yes





 No





 Unknown





Date of Appeal (MMDDYYYY):

ENTITY INTERNAL REPORT REFERENCE
This optional field allows your entity to include an internal file number or other reference information to
help you identify this report in your files. This information is not used by the Data Banks, but it will be
provided on copies of the report sent to queriers.
Entity Internal Report Reference (e.g., claim
number):

CERTIFICATION

I certify that I am authorized to submit this transaction and that all information is true and correct to the
best of my knowledge.
Authorized Submitter's Name:

TEST 333333333333333

Authorized Submitter's Title:
Authorized Submitter's Phone:
Date:






Ext.
08/25/2009

Check this box if you wish to add/update this subject in your subject database for use
in future queries and/or reports. Duplicate entries in your subject database may result in
duplicate queries. You will be notified of potential duplicate entries prior to completing this
subject entry.

Report Input Form

Page 1 of 9

STATE LICENSURE
Report Correction
To submit a correction to previously submitted report DCN 7910000057666471, complete all
necessary modifications in the form below, and press Submit to Data Bank(s).
The report entered here will replace the original report, so please ensure that all known data is entered
in its entirety. Failure to provide sufficient information to permit identification of a single subject may
result in the report being rejected, necessitating resubmission.
Do not print this page. A printable copy of your report submission will be provided after submission.
OMB # 0915-0239 expiration date 10/31/10
OMB # 0915-0126 expiration date 07/31/10
Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to
respond to, a collection of information unless it displays a currently valid OMB control number. The
OMB control numbers for this project are 0915-0239 (HIPDB) and 0915-0126 (NPDB). Public reporting
burden for this collection of information is estimated to average 15 minutes to complete the forms,
including the time for reviewing instructions, searching existing data sources, and completing and
reviewing the collection of information. Send comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports
Clearance Officer, 5600 Fishers Lane, Room 14-22, Rockville, Maryland, 20857.

SUBJECT INFORMATION
Subject Name:
Last Name

First Name

Middle Name

Suffix (e.g., Jr, III)

Other Names Used (Last Name and First Name Required):
Last Name
First Name
Middle Name

Suffix (e.g., Jr, III)

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Report Input Form

Page 2 of 9

2.
3.
4.
5.

Gender:
n Male n
i
j
k
l
m
j Female n
k
l
m
j Unknown
k
l
m
Birth Date
(MMDDYYYY):
Work Organization
Name:
Organization Type: CHOOSE ONE FROM LIST
Description (if 'Other' was selected above):

ADDRESSES
Click

for information on filling out non-U.S. and military addresses.

Work Address
Street Address:
Address Line 2:
City:
State:
ZIP Code:

CHOOSE ONE FROM LIST

Country (if U.S., leave
blank):

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Page 3 of 9

Home Address/Address of
Record
Street Address:
Address Line 2:
City:
CHOOSE ONE FROM LIST

State:
ZIP Code:

Country (if U.S., leave
blank):
Is Subject Deceased?

i No
j
k
l
m
n

j Unknown
k
l
m
n

j Yes--Deceased
k
l
m
n

Date (MMDDYYYY)

SOCIAL SECURITY NUMBERS (SSN) (FORMAT NNNNNNNNN)
1. 000000000
3.

Undo

2.
4.

INDIVIDUAL TAXPAYER IDENTIFICATION NUMBERS (ITIN) (FORMAT 9NNNNNNNN)
1.

FEDERAL EMPLOYER IDENTIFICATION NUMBERS (FEIN)
1.

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Report Input Form

Page 4 of 9

NATIONAL PROVIDER IDENTIFIERS (NPI)
1.

DRUG ENFORCEMENT ADMINISTRATION (DEA) NUMBERS
1.

UNIQUE PHYSICIAN IDENTIFICATION NUMBERS (UPIN)
1.

PROFESSIONAL SCHOOLS ATTENDED
The form will suggest medical schools as you type. Please choose the
matching school or enter the complete school name.
School Name:

Year of
Graduation
(Format YYYY):

1.
2.
3.
4.
5.

https://cajal:440/servlet/WebInputServlet?AAC_CODE_BTN=Continue&AA_CLASS=1110&ACTION_TYPE=1&FORM_N... 10/19/2009

Report Input Form

Page 5 of 9

1. State License Number:

State of Licensure:

CHOOSE ONE FROM LIST

Occupation/Field of
Licensure:

010 Physician (MD)

c
d
e
f
g

No License

6
6

Description (complete only if 'Other' is selected above):

CHOOSE ONE FROM LIST

Specialty:

for information on filling out non-U.S. and military addresses.
Name of
Affiliated/Associated
Health Care Entity:
Street Address:
Address Line 2:

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Report Input Form

Page 6 of 9

City:
State:

CHOOSE ONE FROM LIST

ZIP Code:
Country (if U.S., leave
blank):
Nature of Subject's
Relationship to
Affiliate:

CHOOSE ONE FROM LIST

Other Description (complete only if 'Other' is selected above):

Add Additional Affiliate

ADVERSE ACTION INFORMATION
BASIS FOR ACTION
Select a category and then choose a basis for action code that best describes the reason for the action.
Click Add Additional Basis For Action to provide up to 5 basis for action selections. View a complete
basis for action list.
j Non-Compliance With Requirements
k
l
m
1. n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
i
j
k
l
m
n

https://cajal:440/servlet/WebInputServlet?AAC_CODE_BTN=Continue&AA_CLASS=1110&ACTION_TYPE=1&FORM_N... 10/19/2009

Report Input Form

j Other
k
l
m
n

Page 7 of 9

- Not Classified, Specify (99)

Name of Agency or Program that
Took the Adverse Action Specified
in This Report:
Date Action Was Taken
(MMDDYYYY):
Date Action Became Effective
(MMDDYYYY):
Length of Action:

Permanent
j Indefinite/Unspecified
k
l
m
n
n Specific Period
j
k
l
m
i
j
k
l
m
n

Years:
Months:
Days:
Is Reinstatement Automatic at
Completion of Adverse Action
Period?

j Yes
k
l
m
n
j Yes,
k
l
m
n

with conditions (requires a Revision to Action Report when status changes)

i No
j
k
l
m
n

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Report Input Form

Page 8 of 9

Note: Do not reference any personal identification information (e.g.,
names) of anyone other than the subject of this report. The description must
include sufficient specificity to enable a knowledgeable reviewer to
determine clearly the circumstances of the action(s) or surrender. Refer to
the Fact Sheet on Submitting a Factually Sufficient Narrative Description for
detailed information.
5

There are 4000 characters remaining for the description.
Is the Action on Appeal?

j Yes
k
l
m
n

j No
k
l
m
n

i Unknown
j
k
l
m
n

Date of Appeal (MMDDYYYY):

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Report Input Form

Page 9 of 9

I certify that I am authorized to submit this transaction and that all information is true and correct to the
best of my knowledge.
Authorized Submitter's Name:
Authorized Submitter's Title:
Authorized Submitter's Phone:
Date:

Ext.
10/19/2009

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Adverse Action Report Legacy

Report Correction

To submit a correction to previously submitted report DCN 5500000056940157, complete all
necessary modifications in the form below, and press Submit to Data Bank(s).
The report entered here will replace the original report, so please ensure that all known data is entered
in its entirety. Failure to provide sufficient information to permit identification of a single subject may
result in the report being rejected, necessitating resubmission.
Do not print this page. A printable copy of your report submission will be provided after submission.
OMB # 0915-0239 expiration date 10/31/10
OMB # 0915-0126 expiration date 07/31/10
Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to
respond to, a collection of information unless it displays a currently valid OMB control number. The
OMB control numbers for this project are 0915-0239 (HIPDB) and 0915-0126 (NPDB). Public reporting
burden for this collection of information is estimated to average 15 minutes to complete the forms,
including the time for reviewing instructions, searching existing data sources, and completing and
reviewing the collection of information. Send comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports
Clearance Officer, 5600 Fishers Lane, Room 14-22, Rockville, Maryland, 20857.

SUBJECT INFORMATION
Subject Name:
Last Name
MOUSE

First Name

Middle Name

Suffix (e.g., Jr, III)

Middle Name

Suffix (e.g., Jr, III)

MARY

Other Name Used:
Last Name

First Name

Gender:
 Male 




 Female




Birth Date
(MMDDYYYY): 07071977
Work
Organization
Name:

 Unknown





ADDRESSES
Click

for information on filling out non-U.S. and military addresses.

Work Address
Street Address:

123 MAIN STREET

Address Line 2:
City:

ALEXANDRIA

State:

VA Virginia

ZIP Code:

22222



Country (if U.S., leave
blank):
Home Address/Address of
Record
Street Address:

222 MAPLE ST.

Address Line 2:
City:

ALEXANDRIA

State:

VA Virginia

ZIP Code:

22222



Country (if U.S., leave
blank):
Is Subject Deceased?

 No






 Unknown





 Yes





SOCIAL SECURITY NUMBERS (SSN) (FORMAT NNNNNNNNN):

222222222

DRUG ENFORCEMENT ADMINISTRATION (DEA) NUMBERS
1.

PROFESSIONAL SCHOOLS ATTENDED
School Name:

Year of
Graduation
(Format YYYY):

1. MICKEY UNIVERSITY

2000

2.
3.
4.
5.

OCCUPATION AND STATE LICENSURE INFORMATION

(Provide at least one license. Check 'No License' if the subject does not have a State License Number.
Use the Add Additional License/Occupation button to provide more than one license. Up to 60
licenses may be provided.)

1. State License Number:

123ABC

State of Licensure:

VA Virginia

Occupation/Field of
Licensure:

100 Registered (Professional) Nurse







No License




Description (complete only if 'Other' is selected above):

2. State License Number:
State of Licensure:

CHOOSE ONE FROM LIST

Occupation/Field of
Licensure:

CHOOSE ONE FROM LIST







No License




Description (complete only if 'Other' is selected above):

ADVERSE ACTION INFORMATION
Type of Action Taken (select one):







Licensure







Clinical Privileges







Society Membership

Action Classification:

320.00 Mental Disorder

Date of the Action:

08212009

Length of Action:
Effective Date:

 Permanent




 Specific







 Indefinite






Period -- Months:

Days:

08212009

Reporter's Description of Action
(Note: Do not reference any personal identification information (e.g., names) of anyone other than the
subject of this report.):



Reporter's Description of Action



There are 3968 characters remaining for the description.

ER1234

CERTIFICATION

I certify that I am authorized to submit this transaction and that all information is true and correct to the
best of my knowledge.
Authorized Submitter's Name:

TEST 333333333333333

Authorized Submitter's Title:

TESTER

Authorized Submitter's Phone:

1234567890

Date:

08/26/2009

Ext.

Report Input Form

Page 1 of 8

STATE LICENSURE
Revision to Action
To submit a revision to action on previously submitted report DCN 7910000057666471, enter all
report data for the action, and press Submit to Data Bank(s).
Enter all known data in its entirety. Failure to provide sufficient information to permit identification of a
single subject may result in the report being rejected, necessitating resubmission.
Do not print this page. A printable copy of your report submission will be provided after submission.
OMB # 0915-0239 expiration date 10/31/10
OMB # 0915-0126 expiration date 07/31/10
Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to
respond to, a collection of information unless it displays a currently valid OMB control number. The
OMB control numbers for this project are 0915-0239 (HIPDB) and 0915-0126 (NPDB). Public reporting
burden for this collection of information is estimated to average 15 minutes to complete the forms,
including the time for reviewing instructions, searching existing data sources, and completing and
reviewing the collection of information. Send comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports
Clearance Officer, 5600 Fishers Lane, Room 14-22, Rockville, Maryland, 20857.

SUBJECT INFORMATION
Subject Name:
Last Name

First Name

Middle Name

Suffix (e.g., Jr, III)

Other Names Used (Last Name and First Name Required):
Last Name
First Name
Middle Name

Suffix (e.g., Jr, III)

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Report Input Form

Page 2 of 8

2.
3.
4.
5.

Gender:
n Male n
i
j
k
l
m
j Female n
k
l
m
j Unknown
k
l
m
Birth Date
(MMDDYYYY):
Work Organization
Name:
Organization Type: CHOOSE ONE FROM LIST
Description (if 'Other' was selected above):

ADDRESSES
Click

for information on filling out non-U.S. and military addresses.

Work Address
Street Address:
Address Line 2:
City:
State:
ZIP Code:

CHOOSE ONE FROM LIST

Country (if U.S., leave
blank):

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Home Address/Address of
Record
Street Address:
Address Line 2:
City:
CHOOSE ONE FROM LIST

State:
ZIP Code:

Country (if U.S., leave
blank):
Is Subject Deceased?

i No
j
k
l
m
n

j Unknown
k
l
m
n

j Yes--Deceased
k
l
m
n

Date (MMDDYYYY)

SOCIAL SECURITY NUMBERS (SSN) (FORMAT NNNNNNNNN)
1. 000000000
3.

Undo

2.
4.

INDIVIDUAL TAXPAYER IDENTIFICATION NUMBERS (ITIN) (FORMAT 9NNNNNNNN)
1.

FEDERAL EMPLOYER IDENTIFICATION NUMBERS (FEIN)
1.

NATIONAL PROVIDER IDENTIFIERS (NPI)

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DRUG ENFORCEMENT ADMINISTRATION (DEA) NUMBERS
1.

UNIQUE PHYSICIAN IDENTIFICATION NUMBERS (UPIN)
1.

PROFESSIONAL SCHOOLS ATTENDED
School Name:

Year of
Graduation
(Format YYYY):

1.
2.
3.
4.
5.

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Report Input Form

Page 5 of 8

licenses may be provided.)

1. State License Number:

State of Licensure:

CHOOSE ONE FROM LIST

Occupation/Field of
Licensure:

603 Chiropractor

c
d
e
f
g

No License

6
6

Description (complete only if 'Other' is selected above):

CHOOSE ONE FROM LIST

Specialty:

for information on filling out non-U.S. and military addresses.
Name of
Affiliated/Associated
Health Care Entity:
Street Address:
Address Line 2:
City:
State:

CHOOSE ONE FROM LIST

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ZIP Code:
Country (if U.S., leave
blank):
Nature of Subject's
Relationship to
Affiliate:

CHOOSE ONE FROM LIST

Other Description (complete only if 'Other' is selected above):

Add Additional Affiliate

ADVERSE ACTION INFORMATION
Name of Agency or Program that
Took the Adverse Action Specified
in This Report:
Date Action Was Taken
(MMDDYYYY):
Date Action Became Effective
(MMDDYYYY):
Length of Action:

Note: Date must be on or after Date Action Was Taken of related report
(03/03/2003).

Permanent
j Indefinite/Unspecified
k
l
m
n
n Specific Period
j
k
l
m
j
k
l
m
n

Years:
Months:
Days:
Is Reinstatement Automatic at
Completion of Adverse Action
Period?

n Yes
j
k
l
m
j Yes,
k
l
m
n

with conditions (requires a Revision to Action Report when status changes)

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j No
k
l
m
n

Total Amount of Monetary Penalty, Assessment and/or Restitution or fine (Format NNNNN.NN):
Note: If no amount, leave this field blank.
$
Description of Subject's Act(s) or Omission(s) or Other Reasons for Action(s) Taken and Description of Action(s)
Taken by Reporting Entity
Note: Do not reference any personal identification information (e.g.,
names) of anyone other than the subject of this report. The description must
include sufficient specificity to enable a knowledgeable reviewer to
determine clearly the circumstances of the action(s) or surrender. Refer to
the Fact Sheet on Submitting a Factually Sufficient Narrative Description for
detailed information.
5

There are 4000 characters remaining for the description.
Is the Action on Appeal?

j Yes
k
l
m
n

j No
k
l
m
n

j Unknown
k
l
m
n

Date of Appeal (MMDDYYYY):

ENTITY INTERNAL REPORT REFERENCE

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Page 8 of 8

This optional field allows your entity to include an internal file number or other reference information to
help you identify this report in your files. This information is not used by the Data Banks, but it will be
provided on copies of the report sent to queriers.
Entity Internal Report Reference (e.g., claim
number):
CERTIFICATION
I certify that I am authorized to submit this transaction and that all information is true and correct to the
best of my knowledge.
Authorized Submitter's Name:
Authorized Submitter's Title:
Authorized Submitter's Phone:
Date:

Ext.
10/19/2009

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File Type	application/pdf
File Title	https://netserver:480/ext/EntityRegInput.jsp
Author	vyash
File Modified	2009-11-20
File Created	2009-10-19