0915-0126 NPDB For NPDB Forms

National Practitioner Data Bank for Adverse Information on Physicians and Other Health Care Practitioners: Regulations and Forms

0915-0126_NPDB Forms_2010

National Practitioner Data Bank for Adverse Information on Physicians and Other Health Care Pract

OMB: 0915-0126

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0915-0126 can be found here:

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Medical Malpractice Payment Report
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 # 0915-0126 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 number for this project is 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

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.

First Name

Gender:
Birth Date
(MMDDYYYY):
Work Organization
Name:

Male

Female

Unknown

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):
Home Address/Address of
Record
Street Address:
Address Line 2:
City:
State:
ZIP Code:
Country (if U.S., leave

CHOOSE ONE FROM LIST

blank):

Is Subject Deceased?

Unknown

Yes--Deceased Date (MMDDYYYY)

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

DRUG ENFORCEMENT ADMINISTRATION (DEA) NUMBERS
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):

HOSPITAL AFFILIATION(S)

City

State

CHOOSE ONE FROM LIST

PAYMENT INFORMATION
Relationship of Entity to This Practitioner:

CHOOSE ONE FROM LIST

Payments by This Payer for This Practitioner
Amount of This Payment for This Practitioner (Format NNNNN.NN):

Date of This Payment (MMDDYYYY):
This Payment Represents:

A Single Final Payment

One of Multiple Payments

Total Amount Paid or to Be Paid by This Payer for This Practitioner

(Format NNNNN.NN):
Payment Result of:
Judgment

Settlement

Payment Prior to Settlement

Date of Judgment or Settlement, if Any (MMDDYYYY):
Adjudicative Body Case Number (if Applicable):
Adjudicative Body Name (if Applicable):
Court File Number (if Applicable):
Description of Judgment or Settlement and Any Conditions, Including Terms of Payment
Note: Do not reference any personal identification information (e.g., names) of anyone other than the subject of
this report.

There are 4000 characters remaining for the description.
Payments by This Payer for Other Practitioners in This Case
Total Amount Paid or to Be Paid by This Payer for All Practitioners in This
Case (Including the Amount Specified Above for This Practitioner)
$
(Format NNNNN.NN):
Number of Practitioners for Whom This Payer Has Paid or Will Pay in
This Case:
Payments by Others for This Practitioner
Complete if your entity is an Insurance Company or a Self-Insured Organization.
Yes
Has a State Guaranty Fund or State Excess Judgment Fund Made a

Payment for This Practitioner in This Case, or Is Such a Payment
Expected to Be Made?:

No
Unknown

Amount Paid or Expected to Be Paid by the State Fund (Format
NNNNN.NN):

Complete if your entity is an Insurance Company, an Insurance Guaranty Fund or a State Medical Malpractice
Payment Fund.
Yes
Has a Self-Insured Organization and/or Other Insurance
Company/Companies Made Payment(s) for This Practitioner in This
No
Case, or Is/Are Such Payment(s) Expected to Be Made?:
Unknown
Amount Paid or Expected to Be Paid by Self-Insured Organization(s)
$
and/or Other Insurance Company/Companies (Format NNNNN.NN):

CLASSIFICATION OF ACT(S) OR OMISSION(S)
Patient's Age at Time of Initial Event:

Days (if less than 1 month)
Months (if less than 1 year)
Years
Unknown

Patient's Gender:

Male

Patient Type:

Inpatient

Female

Unknown

Outpatient

Both

Unknown

Description of the Medical Condition With Which the Patient Presented for Treatment (Prior to the Event
That Led to the Malpractice Allegation)
Note: Do not reference any personal identification information (e.g., names) of anyone other than the
subject of this report.

There are 4000 characters remaining for the description.
Description of the Procedure Performed
Note: Do not reference any personal identification information (e.g., names) of anyone other than the
subject of this report.

There are 4000 characters remaining for the description.
Nature of
Allegation:
1.

Specific
Allegation:

CHOOSE ONE FROM LIST

Description (complete only if 'Not Classified' is selected above):
Date of Event
Associated
With Allegation
or Incident
(MMDDYYYY):
2.

Specific
Allegation:

CHOOSE ONE FROM LIST

Description (complete only if 'Not Classified' is selected above):
Date of Event
Associated
With Allegation
or Incident
(MMDDYYYY):

CHOOSE ONE FROM LIST
Outcome:
Description of the Allegations and Injuries or Illnesses Upon Which the Action or Claim Was Based
Note: Do not reference any personal identification information (e.g., names) of anyone other than the
subject of this report.

There are 4000 characters remaining for the description.

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):
CUSTOMER USE
This optional field may be used by the submitter to identify this transaction. This information is returned
without modification and only appears on the response returned to your organization.
Customer Use:
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.
06/18/2010

Send e-mail notification when this and any future responses are available.
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.

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

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.

First Name

4.
5.

Gender:
Male
Female
Unknown
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:
Country (if U.S., leave
blank):
Home Address/Address of
Record
Street Address:
Address Line 2:

CHOOSE ONE FROM LIST

City:
CHOOSE ONE FROM LIST

State:
ZIP Code:

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

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.

1. State License Number:
State of Licensure:

OR
CHOOSE ONE FROM LIST

No License

Occupation/Field of
Licensure:

010 Physician (MD)

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

CHOOSE ONE FROM LIST

Specialty:

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:
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
Clear

Add Additional Basis for Action

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 Health or Welfare of the Patient?
Yes
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

Unknown

Date of Appeal (MMDDYYYY):

Authorized Submitter's Name:
Authorized Submitter's Title:
Authorized Submitter's Phone:
Date:

Ext.
06/18/2010

To submit a query, enter all known subject data.
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.

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):
PIN:
Work
Organization
Name:
Organization
Type:

 Female





 Unknown





CHOOSE ONE FROM LIST

Description (if 'Other' was selected above):

ADDRESSES
Click
Work Address

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



Street Address:
Address Line 2:
City:
State:

CHOOSE ONE FROM LIST

ZIP Code:



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

CHOOSE ONE FROM LIST

ZIP Code:



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

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
School Name:

Year of
Graduation
(Format YYYY):

1.
2.
3.
4.
5.

1. 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):

Specialty:

CHOOSE ONE FROM LIST



Check this box if you wish to store 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.






National Practitioner Data Bank
Healthcare Integrity and Protection Data Bank

SUBJECT INFORMATION

Subject
Information

Output Options

Payment
Information

Final Steps

INDIVIDUAL SELF-QUERY INSTRUCTIONS
Complete the Individual Self-Query form on-line, review the information entered on
the form for completeness and accuracy, click Continue, and print the formatted copy
of your self-query. Sign the formatted copy in ink and in the presence of a Notary
Public, and mail the notarized copy to the address printed at the top of the page.
DO NOT PRINT OR NOTARIZE THIS FORM. A printable copy will be made available
to you upon transmission of this form.
FEE AND PAYMENT INFORMATION
All individual self-queries are automatically sent to both the NPDB and the HIPDB. An
$8.00 fee per self-query is assessed by the NPDB; an $8.00 fee per self-query is also
assessed by the HIPDB. Fees must be paid by credit card (VISA, MasterCard,
Discover or American Express). Cash and checks are not accepted.
CONFIDENTIALITY OF INFORMATION
Persons and entities that receive confidential information from the NPDB-HIPDB,
either directly or indirectly from another party, must use it solely with respect to the
purpose for which it was provided. Any person who violates the confidentiality
provisions of the Data Bank(s) shall be subject to a civil penalty for each
violation.
In compliance with the Privacy Act, the results of an individual self-query are sent only
to the practitioner's home or work address as certified on the self-query form.
Individual health care practitioners who obtain information about themselves from the
NPDB-HIPDB are permitted to share that information with anyone they choose.

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 25 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.

SUBJECT INFORMATION

Print
Self-Query

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

HOME OR WORK ADDRESS
Enter the address (home or work) to which you would like your response sent:
Note: If specifying a work address, be sure to include the employer name in the first line of the address.
Street Address:
Address Line 2:
City:
State:

CHOOSE ONE FROM LIST

ZIP Code:

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

Ext.

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
School Name:

Year of
Graduation
(Format YYYY):

1.
2.
3.
4.
5.

1. State License Number:

c
d
e
f
g

No License

State of Licensure:

CHOOSE ONE FROM LIST

Occupation/Field of
Licensure:

CHOOSE ONE FROM LIST

6
6

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

Specialty:

CHOOSE ONE FROM LIST

Return to Previous Page

National Practitioner Data Bank
Healthcare Integrity and Protection Data Bank

ENTITY REGISTRATION

Provide Entity
Information

Establish
Administrator
Account

Print
Registration

Final Steps

Complete this form with information about your organization and click Continue.
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:
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

EXISTING REGISTRATION
Is your organization already registered with the Data Banks?

j
k
l
m
n

Yes n
i
j
k
l
m

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."
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

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

Health Care Entity**

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

Society**

Malpractice Payer

of These

* 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

n State
j
k
l
m

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
Optional
with the Centers for Medicare & Medicaid
Services (CMS)

n Peer
j
k
l
m

Review Organization

No Requirement

Prohibited

Mandatory

Prohibited

Mandatory

j Hospital*
k
l
m
n

Optional

No Requirement

j Other
k
l
m
n

Health Care Entity, including Professional
Society*

Optional

No Requirement

j
k
l
m
n

Agency Administering a Federal Health Care

Optional

No Requirement

j Private
k
l
m
n

Accreditation Organization

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
n State
j
k
l
m

Medicaid Fraud Control Unit

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

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)
j Federal
k
l
m
n
n State
j
k
l
m

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
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
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n
j
k
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j
k
l
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j
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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.
j
k
l
m
n

Query the NPDB and the HIPDB for each query submitted.

Query only the NPDB for each query submitted.
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
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n
j
k
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n

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.

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:
Date:

Ext.
02/03/2010

Return to NPDB-HIPDB Home Page

Entity: TEST ENTITY (FAIRFAX, VA)
Complete this form to select an authorized agent who can query and/or report on your
behalf. Specify (1) the last four digits of the agent's Data Bank Identification Number, (2)
the Agent Organization Name, City, State, ZIP Code, and Country (if applicable), (3)
whether to allow the agent to query or report, (4) whether query and/or report responses
will be routed to the agent or the entity, and (5) whether the agent's or the entity's EFT
account will be charged when EFT is the method of payment used for a query submission.
Once the data provided here is validated, you will be instructed to print the Agent
Designation Request for your records. This document will serve as the sole record of your
request.
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 INFORMATION
Data Bank Identification Number
(last 4 digits):
Agent Organization Name:
City:
State:
ZIP Code:

CHOOSE ONE FROM LIST

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

CONFIGURATION
I authorize my agent to submit the following transactions on my behalf:
c Query
d
e
f
g
c Proactive Disclosure Service (PDS)
d
e
f
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c Report
d
e
f
g
I authorize my agent to use my entity's EFT account to pay for queries submitted on my entity's behalf:
NOTE: When an entity designates an authorized agent to query and/or report on behalf of the entity,
the entity is ultimately responsible for payment (even if EFT charges are directed to that
agent). Payment may also be made by credit card at the time of querying, regardless of EFT routing
assignment.
j
k
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n

Yes

j
k
l
m
n

Route responses to my agent's submission to:
j Only my entity
k
l
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n
j Only my agent
k
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n
j Both my entity and my agent
k
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n
Return responses to my entity via:
j IQRS
k
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n
j ITP
k
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n
j QRXS
k
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n

CERTIFICATION
I certify that I am authorized to designate the authorized agent identified above to report to
and/or query the NPDB-HIPDB on my behalf.

Name of Certifying Official:
Title of Certifying Official:
Telephone:
Certification Date (MMDDYYYY):

Ext.
03282008

National Practitioner Data Bank
Healthcare Integrity and Protection Data Bank
ACCOUNT DISCREPANCY
If you cannot reconcile your credit card account statement or Electronic Funds Transfer (EFT) account statement, and
determine that your account should be reviewed, please provide the information requested below. Type or print legibly in
ink. Numbers in parentheses indicate the maximum number of characters including spaces and punctuation allowed per field.
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.
Data Bank Identification Number (DBID) (15): |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
Telephone: Area Code (3) _____________ Number (7) _________________________ Extension (5) _________________
Printed Name of Entity Representative (40): ______________________________________________________________
Signature of Entity Representative: ______________________________________________________________
Signature Date: _____________________________________
Credit Card Number (if applicable): |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
Credit Card Expiration Date (MM/YY): |___|___|___|___|
Dollar Amount of the Suspected Error(s): $ _______________
Please provide an explanation of your discrepancy and include the Data Bank Control Number (DCN), if applicable:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Attach a copy of your credit card statement or EFT account statement and the charge receipt. Highlight the charge(s) that you
believe you were charged in error.
For additional information, visit the NPDB-HIPDB Web site at www.npdb-hipdb.hrsa.gov. If you need assistance, contact the
NPDB-HIPDB Customer Service Center by e-mail at help@npdb-hipdb.hrsa.gov or by phone at 1-800–767–6732
(TDD 703-802-9395). Information Specialists are available to speak with you weekdays from 8:30 a.m. to 6:00 p.m.
(5:30 p.m. on Fridays) Eastern Time. The NPDB-HIPDB Customer Service Center is closed on all Federal holidays.

June 2010

1 of 1

NPDB-00958.05.01

Complete this form to authorize payment of user fees directly from your bank account.
Limit your responses to the number of characters, including spaces and punctuation,
specified in parentheses for each field.
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.
ACCOUNT INFORMATION
Bank Routing Number (9 digits):
Bank Account Number (max 17 digits):
Bank Account Type:

j Checking
k
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n
j Savings
k
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Bank routing information can be found on your check. See picture below.

CERTIFICATION

Name of Certifying Official:
Title of Certifying Official:
Telephone:

Ext.

Certification Date (MMDDYYYY):

11182008

SUBJECT STATEMENT AND DISPUTE

National Practitioner Data Bank
Healthcare Integrity and Protection Data Bank

To add, modify, or remove a statement to the report referenced below, and/or to place the report in, or
withdraw the report from, disputed status, complete the appropriate section(s) below, and click Submit
To Data Bank(s). You will receive an on-line confirmation message regarding this transaction. The
reporting entity and any queriers who received a previous version of the report will receive a copy
noting the modifications.
Report Type:
Report Number:
Subject's Name:
Report Maintained Under:

STATE LICENSURE ACTION
7930000052539805
MOOSE, JOHN
[X] Title IV (NPDB)
[X] Section 1128E (HIPDB)

SUBJECT STATEMENT

As the subject of the referenced report, you have the right to include a statement expressing your view
of the action described in the report. The statement becomes part of the report and is disclosed to
authorized queriers. To add a statement, type the statement in the designated area below exactly as you
wish it to appear in the report. To substitute an existing statement with a new one, modify the statement
in the designated area below exactly as you wish it to appear in the report. (If you have a statement on
file, it will appear below.) Your statement must be in English and may not exceed 4,000 characters,
including spaces and punctuation. If you add a statement to the report, it will be formatted in a block
style; paragraph breaks cannot be included.
Note:Patient information is confidential. Do NOT include identifying information (names,
addresses, etc.) about patients or other persons in your statement. All Subject Statements are
reviewed by the Data Banks to determine whether they include individual names, addresses, or
telephone numbers. If this information is discovered, it will be removed and you will be sent an
amended version.
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 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.
Subject Statement

There are 4000 characters remaining for the statement.
DISPUTE
You may dispute either the factual accuracy of the action described in the referenced report or whether
the report was submitted in accordance with Data Bank reporting requirements (e.g., was a reportable
event). You may NOT dispute the appropriateness of any action, finding or judgment, or information
regarding the facts or circumstances that led to the reported action. You also must contact the reporting
entity or its agent, identified in Section A of the report, to attempt to resolve disputed issues. (Do not
contact the reporting entity for information about Data Bank reporting requirements or operational
procedures.) The report will remain in disputed status until either you take action to elevate the report for
Secretarial Review or you withdraw the report from disputed status.
Information in Data Bank reports can be changed only by the entity that submitted the report or by the
Secretary of the U.S. Department of Health and Human Services following review. The report will remain
in the Data Bank(s) unchanged until the reporting entity or the Secretary changes it.
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.
The referenced report is currently NOT in disputed status.
Check here if you wish to place the referenced report in disputed status. If you wish to add a
statement to the report only and do not wish to place the report in disputed status then do not check the
box.
c
d
e
f
g

CURRENT ADDRESSES

Future correspondence from the Data Bank(s) will be mailed to the address specified. Note: If you
provide both your home and work addresses, the Data Bank(s) will send correspondence to your home

address. You may update the addresses that the Data Bank(s) have on file below. However, this does
not change your addresses as reflected in the report filed with the Data Bank(s). Only the entity that
originally submitted the report can modify or correct information provided in the report. You should
contact the entity identified in Section A of the report and request that it make the address correction.
Home Address/Address of Record
Street Address:
Address Line 2:
City:
State:
ZIP Code:

CHOOSE ONE FROM LIST

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

Work Address
Street Address:

123 MAIN STREET

Address Line 2:
City:

FAIRFAX

State:
ZIP Code:

VA Virginia

22033

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

CERTIFICATION
I certify that I am the individual subject identified in Section B of the referenced report, or that I am the
designated employee representing the organization subject referenced in Section B, and I request that
the action(s) above be taken.
Authorized Submitter's Name:
Authorized Submitter's Title:
Authorized Submitter's Phone:
Date (MMDDYYYY):

Ext.
03032009

File Type	application/pdf
File Title	NPDB Forms
File Modified	2010-06-18
File Created	2010-06-18