hipdb_eauth_008

Instructions for Revoking an NPDB-HIPDB Account

1. Click your browser’s Print button or select File>Print… from the menu to send this document to a local printer. Do not close the window that contains this form until you have made sure that the document printed in its entirety.

2. Complete and sign the Account Revocation Request document; notarization is not required.

3. Submit the Account Revocation Request document to NPDB-HIPDB either via mail or fax:

   1. Mail the completed account revocation request to:

National Practitioner Data Bank - Healthcare Integrity and Protection Data Bank

P.O. Box 10832

Chantilly, VA 20153-0832

OR

2. Fax the completed account revocation request to NPDB-HIPDB with a cover letter indicating your name, organization, subject and number of pages to 703-803-1964.

1. Upon receipt, the NPDB-HIPDB will process the account revocation request immediately and keep the request on file.

2. Note that once your account is revoked, you will no longer have access to the NPDB-HIPDB system. You must repeat the registration and identity proofing process to open a new account.

NPDB-HIPDB Account Revocation Request

Section 1 – Instructions: The account holder or person authorized to request revocation on the account holder’s behalf must complete the form below in its entirety. Notarization is not required.

A ccount Holder Information:

Name (First Name, Middle Initial, Last Name):	Title:
Affiliated NPDB-HIPDB Entity/Authorized Agent Organization:	Employee ID:
Business Address:	Telephone:
E-mail:	Name of Entity/Authorized Agent’s Data Bank Administrator:
Account Holder’s NPDB-HIPDB Role: Entity/Authorized Agent Data Bank Administrator Entity/Authorized Agent User (Report & Query) Self Querier	R eport Subject Investigative Search User
Reason for Requesting NPDB-HIPDB Account Revocation (check all that apply): A ccount holder is no longer affiliated with the registered Entity/Authorized Agent organization Account has been or is suspected of having been lost or stolen Account holder’s role in the organization has changed Account holder’s name has changed (e.g., due to marriage) A ccount holder has violated or is suspected of violating the terms of the agreed upon NPDB-HIPDB Subscriber Agreement, or applicable laws and regulations applicable to the account Other (please explain):
Are you the Account Holder? Yes, the account is in my name. I understand that revoking my NPDB-HIPDB account will require that I re-register with NPDB-HIPDB for a new account, if desired. N o, I am an official authorized to request account revocation (please list your name, NPDB-HIPDB role, organization, and contact information (phone and email) in the space below:
Account Holder’s or Authorizing Official’s Signature and Date*: _______________________________________________ __________ (Signature) (Date)

Note: Use an ink pen to cross out any mistake above, write in the correct information and initial it.

Section 2 – Mail/Fax Instructions: Mail the completed account revocation request to National Practitioner Data Bank - Healthcare Integrity and Protection Data Bank, P.O. Box 10832, Chantilly, VA 20153-0832 OR fax the completed account revocation request to NPDB-HIPDB with a cover letter indicating your name, organization, subject and number of pages to 703-803-1964.