Form NPDB Identity Proo NPDB Identity Proo NPDB Identity Proofing Forms

OMB Control No 0915-0126

SUBSCRIBER ACCOUNT AGREEMENT:

BY CLICKING “ACCEPT” BELOW, YOU AGREE TO:

• PROVIDE COMPLETE AND ACCURATE RESPONSES TO REQUESTS FOR INFORMATION DURING THE NATIONAL PRACTICTIONER DATA BANK – HEALTHCARE AND INTEGRITY AND PROTECTION DATA BANK (NPDB-HIPDB) REGISTRATION PROCESS;

• KEEP YOUR PASSWORDS AND TOKENS (IF APPLICABLE) SECURE;

• NOT SHARE YOUR ACCOUNT WITH ANY OTHER INDIVIDUAL;

• USE YOUR NPDB-HIPDB ACCOUNT ONLY FOR AUTHORIZED PURPOSES;

• REVIEW THE ACCURACY OF ACCOUNT INFORMATION;

• REQUEST REVOCATION OF YOUR NPDB-HIPDB ACCOUNT IF YOU EVER SUSPECT THAT THE SECURITY OF YOUR ACCOUNT MAY HAVE BEEN COMPROMISED; AND

• PROMPTLY ADVISE THE NPDB-HIPDB OF ANY CHANGES IN YOUR REGISTRATION INFORMATION AND RESPOND TO NOTICES FROM NPDB-HIPDB, HEALTH RESOURCES AND SERVICES ADMINISTRATION (HRSA) OR THE DEPARTMENT OF HEALTH AND HUMAN SERVICES (HHS) CONCERNING YOUR ACCOUNT.

COMPLETE TERMS OF NPDB-HIPDB ACCOUNT AGREEMENT:

IMPORTANT NOTICE: This NPDB-HIPDB Account Agreement establishes the terms by which "You," the Subscriber are entitled to receive and hold the NPDB-HIPDB Account ("Account").

1. Allowed Uses of NPDB-HIPDB Account and Account Lifetime. NPDB-HIPDB will issue an account to access the NPDB-HIPDB system to You for use in accordance with the terms of this Agreement. As the Subscriber of this account, You must respond in a timely manner to NPDB-HIPDB related notices issued by NPDB-HIPDB, HRSA or HHS. You may use your account only for authorized purposes (to authenticate yourself to the NPDB-HIPDB system to conduct business-related activities electronically). Such purposes are for official NPDB-HIPDB business. The accounts may not be used for purposes of fraud, any other illegal scheme, or any unauthorized purpose. The term of this Agreement shall be contemporaneous with the NPDB-HIPDB Account’s validity and shall terminate six years from the date You registered, unless Your account is revoked prior to such time. Thirty days prior to expiration of “Your” registration, You will be provided with the notice of renewal.

2. Verification of Your Identity. You agree to allow NPDB-HIPDB to verify Your identity by any reasonable means. NPDB-HIPDB may query its databases and other sources to verify the information You provide to determine whether to issue the NPDB-HIPDB account to You. You also authorize the storage and maintenance of any information generated during the registration, identification and authentication, and the account issuance processes. NPDB-HIPDB, in their sole discretion and without incurring liability for any loss arising out of such denial or refusal, may deny a registration for, or otherwise refuse to approve the issuance of, the NPDB-HIPDB account.

3. PRIVACY ACT AND PAPERWORK REDUCTION ACT NOTICE AND DISCLOSURE. In accordance with the Privacy Act of 1974 and the Paperwork Reduction Act of 1980, the following notice explains how the information that You submit in order to obtain a NPDB-HIPDB account is used and maintained:

http://www.npdb-hipdb.hrsa.gov/pubs/Privacy_Policy.pdf

4. NPDB-HIPDB Obligations. NPDB-HIPDB, HRSA and HHS agree that they will verify the information provided by You and accurately transcribe it into the NPDB-HIPDB account.

5. Your Obligations

5.1. Submit Correct Information. You represent and warrant to NPDB-HIPDB, HRSA and HHS that all of the information You submit during the registration process will be accurate, current and complete. You further agree that for purposes of NPDB-HIPDB account validity, You will immediately inform NPDB-HIPDB if any of your registration information changes (e.g., You have a change of e-mail address or a change in your legal name). You also represent and warrant that You are authorized to receive NPDB-HIPDB account in the name that You have designated as part of your registration.

5.2. Review Your Account; Account Acceptance. The NPDB-HIPDB account issued to You will be based on information provided by You. During the account issuance process You are provided with the opportunity to review such information. At all times, You agree to review and verify the accuracy of the information contained in your account. You acknowledge that using the NPDB-HIPDB account constitutes your acceptance of that account. If You fail to notify NPDB-HIPDB of any errors, defects, or problems with your account within 24 hours after accessing it, it will be considered to have been accepted by You. By accepting the NPDB-HIPDB account, You further represent and warrant that the information in your account (i.e., Name, identification numbers, etc.) is accurate, current and correct. Upon acceptance, and at any time thereafter when You use your NPDB-HIPDB account, You acknowledge and assent to the responsibilities identified herein (including those identified in the NPDB-HIPDB policies).

5.3. Protect Your NPDB-HIPDB Account. By requesting a NPDB-HIPDB account, You acknowledge and agree that You are responsible for protecting and maintaining sole possession and control of the account. In addition, You represent and warrant to NPDB-HIPDB that, in regard to such account, You have kept and will keep your passwords private and that You will safeguard and maintain your account (and any user IDs, passphrases, shared secrets, etc.) in strict secrecy and take reasonable security measures to prevent unauthorized access or use of your account and the computer system or media on which your account information is stored.

IF YOU EVER SUSPECT OR DISCOVER THAT THE SECURITY OF EITHER OF YOUR ACCOUNT HAS BEEN OR IS IN DANGER OF BEING COMPROMISED IN ANY WAY, YOU MUST IMMEDIATELY NOTIFY THE NPDB-HIPDB AND REQUEST REVOCATION OF YOUR ACCOUNT. YOU MUST THEN IMMEDIATELY CEASE USING YOUR ACCOUNT.

You can initiate a revocation request online at the NPDB-HIPDB site or You can call the NPDB-HIPDB Customer Service Center at 1-800-767-6732.

5.5. Situations Requiring Revocation of Your Account. You must revoke your account if You discover or suspect that your account have been or are in danger of being compromised or subjected to unauthorized use in any way, or if any information affecting the reliability of your account changes or is no longer true (e.g., Your name changes). You may also revoke your account at any time for any other reason. NPDB-HIPDB may also revoke your account without advance notice if it, in its sole discretion, determines that: (a) the account was not properly issued or was obtained by fraud; (b) the security of the account has or may have been lost or otherwise compromised; (c) the account has become unreliable; (d) information in the account has changed or become untrue; (e) You have violated any applicable agreement or obligation; (f) You request revocation; (g) a governmental authority has lawfully ordered NPDB-HIPDB to revoke your account; (h) this Agreement terminates; or (j) there are any other grounds for revocation. Your right to use your account ceases immediately upon revocation of your account.

6. Interpretation. NPDB-HIPDB accounts are issued to Subscribers to further the mission and operations of NPDB-HIPDB, HRSA and HHS and liability claims shall be subject to the terms of the Federal Tort Claims Act as interpreted by the HHS Office of General Counsel. This Agreement shall be governed by, interpreted and construed under the laws of the United States. If any provision of this Agreement is found to be invalid or unenforceable, then such document shall be deemed amended by modifying such provision to the extent necessary to make it valid and enforceable while preserving it intent or, if that is not possible, by striking the provision and enforcing the remainder of this Agreement.

7. Dispute Resolution. In the event of any dispute or disagreement arising out of or relating to this agreement, the disputing parties shall use their best efforts to settle the dispute or disagreement through negotiations in good faith following notice from one disputing party to the other(s). If the disputing parties cannot reach a mutually agreeable resolution of the dispute or disagreement within sixty (60) days following the date of such notice, then the disputing parties may present the dispute to the NPDB-HIPDB Registration Practices Management body. In the event that the NPDB-HIPDB Practices Management body is unable to resolve the dispute, the parties may bring the matter to the HHS Office of General Counsel for resolution.

8. Risk of Loss. You agree that you assume the risk of any use of your account in violation of this Agreement.

9. DISCLAIMER OF WARRANTIES. The NPDB-HIPDB disclaims any and all warranties of any type, whether express or implied, that are not specifically provided herein, including but not limited to any implied warranty of merchantability, fitness for a particular purpose, title and non-infringement with regard to NPDB-HIPDB services or any NPDB-HIPDB account issued hereunder.

10. LIMITATIONS ON NPDB-HIPDB’S LIABILITY. The NPDB-HIPDB shall have no liability for loss due to use of your account, unless the loss is proven to be a proximate result of the negligence, fraud or willful misconduct of the NPDB-HIPDB. The NPDB-HIPDB’s liability to you shall be limited to the amount paid to the NPDB-HIPDB by you for self-query responses issued to you pursuant to this Agreement.

In no event shall the NPDB-HIPDB be liable for any consequential, indirect, remote, exemplary, punitive, special, or incidental damages, or damages for business interruption, loss of profits, revenues or savings, regardless of the form of action and regardless of whether the NPDB-HIPDB was advised of the possibility of such damages.

The NPDB-HIPDB shall incur no liability if the NPDB-HIPDB is prevented, forbidden or delayed from performing, or omits to perform, any act or requirement by reason of any provision of any applicable law, regulation or order, the failure of any electrical, communication or other system operated by any party other than the NPDB-HIPDB or any act of God, emergency condition or war or other circumstance beyond the control of the NPDB-HIPDB.

Instructions for Registering as an NPDB-HIPDB Certifying Official

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 document until you have made sure that the document printed in its entirety.

2. Make sure you have read the Summary of Terms section of the NPDB-HIPDB Certifying Official Registration document.

3. Do not sign the document yourself yet; a Notary Public must witness your signature as described below.

4. Take the NPDB-HIPDB Certifying Official Registration document and the credentials listed below to a person certified by a State or Federal Government as being authorized to confirm identities (such as Notary Public), that uses a stamp, seal, or other mechanism to authenticate their identity confirmation.

Credentials to Present to the Notary Public:
You must present the following credentials to the Notary that proves your identity and affiliation with your healthcare organization for which you are certifying to the NPDB-HIPDB:

1. One form of ID must be a valid State or Federal government-issued photo ID. Forms of acceptable ID are as follows: A state-issued photo ID (with a serial number) such as a driver’s license, Passport from country of citizenship, federal, state or local government agency (must have name, date of birth, gender, height, eye color and address), US military ID, Certificate of U.S. Citizenship, Certificate of Naturalization, permanent or unexpired temporary resident card, Native American tribal document, or Canadian driver’s license.

AND

2. The work badge issued by your organization OR a signed letter on company letterhead from an authorized official in your organization attesting to your affiliation with the healthcare organization for which you are certifying.

5. Sign and date the NPDB-HIPDB Certifying Official Registration document in the presence of the Notary Public who will complete his/her section of the document.

6. If you are submitting this paperwork as part of a new registration (or re-registration) of your healthcare organization, the following items must be mailed to the NPDB-HIPDB for processing:

1. The original, notarized NPDB-HIPDB Certifying Official Registration document

AND

A photocopy of your work badge or the original authorization letter (whichever you presented to the Notary).

2. The original, notarized registration document for your NPDB-HIPDB Data Bank Administrator(s) (i.e., NPDB-HIPDB Entity/Authorized Agent Data Bank Administrator Registration). If your Data Bank Administrator is not at your location, then their paperwork may be mailed directly to NPDB-HIPDB.

3. Your healthcare organization’s registration document (i.e., the NPDB-HIPDB Entity Registration or Agent Registration document).

5. Mail all registration documents to:

National Practitioner Data Bank - Healthcare Integrity and Protection Data Bank

P.O. Box 10832

Chantilly, VA 20153-0832

Note: Faxed or scanned copies will not be accepted.

5. If you are replacing a Certifying Official for an organization that is currently registered with the NPDB-HIPDB, then please indicate so on the registration document in the field provided. In this case, send only the original, notarized Certifying Official Registration document AND a photocopy of your work badge or the original authorization letter (whichever you presented to the Notary) to the address above.

6. The NPDB-HIPDB will process the registration documents and if the registration is approved, your Data Bank Administrator shall receive confirmation via e-mail with instructions on how to proceed.

NPDB-HIPDB Certifying Official Registration

Section 1 – Registrant Instructions: The Certifying Official (Registrant) must read the terms below, complete the appropriate fields, provide a government-issued ID and either provide a work badge or proof of affiliation letter on company letterhead before signing and dating the document in front of the Notary Public.

S ummary of Terms: You (the "Registrant") certify that the entity identified on this document qualifies under law as specified in the ELIGIBILITY/ STATUTORY AUTHORITY section of the Entity/Agent Registration document and is eligible to perform the querying and/or reporting functions. I understand that the Entity/Authorized Agent 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. By signing below, you acknowledge your acceptance of the Summary of Terms in which you agree to provide complete and accurate responses to requests for information during the registration process. I further certify that I am authorized to submit this registration information to the NIPDB-HIPDB and that the information provided is true, correct, and complete. If I become aware that any information on this document 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 document or contained in any communication supplying information to the NPDB-HIPDB to complete or clarify document may be punishable by criminal, civil, or other administrative actions including fines, penalties, and/or imprisonment under Federal law.

Name (First Name, Middle Initial, Last Name):	Title: A re you replacing a registered Certifying Official? Yes No
Employer/Organization:	Employee ID:
Business Address:	Telephone:
E-mail:	Name of NPDB-HIPDB Data Bank Administrator:
Registrant’s Signature and Date*: ___________ ______________________________________ __________ (*Sign and date in the presence of the Notary Public) (Date)

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

S ection 2 – Notary Public Instructions: The Notary Public must record the information below for the Registrant’s government-issued photo ID for the purpose of identity proofing. In addition, you must verify that the Registrant p resented either a current work badge or a proof of affiliation letter on company letterhead.

Government-issued ID (Photo, Name, Serial Number, Expiration Date, Address, and Date of Birth Required)	Organization Affiliation (check one)
Exact Name Listed on ID	T he Registrant presented his/her work badge as proof of organizational affiliation. OR The Registrant presented an original copy of a P roof of Organizational Affiliation letter on company letterhead as proof of organizational affiliation.
Date of Birth
Serial Number
Expiration Date
Identification Type
Date of Issuance
Issuing Authority

N

Notary Public seal here

otary Public: _______________________
I hereby certify that on this _______ day of ____________, 20__, in the city of ________________ and in the county of ______________________, ________ personally appeared before me the signer and subject of the above section, who signed or attested the same in my presence, and presented one government-issued form of photo ID as proof of his or her identity. In addition, I have reviewed the Registrant’s work badge or an original copy of the Registrant’s organizational affiliation letter on company letterhead submitted as proof of organizational affiliation.

My Commission Expires In*: _______________________

Street Address of Branch or Office: _______________________

Name of Organization Employing Notary: _______________________

* If commission does not expire, indicate "does not expire" in this field.

Instructions for Registering as an NPDB-HIPDB Investigative Search User

5. 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 document until you have made sure that the document printed in its entirety.

6. Make sure you have read the Summary of Terms of the Investigative Search Registration document.

7. Do not sign the registration document yourself yet; a Notary Public must witness your signature as described below.

8. Take the Investigative Search Registration document and the credentials listed below to a person certified by a State or Federal Government as being authorized to confirm identities (such as Notary Public), that uses a stamp, seal, or other mechanism to authenticate their identity confirmation.

Credentials to Present to the Notary Public:
You must present the following credentials to the Notary that proves your identity and affiliation with your organization for which you are registering with the NPDB-HIPDB:

3. One form of ID must be a valid State or Federal government-issued photo ID (that is not a work badge). Forms of acceptable ID are as follows: A State-issued photo ID (with a serial number) such as a driver’s license, Passport from country of citizenship, US military ID, Certificate of U.S. Citizenship, Certificate of Naturalization, permanent or unexpired temporary resident card, Native American tribal document, or Canadian driver’s license.

AND

4. A work badge issued by the federal, state or local government agency (must have name, date of birth, gender, height, eye color and address) OR a signed letter on official agency letterhead from an authorized official in your organization attesting to your affiliation with the agency for which you are registering with the NPDB-HIPDB as an Investigator Search user.

5. Sign and date the Investigative Search Registration document in the presence of the Notary Public who will complete his/her section of the document.

6. Send the original, notarized Investigative Search Registration document with a photocopy of your work badge or the original authorization letter (whichever you presented to the Notary) to:

National Practitioner Data Bank - Healthcare Integrity and Protection Data Bank

P.O. Box 10832

Chantilly, VA 20153-0832

Note: Faxed or scanned copies will not be accepted.

5. NPDB-HIPDB will process the registration request and notify you of the results. If the registration request is approved, you shall receive confirmation via the postal mail with instructions on how to log into the system.

NPDB-HIPDB Investigative Search User Registration

Section 1 – Registrant Instructions: The Investigative Search user (Registrant) must read the terms below, complete the appropriate fields, provide a government-issued ID and either provide a work badge or proof of affiliation letter on company letterhead before signing and dating the document in front of the Notary Public.

S ummary of Terms: You (the "Registrant") are registering to be an Investigative Search user for an organization that is registered or actively registering with the NPDB-HIPDB. As an Investigative Search user, you are responsible for performing searches on both individuals and organizations to determine if there is any prior criminal or fraudulent behavior that has been reported to the HIPDB. By signing below, you acknowledge your acceptance of the Summary of Terms in which you agree to provide complete and accurate responses to request for information during the registration process. I further certify that I am authorized to submit this registration information to the NIPDB-HIPDB and that the information provided is true, correct, and complete. If I become aware that any information on this document 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 document or contained in any communication supplying information to the NPDB-HIPDB to complete or clarify this document may be punishable by criminal, civil, or other administrative actions including fines, penalties, and/or imprisonment under Federal law.

Name (First Name, Middle Initial, Last Name):	Title:
Employer/Organization:	Employee ID:
Business Address:	Telephone:
E-mail:	Name of Your Agency’s NPDB-HIPDB Data Bank Administrator:
Registrant’s Signature and Date*: ___________ ______________________________________ __________ (*Sign and date in the presence of the Notary Public) (Date)

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

S ection 2 – Notary Public Instructions: The Notary Public must record the information below for the Registrant’s government-issued photo ID for the purpose of identity proofing. In addition, you must verify that the Registrant p resented either a current work badge or a proof of affiliation letter on company letterhead.

Government-issued ID (Photo, Name, Serial Number, Expiration Date, Address, and Date of Birth Required)	Organization Affiliation (check one)
Exact Name Listed on ID	T he Registrant presented his/her work badge as proof of organizational affiliation. OR The Registrant presented an original copy of a P roof of Organizational Affiliation letter on agency letterhead as proof of organizational affiliation.
Date of Birth
Serial Number
Expiration Date
Identification Type
Date of Issuance
Issuing Authority

N

Notary Public seal here

otary Public: _______________________
I hereby certify that on this _______ day of ____________, 20__, in the city of ________________ and in the county of ______________________, _____ personally appeared before me the signer and subject of the above section, who signed or attested the same in my presence, and presented one government-issued form of photo ID as proof of his or her identity. In addition, I have reviewed the Registrant’s work badge or an original copy of the Registrant’s organizational affiliation letter on company letterhead submitted as proof of organizational affiliation.

My Commission Expires In*: _______________________

Street Address of Branch or Office: _______________________

Name of Organization Employing Notary: _______________________

* If commission does not expire, indicate "does not expire" in this field.

Instructions for Registering as an NPDB-HIPDB User

9. 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.

10. Make sure you have read the Summary of Terms section of the NPDB-HIPDB User Registration document.

11. Do not sign the form yourself yet; your NPDB-HIPDB Entity/Authorized Agent Data Bank Administrator must witness your signature as described below.

12. Take the NPDB-HIPDB User Registration document and one or two forms of non-expired ID described below to your Data Bank Administrator. Forms of acceptable ID are as follows:

5. ID (1): A current work badge that contains a photograph, serial number, the name of the organization for which you work, and an expiration date. If the work badge has this information, you do not need to supply a second form of ID.

6. ID (2): If you do not have a current work badge, or your work badge does not have a photo, serial number, name of the organization or an expiration date, you must supply a second form of government-issued photo ID such as a driver’s license, passport, military ID, or a federal agency badge. In addition, the Data Bank Administrator must confirm your employment with your organization through an enterprise records check.

13. Complete, sign and date Section 1 of the NPDB-HIPDB User Registration document in the presence of your Data Bank Administrator who will complete Section 2 of the form and mail the original copy to NPDB-HIPDB for you. Note: Faxed or scanned copies will not be accepted.

14. If your Data Bank Administrator approves your request, you will receive an email confirmation with login information to your new account.

NPDB-HIPDB User Registration

Section 1 - Registrant Instructions: The User (Registrant) must read the terms below, provide proof of identity, and then sign and date the form in front of a designated NPDB-HIPDB Data Bank Administrator. A second, government-issued ID is only required if the work badge does not have a photo, serial number, organization name or expiration date.

S ummary of Terms: You (the "Registrant") are applying to be a registered user of the NPDB-HIPDB system. By signing below, you acknowledge your acceptance of the Summary of Terms in which you agree to provide complete and accurate responses to request for information during the registration process. 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 on 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 (First Name, Middle Initial, Last Name:	Employee ID:
Employer/Organization:	Telephone:
Business Address:	E-mail:
Registrant’s Signature and Date*: ___________ _____________________________________________ __________ (*Sign and date in the presence of the NPDB-HIPDB Administrator) (Date)
Note: Use an ink pen to cross out any mistake, write in the correct information and initial it.

S ection 2 - NPDB-HIPDB Data Bank Administrator Instructions: You must record the information below for the Registrant’s work badge for the purpose of identity proofing and employment verification. If the work badge does not have a photo or any of the required fields below, you must record the information from a government-issued photo ID as well as verify the Registrant’s employment records. Send the original, completed form to National Practitioner Data Bank / Healthcare Integrity and Protection Data Bank, P.O. Box 10832, Chantilly, VA 20153-0832. Note: Faxed or scanned copies will not be accepted.

Work Badge (Photo ID)	If the work badge supplied by the Registrant is not available or is not sufficient, complete the column to the right.	Government Issued Photo ID
Exact Name Listed on ID		Exact Name Listed on ID
Date of Birth		Date of Birth
Serial Number		Serial Number
Name of Organization Listed on ID		Expiration Date
Date of Issuance		Identification Type
Expiration Date		Date of Issuance
		Issuing Authority
		Employment Verification (check box)
		The Registrant’s employment has been verified through an enterprise records check.

On this ______ day of ________________, 20___, the Registrant listed above personally appeared before me and signed this registration document in my presence, at which time I reviewed the above-referenced identification credentials, including those containing photographs, and confirmed that: (a) the identification credentials do not appear to have been altered, forged or modified; (b) the picture(s) and name on the Photo ID(s) matched the appearance and name of the individual identified as the Registrant; and (c) the Registrant is the holder of the identification credentials presented. In addition, I have verified the Registrant’s employment by checking his/her work badge or through an enterprise records check.

_______________________________ _ ______________________________________
NPDB-HIPDB Administrator Printed Name NPDB-HIPDB Administrator’s Signature

Instructions for Revoking an NPDB-HIPDB Account

15. 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.

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

17. 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.

SUBSCRIBER ACCOUNT AGREEMENT:

BY CLICKING “ACCEPT” BELOW, YOU AGREEING TO:

• PROVIDE COMPLETE AND ACCURATE RESPONSES TO REQUESTS FOR INFORMATION DURING THE NATIONAL PRACTICTIONER DATA BANK – HEALTHCARE AND INTEGRITY AND PROTECTION DATA BANK (NPDB-HIPDB) REGISTRATION PROCESS;

• KEEP YOUR PASSWORDS AND TOKENS (IF APPLICABLE) SECURE;

• NOT SHARE YOUR ACCOUNT WITH ANY OTHER INDIVIDUAL;

• USE YOUR NPDB-HIPDB ACCOUNT ONLY FOR AUTHORIZED PURPOSES;

• REVIEW THE ACCURACY OF ACCOUNT INFORMATION;

• REQUEST REVOCATION OF YOUR NPDB-HIPDB ACCOUNT IF YOU EVER SUSPECT THAT THE SECURITY OF YOUR ACCOUNT MAY HAVE BEEN COMPROMISED; AND

• PROMPTLY ADVISE THE NPDB-HIPDB OF ANY CHANGES IN YOUR REGISTRATION INFORMATION AND RESPOND TO NOTICES FROM NPDB-HIPDB, HEALTH RESOURCES AND SERVICES ADMINISTRATION (HRSA) OR THE DEPARTMENT OF HEALTH AND HUMAN SERVICES (HHS) CONCERNING YOUR ACCOUNT.

COMPLETE TERMS OF NPDB-HIPDB ACCOUNT AGREEMENT:

IMPORTANT NOTICE: This NPDB-HIPDB Account Agreement establishes the terms by which "You," the Subscriber are entitled to receive and hold the NPDB-HIPDB Account ("Account"). "Your Organization" shall mean the organization You identified on Your registration for the NPDB-HIPDB Account. One purpose of the account is to identify You as being employed, associated or affiliated with Your Organization.

1. Allowed Uses of NPDB-HIPDB Account and Account Lifetime. NPDB-HIPDB will issue an account to access the NPDB-HIPDB system to You for use in accordance with the terms of this Agreement. As the Subscriber of this account, You must respond in a timely manner to NPDB-HIPDB related notices issued by NPDB-HIPDB, HRSA or HHS. You may use your account only for authorized purposes (to authenticate yourself and Your Organization to NPDB-HIPDB system to conduct business-related activities electronically). Such purposes are for official NPDB-HIPDB and “Your Organization” business. The accounts may not be used for purposes of fraud, any other illegal scheme, or any unauthorized purpose. The term of this Agreement shall be contemporaneous with the NPDB-HIPDB Account’s validity and shall terminate six years from the date You registered, unless Your account or “Your Organization’s” account is revoked prior to such time. Thirty days prior to expiration of “Your” registration, You and the registered Data Bank Administrator of the “Your Organization” will be provided with the notice of renewal.

2. Verification of You and Your Organization's Identity. You agree to allow NPDB-HIPDB to verify Your identity and organizational affiliation by any reasonable means. NPDB-HIPDB may query its databases and other sources to verify the information You and Your Organization provide to determine whether to issue the NPDB-HIPDB account to You. Your Organization's human resources department may also be contacted to verify affiliation or employment. You also authorize the storage and maintenance of any information generated during the registration, identification and authentication, and the account issuance processes. NPDB-HIPDB, in their sole discretion and without incurring liability for any loss arising out of such denial or refusal, may deny a registration for, or otherwise refuse to approve the issuance of, the NPDB-HIPDB account.

3. PRIVACY ACT AND PAPERWORK REDUCTION ACT NOTICE AND DISCLOSURE. In accordance with the Privacy Act of 1974 and the Paperwork Reduction Act of 1980, the following notice explains how the information that You submit in order to obtain a NPDB-HIPDB account is used and maintained:

http://www.npdb-hipdb.hrsa.gov/pubs/Privacy_Policy.pdf

4. NPDB-HIPDB Obligations. NPDB-HIPDB, HRSA and HHS agree that they will verify the information provided by You and accurately transcribe it into the NPDB-HIPDB account.

5. Your Obligations

5.1. Submit Correct Information. You represent and warrant to NPDB-HIPDB, HRSA and HHS that all of the information You submit during the registration process will be accurate, current and complete. You further agree that for purposes of NPDB-HIPDB account validity, You will immediately inform NPDB-HIPDB if any of your registration information changes (e.g., You have a change of employment, change of e-mail address or a change in your legal name). You also represent and warrant that You are authorized to receive NPDB-HIPDB account in the name of the Organization that You have designated as part of your registration.

5.2. Review Your Account; Account Acceptance. The NPDB-HIPDB account issued to You for use on behalf of Your Organization will be based on information provided by You and Your Organization. During the account issuance process You are provided with the opportunity to review such information. At all times, You agree to review and verify the accuracy of the information contained in your account. You acknowledge that using the NPDB-HIPDB account constitutes your acceptance of that account. If You fail to notify NPDB-HIPDB of any errors, defects, or problems with your account within 24 hours after accessing it, it will be considered to have been accepted by You. By accepting the NPDB-HIPDB account, You further represent and warrant that the information in your account (i.e., Name, Organizational Affiliation, etc.) is accurate, current and correct. Upon acceptance, and at any time thereafter when You use your NPDB-HIPDB account, You and Your Organization acknowledge and assent to the responsibilities identified herein (including those identified in the NPDB-HIPDB policies).

5.3. Protect Your NPDB-HIPDB Account. By requesting a NPDB-HIPDB account, You acknowledge and agree that You are responsible for protecting and maintaining sole possession and control of the account. In addition, You represent and warrant to NPDB-HIPDB that, in regard to such account, You have kept and will keep your passwords private and that You will safeguard and maintain your account (and any user IDs, passphrases, shared secrets, etc.) in strict secrecy and take reasonable security measures to prevent unauthorized access or use of your account and the computer system or media on which your account information is stored.

IF YOU OR YOUR ORGANIZATION EVER SUSPECT OR DISCOVER THAT THE SECURITY OF EITHER OF YOUR ACCOUNT HAS BEEN OR IS IN DANGER OF BEING COMPROMISED IN ANY WAY, YOU OR YOUR ORGANIZATION MUST IMMEDIATELY NOTIFY THE NPDB-HIPDB AND REQUEST REVOCATION OF YOUR ACCOUNT. YOU MUST THEN IMMEDIATELY CEASE USING YOUR ACCOUNT.

You can initiate a revocation request online at the NPDB-HIPDB site or You can call the NPDB-HIPDB Customer Service Center at 1-800-767-6732.

5.5. Situations Requiring Revocation of Your Account. You must revoke your account if You discover or suspect that your account have been or are in danger of being compromised or subjected to unauthorized use in any way, or if any information affecting the reliability of your account changes or is no longer true (e.g., Your name changes, You are no longer employed, associated or affiliated with Your Organization, etc.). You or Your Organization may also revoke your account at any time for any other reason. NPDB-HIPDB may also revoke your account without advance notice if it, in its sole discretion, determines that: (a) the account was not properly issued or was obtained by fraud; (b) the security of the account has or may have been lost or otherwise compromised; (c) the account has become unreliable; (d) information in the account has changed or become untrue (e.g., You are no longer affiliated with Your Organization); (e) You or Your Organization have violated any applicable agreement or obligation; (f) You or Your Organization requests revocation; (g) a governmental authority has lawfully ordered NPDB-HIPDB to revoke your account; (h) this Agreement terminates; or (j) there are any other grounds for revocation. Your right to use your account ceases immediately upon revocation of your account.

6. Interpretation. NPDB-HIPDB accounts are issued to Subscribers to further the mission and operations of NPDB-HIPDB, HRSA and HHS and liability claims shall be subject to the terms of the Federal Tort Claims Act as interpreted by the HHS Office of General Counsel. This Agreement shall be governed by, interpreted and construed under the laws of the United States. If any provision of this Agreement is found to be invalid or unenforceable, then such document shall be deemed amended by modifying such provision to the extent necessary to make it valid and enforceable while preserving it intent or, if that is not possible, by striking the provision and enforcing the remainder of this Agreement.

7. Dispute Resolution. In the event of any dispute or disagreement arising out of or relating to this agreement, the disputing parties shall use their best efforts to settle the dispute or disagreement through negotiations in good faith following notice from one disputing party to the other(s). If the disputing parties cannot reach a mutually agreeable resolution of the dispute or disagreement within sixty (60) days following the date of such notice, then the disputing parties may present the dispute to the NPDB-HIPDB Registration Practices Management body. In the event that the NPDB-HIPDB Registration Practices Management body is unable to resolve the dispute, the parties may bring the matter to the HHS Office of General Counsel for resolution.

8. Risk of Loss. You agree that you assume the risk of any use of your account in violation of this Agreement.

9. DISCLAIMER OF WARRANTIES. The NPDB-HIPDB disclaims any and all warranties of any type, whether express or implied, that are not specifically provided herein, including but not limited to any implied warranty of merchantability, fitness for a particular purpose, title and noninfringement with regard to NPDB-HIPDB services or any NPDB-HIPDB account issued hereunder.

10. LIMITATIONS ON NPDB-HIPDB’S LIABILITY. The NPDB-HIPDB shall have no liability for loss due to use of your account, unless the loss is proven to be a proximate result of the negligence, fraud or willful misconduct of the NPDB-HIPDB.

In no event shall the NPDB-HIPDB be liable for any consequential, indirect, remote, exemplary, punitive, special, or incidental damages, or damages for business interruption, loss of profits, revenues or savings, regardless of the form of action and regardless of whether the NPDB-HIPDB was advised of the possibility of such damages.

The NPDB-HIPDB shall incur no liability if the NPDB-HIPDB is prevented, forbidden or delayed from performing, or omits to perform, any act or requirement by reason of any provision of any applicable law, regulation or order, the failure of any electrical, communication or other system operated by any party other than the NPDB-HIPDB or any act of God, emergency condition or war or other circumstance beyond the control of the NPDB-HIPDB.

Instructions for Registering as an NPDB-HIPDB Entity/Authorized Agent Data Bank Administrator

20. 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 document until you have made sure that the document printed in its entirety.

21. Make sure you have read the Summary of Terms of the NPDB-HIPDB Entity/Authorized Agent Data Bank Administrator Registration document.

22. Do not sign the document yourself yet; a Notary Public must witness your signature as described below.

23. Take the NPDB-HIPDB Entity/Authorized Agent Data Bank Administrator Registration document and the credentials listed below to a person certified by a State or Federal Government as being authorized to confirm identities (such as Notary Public), that uses a stamp, seal, or other mechanism to authenticate their identity confirmation.

Credentials to Present to the Notary Public:
You must present the following credentials to the Notary that proves your identity and affiliation with your healthcare organization for which you are registering with the NPDB-HIPDB:

7. One form of ID must be a valid State or Federal government-issued photo ID. Forms of acceptable ID are as follows: A State-issued photo ID (with a serial number) such as a driver’s license, Passport from country of citizenship, federal, state or local government agency (must have name, date of birth, gender, height, eye color and address) ID, US military ID, Certificate of U.S. Citizenship, Certificate of Naturalization, permanent or unexpired temporary resident card, Native American tribal document, or Canadian driver’s license.

AND

8. The work badge issued by your organization OR a signed letter on company letterhead from an authorized official in your organization attesting to your affiliation with the healthcare organization for which you are registering with the NPDB-HIPDB as a Data Bank Administrator.

5. Sign and date the NPDB-HIPDB Entity/Authorized Agent Data Bank Administrator Registration document in the presence of the Notary Public who will complete his/her section of the document.

6. If you are submitting this paperwork as part of a new registration (or re-registration) of your healthcare organization, the following items must be mailed to the NPDB-HIPDB for processing:

4. The original, notarized Entity/Authorized Agent Data Bank Administrator Registration document

AND

A photocopy of your work badge or the original authorization letter (whichever you presented to the Notary).

5. The original, notarized registration document for the Certifying Official (i.e., NPDB-HIPDB Certifying Official Registration). If your Certifying Official is not at your location, then their paperwork may be mailed directly to NPDB-HIPDB.
   
   
   

6. Your healthcare organization’s registration document (i.e., the NPDB-HIPDB Entity Registration or Agent Registration document).

Note: Faxed or scanned copies will not be accepted.

5. Mail all registration documents to:

National Practitioner Data Bank - Healthcare Integrity and Protection Data Bank

P.O. Box 10832

Chantilly, VA 20153-0832

5. If you are registering as a new Data Bank Administrator for a healthcare organization that is currently registered, then only send the original, notarized NPDB-HIPDB Entity/Authorized Agent Data Bank Administrator Registration document AND a photocopy of your work badge or the original authorization letter (whichever you presented to the Notary) to the address above.

6. The NPDB-HIPDB will process the registration documents and if the registration is approved, you shall receive confirmation via e-mail with instructions on how to proceed.

NPDB-HIPDB Entity/Authorized Agent Data Bank Administrator Registration

Section 1 – Registrant Instructions: The Data Bank Administrator (Registrant) must read the terms below, complete the appropriate fields, provide a government-issued ID and either provide a work badge or proof of affiliation letter on company letterhead before signing and dating the document in front of the Notary Public.

S ummary of Terms: You (the "Registrant") are registering as a Data Bank Administrator for an Entity or Authorized Agent registered or registering with the NPDB-HIPDB. As a Data Bank Administrator, you are responsible for overseeing the use of the NPDB-HIPDB online services at your organization, identity proofing applicants who request a user account, establishing and revoking individual user accounts, and maintaining your organization’s registration with the NPDB-HIPDB. By signing below, you acknowledge your acceptance of the Summary of Terms in which you agree to provide complete and accurate responses to requests for information during the registration process. I further certify that I am authorized to submit this registration information to the NIPDB-HIPDB and that the information provided is true, correct, and complete. If I become aware that any information in this document 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 document or contained in any communication supplying information to the NPDB-HIPDB to complete or clarify this document may be punishable by criminal, civil, or other administrative actions including fines, penalties, and/or imprisonment under Federal law.

Name (First Name, Middle Initial, Last Name):	Title:
Employer/Organization:	Employee ID:
Business Address:	Telephone:
E-mail:	Name of Your Organization’s Certifying Official:
Registrant’s Signature and Date*: ___________ ______________________________________ __________ (*Sign and date in the presence of the Notary Public) (Date)

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

S ection 2 – Notary Public Instructions: The Notary Public must record the information below for the Registrant’s government-issued photo ID for the purpose of identity proofing. In addition, you must verify that the Registrant p resented either a current work badge or a proof of affiliation letter on company letterhead.

Government-issued ID (Photo, Name, Serial Number, Expiration Date, Address, and Date of Birth Required)	Organization Affiliation (check one)
Exact Name Listed on ID	T he Registrant presented his/her work badge as proof of organizational affiliation. OR The Registrant presented an original copy of a P roof of Organizational Affiliation letter on company letterhead as proof of organizational affiliation.
Date of Birth
Serial Number
Expiration Date
Identification Type
Date of Issuance
Issuing Authority

N

Notary Public seal here

otary Public: _______________________
I hereby certify that on this _______ day of ____________, 20__, in the city of ________________ and in the county of _______________________, _______ personally appeared before me the signer and subject of the above section, who signed or attested the same in my presence, and presented one government-issued form of photo ID as proof of his or her identity. In addition, I have reviewed the Registrant’s work badge or an original copy of the Registrant’s organizational affiliation letter on company letterhead submitted as proof of organizational affiliation.

My Commission Expires In*: _______________________

Street Address of Branch or Office: _______________________

Name of Organization Employing Notary: _______________________

* If commission does not expire, indicate "does not expire" in this field.

Instructions for Registering as an NPDB-HIPDB Certifying Official and Data Bank Administrator

24. 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 document until you have made sure that the document printed in its entirety.

25. Make sure you have read the Summary of Terms section of the NPDB-HIPDB Certifying Official and Data Bank Administrator Registration document.

26. Do not sign the document yourself yet; a Notary Public must witness your signature as described below.

27. Take the NPDB-HIPDB Certifying Official and Data Bank Administrator Registration document and the credentials listed below to a person certified by a State or Federal Government as being authorized to confirm identities (such as Notary Public), that uses a stamp, seal, or other mechanism to authenticate their identity confirmation.

Credentials to Present to the Notary Public:
You must present the following credentials to the Notary that proves your identity and affiliation with your healthcare organization for which you are certifying to the NPDB-HIPDB:

9. One form of ID must be a valid State or Federal government-issued photo ID. Forms of acceptable ID are as follows: A state-issued photo ID (with a serial number) such as a driver’s license, Passport from country of citizenship, federal, state or local government agency (must have name, date of birth, gender, height, eye color and address), US military ID, Certificate of U.S. Citizenship, Certificate of Naturalization, permanent or unexpired temporary resident card, Native American tribal document, or Canadian driver’s license.

AND

10. The work badge issued by your organization OR a signed letter on company letterhead from an authorized official in your organization attesting to your affiliation with the healthcare organization for which you are certifying.

5. Sign and date the NPDB-HIPDB Certifying Official and Data Bank Administrator Registration document in the presence of the Notary Public who will complete his/her section of the document.

6. If you are submitting this paperwork as part of a new registration (or re-registration) of your healthcare organization, the following items must be mailed to the NPDB-HIPDB for processing:

7. The original, notarized NPDB-HIPDB Certifying Official and Data Bank Administrator Registration document

AND

A photocopy of your work badge or the original authorization letter (whichever you presented to the Notary).

8. Your healthcare organization’s registration document (i.e., the NPDB-HIPDB Entity Registration or Agent Registration document).

5. Mail all registration documents to:

National Practitioner Data Bank - Healthcare Integrity and Protection Data Bank

P.O. Box 10832

Chantilly, VA 20153-0832

Note: Faxed or scanned copies will not be accepted.

5. If you are replacing a Certifying Official and Data Bank Administrator for an organization that is currently registered with the NPDB-HIPDB, then please indicate so on the registration document in the field provided. In this case, send only the original, notarized NPDB-HIPDB Certifying Official and Data Bank Administrator Registration document AND a photocopy of your work badge or the original authorization letter (whichever you presented to the Notary) to the address above.

6. The NPDB-HIPDB will process the registration documents and if the registration is approved, you shall receive confirmation via e-mail with instructions on how to proceed.

Section 1 – Registrant Instructions: The Certifying Official/Data Bank Administrator (Registrant) must read the terms below, complete the appropriate fields, provide a government-issued ID and either provide a work badge or proof of affiliation letter on company letterhead before signing and dating the document in front of the Notary Public.

S ummary of Terms: You (the "Registrant"), as the Certifying Official of the healthcare organization identified in this document, certify that the organization qualifies under law as specified in the ELIGIBILITY/ STATUTORY AUTHORITY section of the Entity/Agent Registration document and is eligible to perform the querying and/or reporting functions. I understand that the Entity/Authorized Agent 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. You are also registering as a Data Bank Administrator for an Entity or Authorized Agent registered or registering with the NPDB-HIPDB. As a Data Bank Administrator, you are responsible for overseeing the use of the NPDB-HIPDB online services at your organization, identity proofing applicants who request a user account, establishing and revoking individual user accounts, and maintaining your organization’s registration with the NPDB-HIPDB. By signing below, you acknowledge your acceptance of the Summary of Terms in which you agree to provide complete and accurate responses to requests for information during the registration process. I further certify that I am authorized to submit this registration information to the NIPDB-HIPDB and that the information provided is true, correct, and complete. If I become aware that any information on this document 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 document or contained in any communication supplying information to the NPDB-HIPDB to complete or clarify document may be punishable by criminal, civil, or other administrative actions including fines, penalties, and/or imprisonment under Federal law.

Name (First Name, Middle Initial, Last Name):	Title: A re you replacing a registered Certifying Official/ Data Bank Administrator? Yes No
Employer/Organization:	Employee ID:
Business Address:	Telephone:
E-mail:
Registrant’s Signature and Date*: ___________ ______________________________________ __________ (*Sign and date in the presence of the Notary Public) (Date)

S ection 2 – Notary Public Instructions: Record the information below for the Registrant’s government-issued photo ID for the purpose of identity proofing. In addition, you must verify that the Registrant presented either a c urrent work badge or a proof of affiliation letter on company letterhead.

Government-issued ID (Photo, Name, Serial Number, Expiration Date, Address, and Date of Birth Required)	Organization Affiliation (check one)
Exact Name Listed on ID	T he Registrant presented his/her work badge as proof of organizational affiliation. OR The Registrant presented an original copy of a P roof of Organizational Affiliation letter on company letterhead as proof of organizational affiliation.
Date of Birth
Serial Number
Expiration Date
Identification Type
Date of Issuance
Issuing Authority

N

Notary Public seal here

otary Public: _______________________
I hereby certify that on this _______ day of ____________, 20__, in the city of ________________ and in the county of ______________________, ________ personally appeared before me the signer and subject of the above section, who signed or attested the same in my presence, and presented one government-issued form of photo ID as proof of his or her identity. In addition, I have reviewed the Registrant’s work badge or an original copy of the Registrant’s organizational affiliation letter on company letterhead submitted as proof of organizational affiliation.

My Commission Expires In*: _______________________

Street Address of Branch or Office: _______________________

Name of Organization Employing Notary: _______________________

* If commission does not expire, indicate "does not expire" in this field.

Instructions for Registering as an NPDB-HIPDB Self-Querier

28. 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.

29. Make sure you have read the Summary of Terms of the NPDB-HIPDB Self-Querier Registration document.

30. Do not sign the form yourself yet; a Notary Public must witness your signature as described below.

31. Take the NPDB-HIPDB Self-Querier Registration document and one form of identification (listed below) to a person certified by a State or Federal Government as being authorized to confirm identities (such as Notary Public), that uses a stamp, seal, or other mechanism to authenticate their identity confirmation.

Credentials to Present to the Notary Public:
You must present one valid State or Federal government-issued photo ID to the Notary that proves your identity for which you are registering with the NPDB-HIPDB. Forms of acceptable ID are as follows: A State-issued photo ID (with a serial number) such as a driver’s license, Passport from country of citizenship, federal, state or local government agency (must have name, date of birth, gender, height, eye color and address) ID, US military ID, Certificate of U.S. Citizenship, Certificate of Naturalization, permanent or unexpired temporary resident card, Native American tribal document, or Canadian driver’s license.

5. Sign and date the NPDB-HIPDB Self-Querier Registration document in the presence of the Notary Public who will complete his/her section of the form.

6. Mail the completed, notarized form to:

National Practitioner Data Bank - Healthcare Integrity and Protection Data Bank

P.O. Box 10832

Chantilly, VA 20153-0832

Note: Faxed or scanned copies will not be accepted.

5. If NPDB-HIPDB approves your request, you will receive an email confirmation with login information to your new account.

NPDB-HIPDB Self-Querier Registration

Section 1 – Registrant Instructions: The Authorized User (Registrant) must read the terms below, complete the appropriate fields, and provide a government-issued ID before signing and dating the form in front of the Notary Public.

S ummary of Terms: You (the "Registrant") are applying to be a registered user of the NPDB-HIPDB system. By signing below, you acknowledge your acceptance of the Summary of Terms in which you agree to provide complete and accurate responses to request for information during the registration process. 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 document 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 document or contained in any communication supplying information to the NPDB-HIPDB to complete or clarify this document may be punishable by criminal, civil, or other administrative actions including fines, penalties, and/or imprisonment under Federal law.

Name (First Name, Middle Initial, Last Name:
Employer/Organization:	Telephone:
Business Address:	E-mail:
Registrant’s Signature and Date*: ___________ ______________________________________ __________ (*Sign and date in the presence of the Notary Public) (Date)

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

S ection 2 – Notary Public Instructions: The Notary Public must record the information below for the Registrant’s government-issued photo ID for the purpose of identity proofing.

Government-issued ID (Photo, Name, Serial Number, Expiration Date, Address, and Date of Birth Required)

Exact Name Listed on ID

Date of Birth

Serial Number

Expiration Date

Identification Type

Date of Issuance

Issuing Authority

N

Notary Public seal here

otary Public: _______________________

I hereby certify that on this _______ day of ____________, 20__, in the
city of ________________ and in the county of ______________________, _____ personally appeared before me the signer and subject of the above section, who signed or attested the same in my presence, and presented one government-issued form of photo ID as proof of his or her identity.

My Commission Expires In*: _______________________

Street Address of Branch or Office: _______________________

Name of Organization Employing Notary: _______________________

* If commission does not expire, indicate "does not expire" in this field.

Instructions for Registering as an NPDB-HIPDB User

32. 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.

33. Make sure you have read the Summary of Terms of the NPDB-HIPDB User Registration document.

34. Do not sign the form yourself yet; a Notary Public must witness your signature as described below.

35. Take the NPDB-HIPDB User Registration document and the documents listed below to a person certified by a State or Federal Government as being authorized to confirm identities (such as Notary Public), that uses a stamp, seal, or other mechanism to authenticate their identity confirmation.

Credentials to Present to the Notary Public:
You must present the following credentials to the Notary that proves your identity and affiliation with your healthcare organization for which you are registering with the NPDB-HIPDB:

11. One form of ID must be a valid State or Federal government-issued photo ID. Forms of acceptable ID are as follows: A State-issued photo ID (with a serial number) such as a driver’s license, Passport from country of citizenship, federal, state or local government agency (must have name, date of birth, gender, height, eye color and address) ID, US military ID, Certificate of U.S. Citizenship, Certificate of Naturalization, permanent or unexpired temporary resident card, Native American tribal document, or Canadian driver’s license.

AND

12. The work badge issued by your organization OR a signed letter on company letterhead from an authorized official in your organization attesting to your affiliation with the healthcare organization for which you are registering with the NPDB-HIPDB.

5. Sign and date the User Registration document in the presence of the Notary Public who will complete his/her section of the form.

6. Mail the completed, notarized form to your NPDB-HIPDB Entity/Authorized Agent Data Bank Administrator who will process it. Note: Faxed or scanned copies will not be accepted.

7. If your Data Bank Administrator approves your request, you will receive an email confirmation with login information to your new account.

NPDB-HIPDB User Registration (Notarization Required)

Section 1 – Registrant Instructions: The Authorized User (Registrant) must read the terms below, complete the appropriate fields, provide a government-issued ID and either provide a work badge or proof of affiliation letter on company letterhead before signing and dating the form in front of the Notary Public.

S ummary of Terms: You (the "Registrant") are applying to be a registered user of the NPDB-HIPDB system. By signing below, you acknowledge your acceptance of the Summary of Terms in which you agree to provide complete and accurate responses to request for information during the registration process. 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 document 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 document or contained in any communication supplying information to the NPDB-HIPDB to complete or clarify this document may be punishable by criminal, civil, or other administrative actions including fines, penalties, and/or imprisonment under Federal law.

Name (First Name, Middle Initial, Last Name:	Employee ID:
Employer/Organization:	Telephone:
Business Address:	E-mail:
Registrant’s Signature and Date*: ___________ ______________________________________ __________ (*Sign and date in the presence of the Notary Public) (Date)

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

S ection 2 – Notary Public Instructions: The Notary Public must record the information below for the Registrant’s government-issued photo ID for the purpose of identity proofing. In addition, you must verify that the Registrant p resented either a current work badge or a proof of affiliation letter on company letterhead.

Government-issued ID (Photo, Name, Serial Number, Expiration Date, Address, and Date of Birth Required)	Organization Affiliation (check one)
Exact Name Listed on ID	T he Registrant presented his/her work badge as proof of organizational affiliation. OR The Registrant presented an original copy of a P roof of Organizational Affiliation letter on company letterhead as proof of organizational affiliation.
Date of Birth
Serial Number
Expiration Date
Identification Type
Date of Issuance
Issuing Authority

N

Notary Public seal here

otary Public: _______________________
I hereby certify that on this _______ day of ____________, 20__, in the city of ________________ and in the county of _______________________, ______ personally appeared before me the signer and subject of the above section, who signed or attested the same in my presence, and presented one government-issued form of photo ID as proof of his or her identity. In addition, I have reviewed the Registrant’s work badge or an original copy of the Registrant’s organizational affiliation letter on company letterhead submitted as proof of organizational affiliation.

My Commission Expires In*: _______________________

Street Address of Branch or Office: _______________________

Name of Organization Employing Notary: _______________________

* If commission does not expire, indicate "does not expire" in this field.

Section 3 - NPDB-HIPDB Data Bank Administrator Instructions: Send the original, completed document to:
National Practitioner Data Bank / Healthcare Integrity and Protection Data Bank, P.O. Box 10832, Chantilly, VA 20153-0832. Note: Faxed or scanned copies will not be accepted.