Form 13 Civil Judgement

Entity: TEST ENTITY (FAIRFAX, VA) | User: user

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REPORT INPUT FORM
CIVIL JUDGMENT
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 05/31/14
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 0915-0239 (HIPDB). 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.

PRACTITIONER INFORMATION
We have pre-populated the practitioner information from the most recent report. Please
review all pre-populated information for accuracy.
Personal Information
Practitioner Name
Last Name
SMITH

First Name
JOHN

Add another name used

Gender
 Male 





 Female 



 Unknown




Birth Date (MMDDYYYY)
05051950

Is Subject Deceased?
 No






 Unknown





 Yes





Middle Name

Suffix (Jr, III)

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

State:
ZIP Code:



-

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

Work Information
here if the practitioner's work information is the same as your organization.

 Check





Organization
Name:

GENERAL HOSPITAL

Type:

Click

301 General/Acute Care Hospital



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

Address
Street Address:

123 FAKE STREET

Address Line 2:
City:

FAIRFAX

State:

VA Virginia

ZIP Code:

22030



-

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

Social Security Numbers (SSN)
*****2333
Add another SSN

Edit

Individual Taxpayer Identification Numbers (ITIN)
Add another ITIN

Federal Employer Identification Numbers (FEIN)
Add another FEIN

National Provider Identifiers (NPI)
Add another NPI

Drug Enforcement Administration (DEA) Numbers
Add another DEA Number

Unique Physician Identification Numbers (UPIN)
Add another UPIN

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

123ABC

State of Licensure:

AL Alabama

Occupation/Field of
Licensure:

Physician (MD)

Aerospace Medicine
Specialty:
Add Additional License/Occupation

OR







No License





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

Address Line 2:
City:
State:

CHOOSE ONE FROM LIST

ZIP Code:



-

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

CHOOSE ONE FROM LIST



INFORMATION DESCRIBING ACTION
Jurisdiction Information
Jurisdiction:
 Federal




 State/Local





Venue:
(Court Name)
City:
State:

CHOOSE ONE FROM LIST



Docket/Court File
Number:
Prosecuting Agency
or Civil Plaintiff:
Prosecuting Agency
or Plaintiff Case
Number:
Investigating Agencies
Name

Case Number

Add another Investigating Agency

Statutory Offenses
Statute Title and Section
(e.g., 18 USC. 287)
Add another Statutory Offense

Statutory Offense
(e.g., False Claim)

Count
(e.g., 2)

Act or Omission Codes
Act or Omission CHOOSE ONE FROM LIST
Code:
Add another Act or Omission Code



Narrative Description of Act(s) or Omission(s)
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.
Spell Check

Sentence/Judgment Information
Date of Sentence or Judgment:
(MMDDYYYY)
Is the Action on Appeal?
 Yes




 No




 Unknown





Restitution Amount:
(Format NNNNN.NN)

$

Other Sentence/Judgment
Amount Ordered:
(Format NNNNN.NN)

$

Incarceration:

Years

Months

Days

Suspended Sentence:

Years

Months

Days

Home Detention:

Years

Months

Days

Probation:

Years

Months

Days

Community Service:

Hours

Other Court Orders:
(Describe)




More Sentence/Judgment Information

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 Bank, 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: DEVELOPER
Authorized Submitter's Title:

DEVELOPER

Authorized Submitter's Phone: 7035551212
Date:

Ext.

02/01/2013







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.

Submit to Data Bank

Validate Without Submitting

Store as a Draft

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Entity: TEST ENTITY (FAIRFAX, VA) | User: user

Sign Out

REPORT INPUT FORM
CIVIL JUDGMENT
Report Correction
To submit a correction to previously submitted report DCN 7930000076905945, complete all
necessary modifications in the form below, and press Submit to Data Bank.
The report entered here will replace the original report, so please ensure that all known data is entered
in its entirety. Failure to provide sufficient information to permit identification of a single subject may
result in the report being rejected, necessitating resubmission.
Do not print this page. A printable copy of your report submission will be provided after submission.
OMB # 0915-0239 expiration date 05/31/14
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 0915-0239 (HIPDB). Public reporting burden for this collection of
information is estimated to average 15 minutes to complete the forms, including the time for reviewing
instructions, searching existing data sources, and completing and reviewing the collection of
information. Send comments regarding this burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600
Fishers Lane, Room 14-22, Rockville, Maryland, 20857.

PRACTITIONER INFORMATION
Personal Information
Practitioner Name
Last Name
SMITH

First Name
JOHN

Add another name used

Gender
 Male 





 Female 



 Unknown




Birth Date (MMDDYYYY)
05051950

Is Subject Deceased?
 No






 Unknown





 Yes





Home Address/Address of Record

Middle Name

Suffix (Jr, III)

Street Address:
Address Line 2:
City:
State:

CHOOSE ONE FROM LIST

ZIP Code:



-

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

Work Information
 Check here if the practitioner's work information is the same as your organization.




Organization
Name:

GENERAL HOSPITAL

Type:

Click

301 General/Acute Care Hospital



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

Address
Street Address:

123 FAKE STREET

Address Line 2:
City:

FAIRFAX

State:

VA Virginia

ZIP Code:

22030



-

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

Social Security Numbers (SSN)
*****2333
Add another SSN

Edit

Individual Taxpayer Identification Numbers (ITIN)
Add another ITIN

Federal Employer Identification Numbers (FEIN)

Add another FEIN

National Provider Identifiers (NPI)
Add another NPI

Drug Enforcement Administration (DEA) Numbers
Add another DEA Number

Unique Physician Identification Numbers (UPIN)
Add another UPIN

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

123ABC

State of Licensure:

AL Alabama

Occupation/Field of
Licensure:

Physician (MD)

Aerospace Medicine
Specialty:
Add Additional License/Occupation

OR







No License





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

Address Line 2:
City:
State:

CHOOSE ONE FROM LIST

ZIP Code:



-

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

CHOOSE ONE FROM LIST



INFORMATION DESCRIBING ACTION
Jurisdiction Information
Jurisdiction:
 Federal





 State/Local





Venue:
(Court Name)

FEDERAL COURT

City:

FAIRFAX

State:

AL Alabama

Docket/Court File
Number:

123ABC



Prosecuting Agency
or Civil Plaintiff:
PLAINTIFF
Prosecuting Agency
or Plaintiff Case
CASE NUMBER
Number:
Investigating Agencies
Name
INVESTIGATINV AGENCY

Case Number
123 ABC

Add another Investigating Agency

Statutory Offenses
Statute Title and Section
(e.g., 18 USC. 287)
18 USC
Add another Statutory Offense

Statutory Offense
(e.g., False Claim)
FALSE CLAIM

Count
(e.g., 2)
2

Act or Omission Codes
Act or Omission 200 Fraudulent Billing/Cost Reporting
Code:
Add another Act or Omission Code



Narrative Description of Act(s) or Omission(s)
Note: Do not reference any personal identification information (e.g., names) of anyone other
than the subject of this report.
DESCRIPTION

There are 3989 characters remaining for the description.
Spell Check

Sentence/Judgment Information
Date of Sentence or Judgment: 01012013
(MMDDYYYY)
Is the Action on Appeal?
 Yes




 No





 Unknown





Restitution Amount:
(Format NNNNN.NN)

$

Other Sentence/Judgment
Amount Ordered:
(Format NNNNN.NN)

$

Incarceration:

Years

Months

Days

Suspended Sentence:

Years

Months

Days

Home Detention:

Years

Months

Days

Probation:

Years

Months

Days

Community Service:

Hours 45

Other Court Orders:
(Describe)




More Sentence/Judgment Information

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 Bank, 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: DEVELOPER
Authorized Submitter's Title:

DEVELOPER

Authorized Submitter's Phone: 7035551212
Date:







Ext.

02/01/2013

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

Submit to Data Bank

Validate Without Submitting

Store as a Draft

Return to Options

Entity: TEST ENTITY (FAIRFAX, VA) | User: user

Sign Out

REPORT INPUT FORM
CIVIL JUDGMENT
Organization 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 05/31/14
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 0915-0239 (HIPDB). 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
We have pre-populated the practitioner information from the most recent report. Please
review all pre-populated information for accuracy.
Organization Information
Organization Name
MEDICAL ORGANIZATION
Add another name used

Click

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

Address
Street Address:

123 MAIN STREET

Address Line 2:
City:

FAIRFAX

State:

VA Virginia

ZIP Code:

22033

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



-

Type
Organization Type:

361 Chiropractic Group/Practice



Federal Employer Identification Numbers (FEIN)
123456789
Add another FEIN

Social Security Numbers (SSN)
Add another SSN

Individual Taxpayer Identification Numbers (ITIN)
Add another ITIN

Drug Enforcement Administration (DEA) Numbers
Add another DEA Number

National Provider Identifiers (NPI)
Add another NPI

Medicare Provider/Supplier Numbers
Add another Medicare Provider/Supplier Number

Organization State Licensure Information
(If no State License, check the 'No License' box.)
State License
Number:

123ABC

State of Licensure:

AL Alabama

Add another License

OR


 No





License

Principal Officers and Owners
Last Name
First Name

Middle Name Suffix

Title

Add another Principal Officer or Owner

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

CHOOSE ONE FROM LIST

ZIP Code:



-

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

CHOOSE ONE FROM LIST



INFORMATION DESCRIBING ACTION
Jurisdiction Information
Jurisdiction:
 Federal




 State/Local





Venue:
(Court Name)
City:
State:
Docket/Court File
Number:
Prosecuting Agency
or Civil Plaintiff:

CHOOSE ONE FROM LIST



Prosecuting Agency
or Plaintiff Case
Number:
Investigating Agencies
Name

Case Number

Add another Investigating Agency

Statutory Offenses
Statute Title and Section
(e.g., 18 USC. 287)

Statutory Offense
(e.g., False Claim)

Count
(e.g., 2)

Add another Statutory Offense

Act or Omission Codes
Act or Omission CHOOSE ONE FROM LIST
Code:
Add another Act or Omission Code



Narrative Description of Act(s) or Omission(s)
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.
Spell Check

Sentence/Judgment Information
Date of Sentence or Judgment:
(MMDDYYYY)
Is the Action on Appeal?

 Yes





Restitution Amount:
(Format NNNNN.NN)

$

 No




 Unknown





Other Sentence/Judgment
Amount Ordered:
(Format NNNNN.NN)

$

Suspended Sentence:

Years

Months

Days

Probation:

Years

Months

Days

Community Service:

Hours

Other Court Orders:
(Describe)




More Sentence/Judgment Information

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 Bank, 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: DEVELOPER
Authorized Submitter's Title:

DEVELOPER

Authorized Submitter's Phone: 7035551212
Date:

Ext.

02/01/2013







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.

Submit to Data Bank

Validate Without Submitting

Store as a Draft

Return to Options

Entity: TEST ENTITY (FAIRFAX, VA) | User: user

Sign Out

REPORT INPUT FORM
CIVIL JUDGMENT
Report Correction
To submit a correction to previously submitted report DCN 7930000076905971, complete all
necessary modifications in the form below, and press Submit to Data Bank.
The report entered here will replace the original report, so please ensure that all known data is entered
in its entirety. Failure to provide sufficient information to permit identification of a single subject may
result in the report being rejected, necessitating resubmission.
Do not print this page. A printable copy of your report submission will be provided after submission.
OMB # 0915-0239 expiration date 05/31/14
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 0915-0239 (HIPDB). Public reporting burden for this collection of
information is estimated to average 15 minutes to complete the forms, including the time for reviewing
instructions, searching existing data sources, and completing and reviewing the collection of
information. Send comments regarding this burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600
Fishers Lane, Room 14-22, Rockville, Maryland, 20857.

SUBJECT INFORMATION
Organization Information
Organization Name
MEDICAL ORGANIZATION
Add another name used

Click

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

Address
Street Address:

123 MAIN STREET

Address Line 2:
City:

FAIRFAX

State:

VA Virginia

ZIP Code:

22033

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



-

Type
Organization Type:

361 Chiropractic Group/Practice



Federal Employer Identification Numbers (FEIN)
123456789
Add another FEIN

Social Security Numbers (SSN)
Add another SSN

Individual Taxpayer Identification Numbers (ITIN)
Add another ITIN

Drug Enforcement Administration (DEA) Numbers
Add another DEA Number

National Provider Identifiers (NPI)
Add another NPI

Medicare Provider/Supplier Numbers
Add another Medicare Provider/Supplier Number

Organization State Licensure Information
(If no State License, check the 'No License' box.)
State License
Number:

123ABC

State of Licensure:

AL Alabama

Add another License

OR


 No





License

Principal Officers and Owners
Last Name
First Name

Middle Name Suffix

Title

Add another Principal Officer or Owner

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

CHOOSE ONE FROM LIST

ZIP Code:



-

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

CHOOSE ONE FROM LIST



INFORMATION DESCRIBING ACTION
Jurisdiction Information
Jurisdiction:
 Federal





 State/Local





Venue:
(Court Name)

FEDERAL COURT

City:

FAIRFAX

State:

VA Virginia

Docket/Court File
Number:

123ABC

Prosecuting Agency
or Civil Plaintiff:
PROSECUTING AGENCY



Prosecuting Agency
or Plaintiff Case
CASE NUMBER 123
Number:
Investigating Agencies
Name
123

Case Number
ABC

Add another Investigating Agency

Statutory Offenses
Statute Title and Section
(e.g., 18 USC. 287)
18 USC 287

Statutory Offense
(e.g., False Claim)
FALSE CLAIM

Count
(e.g., 2)
2

Add another Statutory Offense

Act or Omission Codes
Act or Omission 207 Misrepresentation of Services/ Supplies Provided
Code:
Add another Act or Omission Code



Narrative Description of Act(s) or Omission(s)
Note: Do not reference any personal identification information (e.g., names) of anyone other
than the subject of this report.
NARRATIVE DESCRIPTION OF ACT(S) OR OMISSION(S)

There are 3954 characters remaining for the description.
Spell Check

Sentence/Judgment Information
Date of Sentence or Judgment: 01032013
(MMDDYYYY)
Is the Action on Appeal?

 Yes





Restitution Amount:
(Format NNNNN.NN)

$

 No





 Unknown





Other Sentence/Judgment
Amount Ordered:
(Format NNNNN.NN)

$

Suspended Sentence:

Years

Months

Days

Probation:

Years

Months

Days

Community Service:

Hours 44

Other Court Orders:
(Describe)




More Sentence/Judgment Information

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 Bank, 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: DEVELOPER
Authorized Submitter's Title:

DEVELOPER

Authorized Submitter's Phone: 7035551212
Date:







Ext.

02/01/2013

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

Submit to Data Bank

Validate Without Submitting

Store as a Draft

Return to Options