Form 17 One Time Query for an Individual

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

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QUERY INPUT
To submit a query, enter all known subject data.
OMB # 0915-0239 expiration date 05/31/14
OMB # 0915-0126 expiration date 12/31/13
OMB # 0915-0331 expiration date 12/31/13
Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to
respond to, a collection of information unless it displays a currently valid OMB control number. The OMB
control numbers for this project are 0915-0239, 0915-0126 and 0915-0331. Public reporting burden for
this collection of information is estimated to average 5 minutes to complete this form, including the time
for reviewing instructions, searching existing data sources, and completing and reviewing the collection
of information. Send comments regarding this burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600
Fishers Lane, Room 14-22, Rockville, Maryland, 20857.
PRACTITIONER INFORMATION
Personal Information
Practitioner Name
Last Name

First Name

Middle Name

Suffix (Jr, III)

Add another name used

Gender
 Male 
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 Female 
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 Unknown
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Birth Date (MMDDYYYY)

Home Address/Address of Record
Street Address:
Address Line 2:
City:
State:
ZIP Code:

CHOOSE ONE FROM LIST



-

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

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

Click

CHOOSE ONE FROM LIST

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

Address
Street Address:
Address Line 2:
City:
State:

CHOOSE ONE FROM LIST

ZIP Code:



-

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

Social Security Numbers (SSN)
Add another SSN

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

Professional Schools Attended
Year of
Graduation (YYYY)

School Name:
Add another Professional School

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:

OR

State of Licensure:

CHOOSE ONE FROM LIST

Occupation/Field of
Licensure:

CHOOSE ONE FROM LIST

CHOOSE ONE FROM LIST
Specialty:
Add Additional License/Occupation

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No License

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 Check this box if you wish to store this subject in your subject database for use in
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future queries and/or reports. Duplicate entries in your subject database may result in
duplicate queries.

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