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pdfEntity: MALPRACTICE ENTITY (FAIRFAX, VA) | User: JohnSmith
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ENROLL SUBJECT
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.
SUBJECT INFORMATION
Personal Information
Practitioner Name
Last Name
First Name
Middle Name
Suffix (Jr, III)
Add another name used
Entity Subject Identification Number
This optional field allows your entity to include a unique number or other reference
information to help you identify this subject. This information is not used by the Data Bank.
(e.g., employee number)
Gender
Male
Female
Unknown
Birth Date (MMDDYYYY)
Department:
CHOOSE ONE FROM LIST
Home Address/Address of Record
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:
Type:
Click
CHOOSE ONE FROM LIST
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
No License
Check the box if the subject(s) will leave this organization on a known date.
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Entity: TEST ENTITY (FAIRFAX, VA) | User: user
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UPDATE SUBJECT
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 (HIPDB), 0915-0126 (NPDB) and 0915-0331
(NPDB). Public reporting burden for this collection of information is estimated to average 5 minutes to
complete this form, including the time for reviewing instructions, searching existing data sources, and
completing and reviewing the collection of information. Send comments regarding this burden estimate
or any other aspect of this collection of information, including suggestions for reducing this burden, to
HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14-22, Rockville, Maryland, 20857.
SUBJECT INFORMATION
Personal Information
Practitioner Name
Last Name
First Name
Middle Name
Suffix (Jr, III)
Add another name used
Entity Subject Identification Number
This optional field allows your entity to include a unique number or other reference
information to help you identify this subject. This information is not used by the Data Bank.
(e.g., employee number)
Gender
Male
Female
Birth Date (MMDDYYYY)
Department:
Unknown
Home Address/Address of Record
Street Address:
Address Line 2:
City:
State:
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:
Type:
Click
for information on filling out non-U.S. and military addresses.
Address
Street Address:
Address Line 2:
City:
State:
ZIP Code:
-
Country:
(if U.S., leave
blank)
Social Security Numbers (SSN)
Edit
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:
State of Licensure:
Occupation/Field of
Licensure:
Specialty:
Add Additional License/Occupation
OR
No License
| File Type | application/pdf |
| Author | hannonn |
| File Modified | 2013-03-22 |
| File Created | 2013-03-22 |