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REQUEST FOR REPORT REVIEW
At your request, the report identified below has been placed in disputed status. All queriers who previously received the
report are notified that the information they received from the National Practitioner Data Bank (NPDB) and/or the
Healthcare Integrity and Protection Data Bank (HIPDB) is in dispute. The reporting entity, identified in Section A, also
has been notified.
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 8 hours to complete the activities associated with 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.
Report Type:
Report Number:
Subject's Name:
Report Maintained Under:
STATE LICENSURE ACTION
5500000034475697
SMITH, JOHN
[X] Title IV
[X] Section 1921
[X] Section 1128E
REQUESTING REPORT REVIEW
Before requesting a review by the Secretary of the U.S. Department of Health and Human Services (HHS), you must
first attempt to resolve the disagreement with the reporting entity. If your disagreement cannot be resolved through
discussions with the reporting entity (e.g., the reporting entity declines to change the report), you may then request that
the Secretary review the report for accuracy.
Please be advised that the Secretary will review your case only to determine the following:
Whether a report should have been filed in accordance with reporting regulations, and if so,
If the information contained in the report is a factually accurate reflection of the action taken and the
reasons the action was taken are specified in relevant documents.
The Secretary will not review the merits of a medical malpractice claim in the case of a payment or the appropriateness
of, or basis for, an adverse action or judgment or conviction. The Secretary can only determine if the action was
reportable and if the report accurately describes the action and the reasons the action was taken. The Secretary cannot
review the extent to which entities followed due process guidelines. Due process issues must be resolved between the
subject and the reporter.
As part of the Report Review process, you should submit to the Data Bank documentation that supports your position
that the reporting entity's information is inaccurate. Documentation must relate directly to the facts in dispute and
substantially contribute to a determination of the factual accuracy of the report. Documentation may not exceed 10
pages, including attachments and exhibits. Click Help for examples of acceptable documentation.
You must also submit proof that you attempted to resolve the disagreement with the reporting entity, but were
unsuccessful (e.g., a copy of your correspondence to the reporting entity and the entity's response, if any).
To proceed with your request for Report Review, follow the instructions below and click Continue. Otherwise, click
Return to Report Response Options at the bottom of this page.
Do not print this page. A printable copy of your request will be provided after submission.
Below is the Subject Statement that you submitted in reference to the specified report. To change this statement, click
Return to Report Response Options at the bottom of the page, then click Statement and Dispute. Once you are
satisfied with your Subject Statement, return to this screen to continue processing your request for Report Review.
statement
COMMENTS TO SECRETARY
Comments directed to the Secretary must be entered below. Enter a clear and brief statement describing which facts
are in dispute, what you believe to be the correct facts, and, if appropriate, why you believe the report should not have
been filed. Your comments must be in English and may not exceed 4,000 characters, including spaces and
punctuation. These comments are to the Secretary and do not replace the Subject Statement that you may have
previously submitted. These comments will not be disclosed as part of your report.
Report Review Statement
There are 4000 characters remaining for the comments.
Spell Check
Resolution Attempt
I have attempted to resolve my dispute with the reporting entity and, after 30 days, have received no
response.
OR
I have attempted to resolve my dispute with the reporting entity; however, the entity has declined to correct
or void the report.
CURRENT ADDRESSES
Your profile will be updated to reflect the addresses below. However, you should be aware that this does not change
your mailing address as reflected in the report filed with the Data Bank.
Email Addresses
The email address you provide will only be used to provide you with notifications that new activity has occurred
concerning this report.
Email Address:
email@address.com
Confirm Email Address:
email@address.com
Add another
Address Line 2:
City:
DENVER
State:
ZIP Code:
CO Colorado
12345
-
Country (if U.S., leave blank):
Work Address
Street Address:
123 FAKE COURT
Address Line 2:
SUITE 100
City:
DENVER
State:
ZIP Code:
CO Colorado
80206
-
Country (if U.S., leave blank):
Certification Data
I certify that I am the individual subject or the subject's duly appointed attorney for such matters
identified in Section B of the referenced report, or that I am the designated employee representing the
organization subject referenced in Section B, and I request that the action(s) above be taken.
Authorized Submitter's Name:
Authorized Submitter's Title:
Authorized Submitter's Phone:
Date:
Ext.
12/03/2012
Continue
Return to Report Response
Options
Sign Out
REQUEST FOR REPORT REVIEW
At your request, the report identified below has been placed in disputed status. All queriers who previously received the
report are notified that the information they received from the National Practitioner Data Bank (NPDB) and/or the
Healthcare Integrity and Protection Data Bank (HIPDB) is in dispute. The reporting entity, identified in Section A, also
has been notified.
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 8 hours to complete the activities associated with 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.
Report Type:
Report Number:
Subject's Name:
Report Maintained Under:
STATE LICENSURE ACTION
5500000034475697
ABC ORGANIZATION
[X] Title IV
[X] Section 1921
[X] Section 1128E
REQUESTING REPORT REVIEW
Before requesting a review by the Secretary of the U.S. Department of Health and Human Services (HHS), you must
first attempt to resolve the disagreement with the reporting entity. If your disagreement cannot be resolved through
discussions with the reporting entity (e.g., the reporting entity declines to change the report), you may then request that
the Secretary review the report for accuracy.
Please be advised that the Secretary will review your case only to determine the following:
Whether a report should have been filed in accordance with reporting regulations, and if so,
If the information contained in the report is a factually accurate reflection of the action taken and the
reasons the action was taken are specified in relevant documents.
The Secretary will not review the merits of a medical malpractice claim in the case of a payment or the appropriateness
of, or basis for, an adverse action or judgment or conviction. The Secretary can only determine if the action was
reportable and if the report accurately describes the action and the reasons the action was taken. The Secretary cannot
review the extent to which entities followed due process guidelines. Due process issues must be resolved between the
subject and the reporter.
As part of the Report Review process, you should submit to the Data Bank documentation that supports your position
that the reporting entity's information is inaccurate. Documentation must relate directly to the facts in dispute and
substantially contribute to a determination of the factual accuracy of the report. Documentation may not exceed 10
pages, including attachments and exhibits. Click Help for examples of acceptable documentation.
You must also submit proof that you attempted to resolve the disagreement with the reporting entity, but were
unsuccessful (e.g., a copy of your correspondence to the reporting entity and the entity's response, if any).
To proceed with your request for Report Review, follow the instructions below and click Continue. Otherwise, click
Return to Report Response Options at the bottom of this page.
Do not print this page. A printable copy of your request will be provided after submission.
Below is the Subject Statement that you submitted in reference to the specified report. To change this statement, click
Return to Report Response Options at the bottom of the page, then click Statement and Dispute. Once you are
satisfied with your Subject Statement, return to this screen to continue processing your request for Report Review.
statement
COMMENTS TO SECRETARY
Comments directed to the Secretary must be entered below. Enter a clear and brief statement describing which facts
are in dispute, what you believe to be the correct facts, and, if appropriate, why you believe the report should not have
been filed. Your comments must be in English and may not exceed 4,000 characters, including spaces and
punctuation. These comments are to the Secretary and do not replace the Subject Statement that you may have
previously submitted. These comments will not be disclosed as part of your report.
Report Review Statement
There are 4000 characters remaining for the comments.
Spell Check
Resolution Attempt
I have attempted to resolve my dispute with the reporting entity and, after 30 days, have received no
response.
OR
I have attempted to resolve my dispute with the reporting entity; however, the entity has declined to correct
or void the report.
CURRENT ADDRESSES
Your profile will be updated to reflect the addresses below. However, you should be aware that this does not change
your mailing address as reflected in the report filed with the Data Bank.
Email Addresses
The email address you provide will only be used to provide you with notifications that new activity has occurred
concerning this report.
Email Address:
email@address.com
Confirm Email Address:
email@address.com
Add another
Address Line 2:
SUITE 100
City:
DENVER
State:
ZIP Code:
CO Colorado
80206
-
Country (if U.S., leave blank):
Certification Data
I certify that I am the individual subject or the subject's duly appointed attorney for such matters
identified in Section B of the referenced report, or that I am the designated employee representing the
organization subject referenced in Section B, and I request that the action(s) above be taken.
Authorized Submitter's Name:
Authorized Submitter's Title:
Authorized Submitter's Phone:
Date:
Ext.
12/03/2012
Continue
Return to Report Response
Options
| File Type | application/pdf |
| Author | hannonn |
| File Modified | 2013-03-22 |
| File Created | 2013-03-22 |