Form 24 Entity Registration (Initial)

the

DataBank

P.O. Box 10832
Chantilly, VA 20153-0832
http://www.npdb-hipdb.hrsa.gov

Entity Registration Instructions
1. Make note of the DBID and User ID in Section A below. After your registration has been successfully processed you will
use these values in addition to your password to log in to the Integrated Querying and Reporting Service (IQRS).
Data Bank Identification Number:

User ID:

2. Sign the Entity Registration document.
3. The Certifying Official and Administrator must take the following steps in order to complete their registration documents:
A. Make sure you have read the Summary of Terms section of the Registration document.
B. Do not sign the document yourself yet; a Notary Public must witness your signature as described below.
C. Take the 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 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.
D. Sign and date the registration document in the presence of the Notary Public who will complete his/her section of the
document.
4. The following 5 items must be mailed to the Data Bank for processing (faxed/scanned copies will not be accepted):
A. The signed Entity Registration document.
B. The original notarized NPDB-HIPDB Certifying Official Registration document.
C. Proof of the Certifying Official's affiliation with your healthcare organization for which you are certifying to the NPDBHIPDB. You must provide one of the following:
(1) A photocopy of the work badge issued by your organization. The badge must contain a photograph, the name of
the organization for which you work, and a non-expired expiration date.
(2) 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. A sample letter can be viewed by logging in to
the IQRS and clicking the sample link on the Registration Confirmation screen.
D. The original notarized Data Bank Administrator Registration document.
E. Proof of the Administrator's affiliation with your organization for which you are certifying to the NPDB-HIPDB.
5. Mail the document(s) to:
The Data Bank
P.O. Box 10832
Chantilly, VA 20153-0832

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

Registration Checklist
Before sending your registration, please ensure the following:
All documents listed in the Entity Registration Instructions are included:
Entity Registration document
NPDB-HIPDB Certifying Official Registration document
Proof of the Certifying Official's affiliation with the healthcare organization you are certifying to the NPDB-HIPDB
NPDB-HIPDB Administrator Registration document
Proof of the Administrator's affiliation with the organization you are certifying to the NPDB-HIPDB
Entity Registration document:
Signed and dated by the Certifying Official
Current and accurate organization identification information
Certifying Official and Data Bank Administrator Registration documents:
Must be notarized
Government-issued ID fields are completed
Stamp or seal is located on the document
Proof of affiliation - If a work badge is used, it must contain all of the following:
Name of the individual
Photo of the individual
Name of the organization
Unexpired expiration date
Work badges without expiration dates are not accepted
Proof of affiliation - If a letter is used, it must meet both of the following:
Be on your organization’s letterhead
Be signed by an authorized official from your organization who can attest to your employment (for example, a member
of your human resources department or another manager or official from within your organization)
Proof-of-affiliation letters may not be signed by the Certifying Official or Data Bank Administrator listed on the
account
All signatures on all documents must be original (Photocopied, stamped, or computer-generated signatures are not
accepted)
Mail the documents to one of the following addresses:
Regular Mail: The Data Bank
Overnight Mail: The Data Bank
P.O. Box 10832
4094 Majestic Lane, PMB-332
Chantilly, VA 20153-0832
Fairfax, VA 22033

the

DataBank

DCN: 7910000074179870
Page 1 of 2

P.O. Box 10832
Chantilly, VA 20153-0832
http://www.npdb-hipdb.hrsa.gov

Entity Registration
A. ENTITY IDENTIFICATION INFORMATION
Name of Entity:
Street Address:
City, Country, Zip:
Taxpayer Identification Number:
Ownership of the Entity:
Primary Function of the Entity:
B. ELIGIBILITY/STATUTORY AUTHORITY
NPDB - Title IV

Function/Service:
Hospital
Querying: Mandatory

Reporting: Mandatory

Must provide health care services directly or indirectly and follow a formal peer review process to further quality health
care.
Function/Service:
Hospital
Querying: Optional
Reporting: No Requirement
Must provide health care services directly or indirectly and follow a formal peer review process to further quality health
care.
NPDB - Section 1921

HIPDB - Section 1128E

Function/Service:
Hospital
Querying: Prohibited

Query Preference:

NPDB Only

C. POINT OF CONTACT FOR REPORTS
Name or Office:
Title or Department:
Telephone:
D. ENTITY ADMINISTRATOR
Name:
Title:
Telephone:
Email Address:
E. CERTIFYING OFFICIAL
Name:
Title:
Telephone:
Email Address:
Certification Date:

Reporting: Prohibited

the

DataBank

P.O. Box 10832
Chantilly, VA 20153-0832

DCN: 7910000074179870
Page 2 of 2

http://www.npdb-hipdb.hrsa.gov
I read and understand my responsibilities under:
• Title IV of Public Law 99-660, the Healthcare Quality Improvement Act, as amended;
• Public Law 100-93, Section 5[b] of the Medicare and Medicaid Patient and Program Protection Act of 1987, [Section 1921 of the Social
Security Act]; and
• Section 221[a], Public Law 104-191, the Health Insurance Portability and Accountability Act of 1996, more commonly referred to as
Section 1128E of the Social Security Act.
I certify that the entity identified above qualifies under law as specified in the ELIGIBILITY/STATUTORY AUTHORITY section and is eligible to
perform the querying and/or reporting functions. I understand that the entity 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. 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 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

______________________________
Signature of Certifying Official

__________________________________
Signature Date (MM-DD-YYYY)

the

DataBank

DCN: 7910000074179870
Page 1 of 1

P.O. Box 10832
Chantilly, VA 20153-0832
http://www.npdb-hipdb.hrsa.gov

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.

Registrant use only

Summary 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 NPDB-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:

Email:

Employee ID:

Employer/Organization:
Business Address:

Telephone:

Name of NPDB-HIPDB Data Bank Administrator:

Applicant’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.

Section 2 - Notary Public Instructions: The Notary Public must record the information below for the Applicant’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)

Notary Public use only

Exact Name Listed on ID
Serial Number

Date of Birth

Identification Type

Issuing Authority

Date of Issuance

Expiration Date

Notary 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 form, who signed or attested the same in my presence,
My Commission Expires In: _______________________
Street Address of Branch or Office: _______________________
Name of Organization Employing Notary: _______________________

Notary Public seal here

the

DataBank

DCN: 7910000074179870
Page 1 of 1

P.O. Box 10832
Chantilly, VA 20153-0832
http://www.npdb-hipdb.hrsa.gov

NPDB-HIPDB 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.

Registrant use only

Summary 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 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 NPDBHIPDB 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:

Email:

Employee ID:

Employer/Organization:
Business Address:

Telephone:

Name of NPDB-HIPDB Certifying Official:

Applicant’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.

Section 2 - Notary Public Instructions: The Notary Public must record the information below for the Applicant’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)

Notary Public use only

Exact Name Listed on ID
Serial Number

Date of Birth

Identification Type

Issuing Authority

Date of Issuance

Expiration Date

Notary 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 form, who signed or attested the same in my presence,
My Commission Expires In: _______________________
Street Address of Branch or Office: _______________________
Name of Organization Employing Notary: _______________________

Notary Public seal here