Form 29 Authorized Agent Designation

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

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DESIGNATE AUTHORIZED AGENT

Complete this form to select an authorized agent who can query and/or report on your behalf. Specify (1)
the last four digits of the agent's Data Bank Identification Number, (2) the Agent Organization Name, City,
State, ZIP Code, and Country (if applicable), (3) whether to allow the agent to query or report, (4) whether
query and/or report responses will be routed to the agent or the entity, and (5) whether the agent's or the
entity's EFT account will be charged when EFT is the method of payment used for a query submission.
Once the data provided here is validated, you will be instructed to print the Agent Designation Request for
your records. This document will serve as the sole record of your request.
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 15 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.
AGENT INFORMATION
Data Bank Identification Number
(last 4 digits):
Agent Organization Name:
City:
State:
ZIP Code:

CHOOSE ONE FROM LIST



-

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

CONFIGURATION
I authorize my agent to submit the following transactions on my behalf:
 One-Time Query




 Report




I authorize my agent to use my entity's EFT account to pay for queries submitted on my entity's behalf:
NOTE: When an entity designates an authorized agent to query and/or report on behalf of the entity,
the entity is ultimately responsible for payment (even if EFT charges are directed to that
agent). Payment may also be made by credit card at the time of querying, regardless of EFT routing
assignment.
 Yes




 No




Route responses to my agent's submission to:
 Only my entity




 Only my agent




 Both my entity and my agent




Return responses to my entity via:

IQRS
ITP
 QRXS















CERTIFICATION
I certify that I am authorized to designate the authorized agent identified above to report to and/or query the
Data Bank on my behalf.

Name of Certifying Official:
Title of Certifying Official:
Telephone:
Certification Date (MMDDYYYY):

Ext.
11302012

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

Sign Out

DESIGNATE AUTHORIZED AGENT

Complete this form to modify an authorized agent who can query and/or report on your behalf. Specify (1)
whether query and/or report responses will be routed to the agent or the entity, and (2) whether the agent's
or the entity's EFT account will be charged when EFT is the method of payment used for a query
submission. Once the data provided here is validated, you will be instructed to print the Agent Designation
Request for your records. This document will serve as the sole record of your request.
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.
AGENT INFORMATION
Agent Organization Name:
Address:
City, State, Zip

MALPRACTICE ENTITY
123 FAKE STREET
SUITE 100
ASHBURN, VA 20148

CONFIGURATION
I authorize my agent to submit the following transactions on my behalf:
 One-Time Query





 Report





I authorize my agent to use my entity's EFT account to pay for queries submitted on my entity's behalf:
NOTE: When an entity designates an authorized agent to query and/or report on behalf of the entity,
the entity is ultimately responsible for payment (even if EFT charges are directed to that
agent). Payment may also be made by credit card at the time of querying, regardless of EFT routing
assignment.
 Yes




 No





Route responses to my agent's submission to:
 Only my entity




 Only my agent




 Both my entity and my agent





Return responses to my entity via:
 IQRS





 ITP




 QRXS





CERTIFICATION

I certify that I am authorized to designate the authorized agent identified above to report to and/or query the
Data Bank on my behalf.

Name of Certifying Official:
Title of Certifying Official:
Telephone:
Certification Date (MMDDYYYY):

Ext.
11302012

Continue

Return to Administrator Options