Form 2 60.10: Adverse Actions - Private Accreditation

Report Input Form

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ACCREDITATION

Organization Subject: Initial Report

Please provide as much of the following information as possible. Failure to provide sufficient
information to permit identification of a single subject will result in the report being rejected,
necessitating resubmission.
Do not print this page. A printable copy of your report submission will be provided after submission.
OMB # 0915-0126 expiration date 07/31/10
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 number for this project is 0915-0126 (NPDB). Public reporting burden for this collection of
information is estimated to average 45 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
Organization
Name:
Other Organization Names Used:
1.
2.
3.
4.
5.
Click

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

Street Address:
Address Line 2:
City:
State:
ZIP Code:

-

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

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Organization Type:
Description (if 'Other' was selected above):

FEDERAL EMPLOYER IDENTIFICATION NUMBERS (FEIN)
1.

2.

3.

4.

SOCIAL SECURITY NUMBERS (SSN) (FORMAT NNNNNNNNN)
1.

2.

3.

4.

PRINCIPAL OFFICERS AND OWNERS
Last Name

First Name

Suffix (e.g., Jr.,
Title
III)

Middle Name

1.
2.
3.
4.
5.
ORGANIZATION STATE LICENSURE INFORMATION
(If no State License, check the 'No License' box.)

1. State License Number:

OR

No License

OR

No License

OR

No License

State of Licensure:

2. State License Number:
State of Licensure:

3. State License Number:
State of Licensure:

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DRUG ENFORCEMENT ADMINISTRATION (DEA) NUMBERS
1.

2.

3.

4.

CLINICAL LABORATORY IMPROVEMENT ACT (CLIA) NUMBERS
1.

2.

3.

4.

5.

6.

FEDERAL FOOD AND DRUG ADMINISTRATION (FDA) NUMBERS
1.

2.

3.

4.

5.

6.

NATIONAL PROVIDER IDENTIFIERS (NPI)
1.

2.

3.

4.

MEDICARE PROVIDER/SUPPLIER NUMBERS
1.

2.

3.

4.

HEALTH CARE ENTITIES WITH WHICH THE SUBJECT IS AFFILIATED OR ASSOCIATED
Inclusion of an affiliated/associated health care entity in this report does not imply complicity in the
reported action.
for information on filling out non-U.S. and military addresses.

Click
1.

Name of
Affiliated/Associated
Health Care Entity:
Street Address:
Address Line 2:
City:
State:
ZIP Code:

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Country (if U.S., leave
blank):
Nature of Subject's
Relationship to Affiliate:
Other Description (complete only if 'Other' is selected above):

ADVERSE ACTION INFORMATION
BASIS FOR ACTION
Select a category and then choose a basis for action code that best describes the reason for the
action. Click Add Additional Basis For Action to provide up to 2 basis for action selections. View a
complete basis for action list.
1.

Non-Compliance
Other

Name of Agency or
Program that Took the
Adverse Action Specified in
This Report:
Date Action Was Taken
(MMDDYYYY):
Date Action Became
Effective (MMDDYYYY):
Length of Action:

Permanent

Indefinite/Unspecified

Specific Period
Years:
Months:
Days:
Is Reinstatement Automatic
Yes
at Completion of Adverse
Yes, with conditions (requires a Revision to Action Report when status
Action Period?
changes)
No
Total Amount of Monetary Penalty, Assessment and/or Restitution or fine (Format

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NNNNN.NN):
Note: If no amount, leave this field blank.
$
Description of Subject's Act(s) or Omission(s) or Other Reasons for Action(s) Taken and
Description of Action(s) Taken by Reporting Entity
Note: Do not reference any personal identification
information (e.g., names) of anyone other than the subject
of this report. The description must include sufficient
specificity to enable a knowledgeable reviewer to determine
clearly the circumstances of the action(s) or surrender.
Refer to Reporting, Submitting a Factually-Sufficient
Narrative, for detailed information.

There are 4000 characters remaining for the description.

ENTITY INTERNAL REPORT REFERENCE
This optional field allows your entity to include an internal file number or other reference information to
help you identify this report in your files. This information is not used by the Data Banks, but it will be
provided on copies of the report sent to queriers.
Entity Internal Report Reference (e.g., claim
number):

CUSTOMER USE
This optional field may be used by the submitter to identify this transaction. This information is
returned without modification and only appears on the response returned to your organization.
Customer Use:
Authorized Submitter's Name:
CERTIFICATION

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Authorized Submitter's Title:
Authorized Submitter's Phone:
Date:

Ext.
11/11/2010

Send e-mail notification when this and any future responses are available.
Check this box if you wish to add/update this subject in your subject database for use
in future queries and/or reports. Duplicate entries in your subject database may result in
duplicate queries. You will be notified of potential duplicate entries prior to completing
this subject entry.

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