3 60.10: Adverse Actions - Peer Review Organizations

Report Input Form

https://cajal:460/servlet/WebInputServlet?ACTION_TYPE=7&FORM...

PEER REVIEW ORGANIZATION

Individual 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
Subject Name:
Last Name

First Name

Middle Name

Suffix (e.g., Jr, III)

Other Names Used (Last Name and First Name Required):
Last Name
First Name
Middle Name

Suffix (e.g., Jr, III)

1.
2.
3.
4.
5.

Gender:
Birth
Date(MMDDYYYY):
Work Organization
Name:
Organization Type:

1 of 6

Male

Female

Unknown

11/11/2010 3:15 PM

Report Input Form

https://cajal:460/servlet/WebInputServlet?ACTION_TYPE=7&FORM...

Description (if 'Other' was selected above):

ADDRESSES
Click

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

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

-

Country (if U.S., leave
blank):
Home Address/Address of
Record
Street Address:
Address Line 2:
City:
State:
ZIP Code:

-

Country (if U.S., leave
blank):
Is Subject Deceased?

No

Unknown

Yes--Deceased Date (MMDDYYYY)

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

2.

3.

4.

FEDERAL EMPLOYER IDENTIFICATION NUMBERS (FEIN)
1.

2.

3.

4.

NATIONAL PROVIDER IDENTIFIERS (NPI)
1.

2 of 6

2.

11/11/2010 3:15 PM

Report Input Form

3.

https://cajal:460/servlet/WebInputServlet?ACTION_TYPE=7&FORM...

4.

DRUG ENFORCEMENT ADMINISTRATION (DEA) NUMBERS
1.

2.

3.

4.

UNIQUE PHYSICIAN IDENTIFICATION NUMBERS (UPIN)
1.

2.

3.

4.

PROFESSIONAL SCHOOLS ATTENDED
The form will suggest medical schools as you type. Please choose the matching
school or enter the complete school name.
School Name:

Year of
Graduation
(Format YYYY):

1.
2.
3.
4.
5.

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

No License

State of Licensure:
Occupation/Field of
Licensure:
Description (complete only if 'Other' is selected above):

Specialty:

3 of 6

11/11/2010 3:15 PM

Report Input Form

https://cajal:460/servlet/WebInputServlet?ACTION_TYPE=7&FORM...

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:

-

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

FINDING INFORMATION

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

Fraud, Deception, or Misrepresentation
Unsafe Practice or Substandard Care
Other

Type of Negative Finding:

4 of 6

1830 -

Recommendation to Sanction

11/11/2010 3:15 PM

Report Input Form

https://cajal:460/servlet/WebInputServlet?ACTION_TYPE=7&FORM...

1889 -

Other Finding - Not Classified, Specify

Date of Finding (MMDDYYYY):

Description of Finding:
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:

CERTIFICATION

5 of 6

11/11/2010 3:15 PM

Report Input Form

https://cajal:460/servlet/WebInputServlet?ACTION_TYPE=7&FORM...

I certify that I am authorized to submit this transaction and that all information is true and correct to the
best of my knowledge.
Authorized Submitter's Name:
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.

6 of 6

11/11/2010 3:15 PM