Form 4 DEA/Federal Licensure

Entity: ABC (FAIRFAX, VA) | User: admin1234

REPORT INPUT FORM

DEA/FEDERAL LICENSURE

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 # 0915-0239 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 (HIPDB), 0915-0126 (NPDB) and 0915-0331
(NPDB). Public reporting burden for this collection of information is estimated to average 45 minutes to
complete the forms, 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.
PRACTITIONER INFORMATION

Sign Out

Personal Information
Practitioner Name
Last Name

First Name

Middle Name

Add another name used

Gender
Male

Female

Unknown

Birth Date (MMDDYYYY)

Is Subject Deceased?
No

Unknown

Yes

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

-

Suffix (Jr, III)

Work Information
Check here if the practitioner's work information is the same as your organization.
Organization
Name:
Type:

Click

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

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

-

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

Social Security Numbers (SSN)

Add another SSN

Individual Taxpayer Identification Numbers (ITIN)

Add another ITIN

Federal Employer Identification Numbers (FEIN)

Add another FEIN

National Provider Identifiers (NPI)

Add another NPI

Drug Enforcement Administration (DEA) Numbers

Add another DEA Number

Unique Physician Identification Numbers (UPIN)

Add another UPIN

Professional Schools Attended
The form will suggest schools as you type. Please choose the matching school or enter the
complete school name.
Year of
School Name:
Graduation (YYYY)
Add another Professional School

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:
State of Licensure:
Occupation/Field of
Licensure:
Specialty:
Add Additional License/Occupation

OR

No License

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. Click
for information on filling out non-U.S. and military
addresses.
Name of
Affiliated/Associated
Health Care Entity:
Address
Street Address:
Address Line 2:
City:
State:
ZIP Code:

-

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

Nature of Subject's
Relationship to
Affiliate:
Add another Affiliate

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 5 basis for action
selections. View a complete basis for action list.
1.

Non-Compliance With Requirements
Criminal Conviction or Adjudication
Confidentiality, Consent or Disclosure Violations
Misconduct or Abuse
Fraud, Deception, or Misrepresentation
Unsafe Practice or Substandard Care
Improper Supervision or Allowing Unlicensed Practice
Improper Prescribing, Dispensing, Administering Medication/Drug
Violation
Other
Clear
Add Additional Basis for Action

Adverse Action Information
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
Is Reinstatement Automatic at Completion of Adverse Action Period?
Yes
Yes, with conditions (requires a Revision to Action Report when status changes)
No
Total Amount of Monetary Penalty,
Assessment and/or Restitution or fine: $
(Format NNNNN.NN)
Note: If no amount, leave this field blank.
Is the Action on Appeal?
Yes
No
Unknown
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 Bank, 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
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.
02/04/2013

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.

Entity: ABC (FAIRFAX, VA) | User: admin1234

REPORT INPUT FORM

DEA/FEDERAL LICENSURE

Report Correction

To submit a correction to previously submitted report DCN 7930000076906096, complete all
necessary modifications in the form below, and press Submit to Data Bank.
The report entered here will replace the original report, so please ensure that all known data is entered
in its entirety. Failure to provide sufficient information to permit identification of a single subject may
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 # 0915-0239 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 (HIPDB), 0915-0126 (NPDB) and 0915-0331
(NPDB). Public reporting burden for this collection of information is estimated to average 15 minutes to
complete the forms, 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.
PRACTITIONER INFORMATION

Sign Out

Personal Information
Practitioner Name
Last Name

First Name

Middle Name

Add another name used

Gender
Male

Female

Unknown

Birth Date (MMDDYYYY)

Is Subject Deceased?
No

Unknown

Yes

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

-

Suffix (Jr, III)

Work Information
Check here if the practitioner's work information is the same as your organization.
Organization
Name:
Type:

Click

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

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

-

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

Social Security Numbers (SSN)

Add another SSN

Individual Taxpayer Identification Numbers (ITIN)

Add another ITIN

Federal Employer Identification Numbers (FEIN)

Add another FEIN

National Provider Identifiers (NPI)

Add another NPI

Drug Enforcement Administration (DEA) Numbers

Add another DEA Number

Unique Physician Identification Numbers (UPIN)

Add another UPIN

Professional Schools Attended
The form will suggest schools as you type. Please choose the matching school or enter the
complete school name.
Year of
School Name:
Graduation (YYYY)
Add another Professional School

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:
State of Licensure:
Occupation/Field of
Licensure:
Specialty:
Add Additional License/Occupation

OR

No License

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. Click
for information on filling out non-U.S. and military
addresses.
Name of
Affiliated/Associated
Health Care Entity:
Address
Street Address:
Address Line 2:
City:
State:
ZIP Code:
Country:
(if U.S., leave
blank)

Nature of Subject's
Relationship to
Affiliate:
Add another Affiliate

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 5 basis for action
selections. View a complete basis for action list.
1.

Non-Compliance With Requirements
Default on Health Education Loan or Scholarship Obligations
Drug Screening Violation
Failure to Comply With Continuing Education or Competency
Requirements
Failure to Comply With Health and Safety Requirements
Failure to Cooperate With Board Investigation
Failure to Maintain Adequate or Accurate Records
Failure to Maintain Records or Provide Medical, Financial or Other
Required Information
Failure to Meet Licensing Board Reporting Requirements
Failure to Meet the Initial Requirements of a License
Failure to Pay Child Support/Delinquent Child Support
License Revocation, Suspension or Other Disciplinary Action Taken by a
Federal, State or Local Licensing Authority
Practicing Beyond the Scope of Practice
Practicing With an Expired License
Practicing Without a License
Practicing Without a Valid License
Violation of Federal or State Statutes, Regulations or Rules
Violation of Federal or State Tax Code
Violation of State Health Code
Violation of or Failure to Comply With Licensing Board Order

Criminal Conviction or Adjudication
Confidentiality, Consent or Disclosure Violations
Misconduct or Abuse
Fraud, Deception, or Misrepresentation
Unsafe Practice or Substandard Care
Improper Supervision or Allowing Unlicensed Practice
Improper Prescribing, Dispensing, Administering Medication/Drug
Violation
Other
Clear
Add Additional Basis for Action

Adverse Action Information
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
Is Reinstatement Automatic at Completion of Adverse Action Period?
Yes
Yes, with conditions (requires a Revision to Action Report when status changes)
No
Total Amount of Monetary Penalty,
Assessment and/or Restitution or fine: $
(Format NNNNN.NN)
Note: If no amount, leave this field blank.
Is the Action on Appeal?
Yes
No
Unknown
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.
TEST

There are 3996 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 Bank, 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
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.
02/04/2013

Send e-mail notification when this and any future responses are available.

Entity: ABC (FAIRFAX, VA) | User: admin1234

REPORT INPUT FORM

DEA/FEDERAL LICENSURE

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 # 0915-0239 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 (HIPDB), 0915-0126 (NPDB) and 0915-0331
(NPDB). Public reporting burden for this collection of information is estimated to average 45 minutes to
complete the forms, 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

Sign Out

Organization Information
Organization Name

Add another name used

Click

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

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

-

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

Type
Organization Type:

Federal Employer Identification Numbers (FEIN)

Add another FEIN

Social Security Numbers (SSN)

Add another SSN

Individual Taxpayer Identification Numbers (ITIN)

Add another ITIN

Drug Enforcement Administration (DEA) Numbers

Add another DEA Number

Clinical Laboratory Improvement Act (CLIA) Numbers

Add another CLIA Number

Federal Food and Drug Administration (FDA) Numbers

Add another FDA Number

National Provider Identifiers (NPI)

Add another NPI

Medicare Provider/Supplier Numbers

Add another Medicare Provider/Supplier Number

Organization State Licensure Information
(If no State License, check the 'No License' box.)
State License
Number:
State of Licensure:

OR

No License

Add another License

Principal Officers and Owners
Last Name

First Name

Middle Name

Add another Principal Officer or Owner

Suffix

Title

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. Click
for information on filling out non-U.S. and military
addresses.
Name of
Affiliated/Associated
Health Care Entity:
Address
Street Address:
Address Line 2:
City:
State:
ZIP Code:

-

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

Nature of Subject's
Relationship to
Affiliate:
Add another Affiliate

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 5 basis for action
selections. View a complete basis for action list.
1.

Non-Compliance With Requirements
Criminal Conviction or Adjudication
Confidentiality, Consent or Disclosure Violations
Conflict of Interest
Fraud, Deception, or Misrepresentation
Substandard Care or Patient Neglect/Abuse
Improper Supervision or Allowing Unlicensed Practice
Improper Prescribing, Dispensing, Administering Medication/Drug
Violation
Other
Clear
Add Additional Basis for Action

Adverse Action Information
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
Is Reinstatement Automatic at Completion of Adverse Action Period?
Yes
Yes, with conditions (requires a Revision to Action Report when status changes)
No
Total Amount of Monetary Penalty,
Assessment and/or Restitution or fine: $
(Format NNNNN.NN)
Note: If no amount, leave this field blank.
Is the Action on Appeal?
Yes
No
Unknown
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 Bank, 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
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.
02/04/2013

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.

Entity: ABC (FAIRFAX, VA) | User: admin1234

REPORT INPUT FORM

DEA/FEDERAL LICENSURE

Report Correction

To submit a correction to previously submitted report DCN 7930000076906098, complete all
necessary modifications in the form below, and press Submit to Data Bank.
The report entered here will replace the original report, so please ensure that all known data is entered
in its entirety. Failure to provide sufficient information to permit identification of a single subject may
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 # 0915-0239 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 (HIPDB), 0915-0126 (NPDB) and 0915-0331
(NPDB). Public reporting burden for this collection of information is estimated to average 15 minutes to
complete the forms, 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

Sign Out

Organization Information
Organization Name

Add another name used

Click

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

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

-

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

Type
Organization Type:

Federal Employer Identification Numbers (FEIN)

Add another FEIN

Social Security Numbers (SSN)

Add another SSN

Individual Taxpayer Identification Numbers (ITIN)

Add another ITIN

Drug Enforcement Administration (DEA) Numbers

Add another DEA Number

Clinical Laboratory Improvement Act (CLIA) Numbers

Add another CLIA Number

Federal Food and Drug Administration (FDA) Numbers

Add another FDA Number

National Provider Identifiers (NPI)

Add another NPI

Medicare Provider/Supplier Numbers

Add another Medicare Provider/Supplier Number

Organization State Licensure Information
(If no State License, check the 'No License' box.)
State License
Number:
State of Licensure:

OR

No License

Add another License

Principal Officers and Owners
Last Name

First Name

Middle Name

Add another Principal Officer or Owner

Suffix

Title

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. Click
for information on filling out non-U.S. and military
addresses.
Name of
Affiliated/Associated
Health Care Entity:
Address
Street Address:
Address Line 2:
City:
State:
ZIP Code:
Country:
(if U.S., leave
blank)

Nature of Subject's
Relationship to
Affiliate:
Add another Affiliate

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 5 basis for action
selections. View a complete basis for action list.
1.

Non-Compliance With Requirements
Exclusion or Suspension From a Federal or State Health Care Program
Failure to Comply With Health and Safety Requirements
Failure to Maintain Adequate or Accurate Records
Failure to Maintain Equipment/Missing or Inadequate Equipment
Failure to Maintain Records or Provide Medical, Financial or Other
Required Information
Failure to Maintain Supplies/Missing or Inadequate Supplies
Failure to Meet Licensing Board Reporting Requirements
Failure to Meet the Initial Requirements of a License
Failure to Take Corrective Action
Financial Insolvency
Lack of Appropriately Qualified Professionals
License Revocation, Suspension or Other Disciplinary Action Taken by a
Federal, State or Local Licensing Authority
Operating Beyond Scope of License
Operating Without a License or Permits or on a Lapsed License
Violation of Federal or State Statutes, Regulations or Rules
Violation of State Health Code
Violation of or Failure to Comply With Licensing Board Order

Criminal Conviction or Adjudication
Confidentiality, Consent or Disclosure Violations
Conflict of Interest
Fraud, Deception, or Misrepresentation
Substandard Care or Patient Neglect/Abuse
Improper Supervision or Allowing Unlicensed Practice
Improper Prescribing, Dispensing, Administering Medication/Drug
Violation
Other
Clear
Add Additional Basis for Action

Adverse Action Information
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
Is Reinstatement Automatic at Completion of Adverse Action Period?
Yes
Yes, with conditions (requires a Revision to Action Report when status changes)
No
Total Amount of Monetary Penalty,
Assessment and/or Restitution or fine: $
(Format NNNNN.NN)
Note: If no amount, leave this field blank.
Is the Action on Appeal?
Yes
No
Unknown
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.
TEST

There are 3996 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 Bank, 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
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.
02/04/2013

Send e-mail notification when this and any future responses are available.