Form 5 Peer Review Organization

Entity: QIO ENTITY (CENTREVILLE, VA) | User: JohnSmith

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REPORT INPUT 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 # 0915-0331 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 number for this project is 0915-0331. 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.

PRACTITIONER INFORMATION
Personal Information
Practitioner Name
Last Name
DOE

First Name
JOHN

Add another name used

Gender
 Male 




 Female 



 Unknown




Birth Date (MMDDYYYY)

Is Subject Deceased?
 No





 Unknown





 Yes





Home Address/Address of Record
Street Address:

Middle Name

Suffix (Jr, III)

Address Line 2:
City:
State:

CHOOSE ONE FROM LIST

ZIP Code:



-

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

Work Information
here if the practitioner's work information is the same as your organization.

 Check





Organization
Name:
Type:

Click

CHOOSE ONE FROM LIST



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

Address
Street Address:
Address Line 2:
City:
State:

CHOOSE ONE FROM LIST

ZIP Code:

-

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

Social Security Numbers (SSN)
Add another SSN

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:

OR

State of Licensure:

CHOOSE ONE FROM LIST

Occupation/Field of
Licensure:

Physician (MD)

CHOOSE ONE FROM LIST
Specialty:
Add Additional License/Occupation







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:
CHOOSE ONE FROM LIST

State:
ZIP Code:



-

Country:
(if U.S., leave blank)
Nature of Subject's
Relationship to
Affiliate:
Add another Affiliate

CHOOSE ONE FROM LIST



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
Clear

Add Additional Basis for Action

Finding Information
Type of Negative
Finding:












1830 - Recommendation to Sanction
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.
Spell Check

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: DEVELOPER
Authorized Submitter's Title:

DEVELOPER

Authorized Submitter's Phone: 7035551212
Date:

Ext.

12/03/2012







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.

Submit to Data Bank

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Store as a Draft

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Entity: QIO ENTITY (CENTREVILLE, VA) | User: JohnSmith

Sign Out

REPORT INPUT FORM
PEER REVIEW ORGANIZATION
Report Correction
To submit a correction to previously submitted report DCN 7940000075353282, 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 # 0915-0331 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 number for this project is 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.

PRACTITIONER INFORMATION
Personal Information
Practitioner Name
Last Name
DOE

First Name
JOHN

Add another name used

Gender
 Male 





 Female 



 Unknown




Birth Date (MMDDYYYY)
05051950

Is Subject Deceased?
 No






 Unknown





 Yes





Home Address/Address of Record

Middle Name

Suffix (Jr, III)

Street Address:

123 FAKE STREET

Address Line 2:
City:

FAIRFAX

State:

VA Virginia

ZIP Code:

22030



-

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

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

Click

CHOOSE ONE FROM LIST



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

Address
Street Address:
Address Line 2:
City:
CHOOSE ONE FROM LIST

State:
ZIP Code:

-

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

Social Security Numbers (SSN)
*****6789
Add another SSN

Edit

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)
COLLEGE
2000
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:

123ABC

State of Licensure:

AL Alabama

Occupation/Field of
Licensure:

Physician (MD)

Aerospace Medicine
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:
CHOOSE ONE FROM LIST

State:
ZIP Code:



-

Country:
(if U.S., leave blank)
Nature of Subject's
Relationship to
Affiliate:
Add another Affiliate

CHOOSE ONE FROM LIST



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




 Improper






or Abusive Billing Practices

 Submitting















False Claims

Unsafe Practice or Substandard Care
Other
Clear

Add Additional Basis for Action

Finding Information
Type of Negative
Finding:
Date of Finding:
(MMDDYYYY)













1830 - Recommendation to Sanction
1889 - Other Finding - Not Classified, Specify

05052012

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.
DESCRIPTION OF FINDING

There are 3978 characters remaining for the description.
Spell Check

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: DEVELOPER
Authorized Submitter's Title:

DEVELOPER

Authorized Submitter's Phone: 7035551212
Date:







Ext.

12/03/2012

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

Submit to Data Bank

Validate Without Submitting

Store as a Draft

Return to Options