Form 6 Accreditation

Entity: ACCREDITATION ENTITY (FAIRFAX, VA) | User: user

REPORT INPUT FORM

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 # 0915-0331 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 (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

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Organization Information
Organization Name

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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)

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Drug Enforcement Administration (DEA) Numbers

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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)

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

Non-Compliance
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.
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.
02/01/2013

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: ACCREDITATION ENTITY (FAIRFAX, VA) | User: user

REPORT INPUT FORM

ACCREDITATION

Report Correction

To submit a correction to previously submitted report DCN 7930000076906058, 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 (NPDB). 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.

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)
Edit
Add another SSN

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

Non-Compliance
Noncompliance with Private Accreditation Standards That Indicate a Risk
to the Safety of Patient(s) or Quality of Health Care Services

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.
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.
02/01/2013

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