Form 8 Professional Society

Entity: PRIVATE SECTOR ENTITY (FAIRFAX, VA) | User: user

REPORT INPUT FORM

PROFESSIONAL SOCIETY

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:

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

Drug Enforcement Administration (DEA) Numbers

Add another DEA Number

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:

OR

No License

Occupation/Field of
Licensure:
Add Additional License/Occupation

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
Date Action Was Taken:
(MMDDYYYY)
Date Action Became Effective:
(MMDDYYYY)
Length of Action:
Permanent
Indefinite/Unspecified
Specific Period
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:

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: PRIVATE SECTOR ENTITY (FAIRFAX, VA) | User: user

REPORT INPUT FORM

PROFESSIONAL SOCIETY

Report Correction

To submit a correction to previously submitted report DCN 7930000076906061, 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:

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

Drug Enforcement Administration (DEA) Numbers

Add another DEA Number

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:

OR

No License

Occupation/Field of
Licensure:
Add Additional License/Occupation

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
Clinical Privileges Restricted, Suspended or Revoked by Another Hospital
or Health Care Facility
Failure to Comply With Corrective Action Plan
Failure to Comply With Terms of Probation or other Previously Imposed
Requirements
Failure to Maintain Adequate or Accurate Records
Failure to Maintain Records or Provide Medical, Financial or Other
Required Information
License Revocation, Suspension or Other Disciplinary Action Taken by a
Federal, State or Local Licensing Authority
Practicing Beyond the Scope of Practice
Practicing Beyond the Scope of Privileges
Practicing With an Expired License
Practicing Without a License
Practicing Without a Valid License
Surrendered License to Practice
Violation of By-Laws, Protocols or Guidelines
Violation of Code of Ethics

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
Date Action Was Taken:
(MMDDYYYY)
Date Action Became Effective:
(MMDDYYYY)
Length of Action:
Permanent
Indefinite/Unspecified
Specific Period
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:

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