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REPORT INPUT FORM
EXCLUSION/DEBARMENT
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
We have pre-populated the practitioner information from the most recent report. Please
review all pre-populated information for accuracy.
Personal Information
Practitioner Name
Last Name
SMITH
First Name
JOHN
Add another name used
Gender
Male
Female
Unknown
Birth Date (MMDDYYYY)
05051950
Is Subject Deceased?
No
Unknown
Yes
Middle Name
Suffix (Jr, III)
Home Address/Address of Record
Street Address:
Address Line 2:
City:
CHOOSE ONE FROM LIST
State:
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:
GENERAL HOSPITAL
Type:
Click
301 General/Acute Care Hospital
for information on filling out non-U.S. and military addresses.
Address
Street Address:
123 FAKE STREET
Address Line 2:
City:
FAIRFAX
State:
VA Virginia
ZIP Code:
22030
-
Country:
(if U.S., leave blank)
Social Security Numbers (SSN)
*****2333
Add another SSN
Edit
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:
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
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.
Criminal Conviction
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
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.
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.
01/31/2013
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.
Submit to Data Bank
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Store as a Draft
Return to Options
Entity: TEST ENTITY (FAIRFAX, VA) | User: user
Sign Out
REPORT INPUT FORM
EXCLUSION/DEBARMENT
Report Correction
To submit a correction to previously submitted report DCN 7930000076905924, 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
Personal Information
Practitioner Name
Last Name
SMITH
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:
Address Line 2:
City:
State:
CHOOSE ONE FROM LIST
ZIP Code:
-
Country:
(if U.S., leave blank)
Work Information
Check here if the practitioner's work information is the same as your organization.
Organization
Name:
GENERAL HOSPITAL
Type:
Click
301 General/Acute Care Hospital
for information on filling out non-U.S. and military addresses.
Address
Street Address:
123 FAKE STREET
Address Line 2:
City:
FAIRFAX
State:
VA Virginia
ZIP Code:
22030
-
Country:
(if U.S., leave blank)
Social Security Numbers (SSN)
*****2333
Add another SSN
Edit
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:
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
addresses.
Name of
Affiliated/Associated
Health Care Entity:
for information on filling out non-U.S. and military
Address
Street Address:
Address Line 2:
City:
State:
CHOOSE ONE FROM LIST
ZIP Code:
-
Country:
(if U.S., leave blank)
Nature of Subject's
Relationship to
Affiliate:
Add another Affiliate
CHOOSE ONE FROM LIST
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.
Criminal Conviction
Conviction
Relating to Controlled Substances
Conviction
Relating to Fraud
Conviction
Relating to Obstruction of an Investigation
Conviction
Relating to Patient Abuse or Neglect
Criminal
Conviction - Not Classified
Felony
Conviction Relating to Controlled Substance Violations
Felony
Conviction Relating to Health Care Fraud
Program-Related
Other
Clear
Conviction
Add Additional Basis for Action
Adverse Action Information
Name of Agency or Program that Took
the Adverse Action Specified in This
Report:
AGENCY
Date Action Was Taken:
(MMDDYYYY)
01012013
Date Action Became Effective:
(MMDDYYYY)
01022013
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
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.
DESCRIPTION OF SUBJECT'S ACTS
There are 3971 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.
01/31/2013
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
Entity: MALPRACTICE ENTITY (FAIRFAX, VA) | User: user
REPORT INPUT FORM
EXCLUSION/DEBARMENT
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.
Criminal Conviction
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
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.
02/01/2013
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: MALPRACTICE ENTITY (FAIRFAX, VA) | User: user
REPORT INPUT FORM
EXCLUSION/DEBARMENT
Report Correction
To submit a correction to previously submitted report DCN 7930000076906052, 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.
Criminal Conviction
Conviction Relating to Controlled Substances
Conviction Relating to Fraud
Conviction Relating to Obstruction of an Investigation
Conviction Relating to Patient Abuse or Neglect
Criminal Conviction - Not Classified
Felony Conviction Relating to Controlled Substance Violations
Felony Conviction Relating to Health Care Fraud
Program-Related Conviction
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
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.
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:
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.
| File Type | application/pdf |
| Author | hannonn |
| File Modified | 2013-03-22 |
| File Created | 2013-03-22 |