Form 19 Self-Query on an Individual

SUBJECT INFORMATION

Subject
Information

Output
Options

Payment
Information

Verify Your
Identity

INDIVIDUAL SELF-QUERY INSTRUCTIONS
DO NOT PRINT OR NOTARIZE THIS FORM. If required, a printable copy will be made available to you
later during the process.
Hide Confidentiality of Information Statement
Confidentiality of Information
Persons and entities that receive confidential information from the Data Bank, either directly or
indirectly from another party, must use it solely with respect to the purpose for which it was
provided. Any person who violates the confidentiality provisions of the Data Bank shall be
subject to a civil penalty for each violation.
In compliance with the Privacy Act, the results of an individual self-query are sent only to the
practitioner's home or work address as certified on the self-query form. Individual health care
practitioners who obtain information about themselves from the Data Bank are permitted to share
that information with anyone they choose.

Hide Public Burden Statement
Public Burden Statement
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 25 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

First Name

Add another name used

Gender
Male

Female

Birth Date (MMDDYYYY)

Middle Name

Suffix (Jr, III)

Home or Work Address

Organization
Name:
Type:

Enter the address (home or work) to which you would like your response sent. The Data Bank is
prohibited by law from sending a self-query response to a third party.
Note: If specifying a work address, be sure to include the employer name in the first line of the
address.
Address
Street Address:
Address Line 2:
City:
State:
ZIP Code:

-

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

Telephone:

Ext.

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
Year of
Graduation (YYYY)

School Name:
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