Form 20 Self-Query on an Organization

SUBJECT INFORMATION

Subject
Information

Output
Options

Payment
Information

Verify Your
Identity

ORGANIZATION 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 organization self-query are sent only to the
organization's address as certified on the self-query form. Health care organizations that 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.

SUBJECT INFORMATION
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:
Add another License

OR

No License

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.
01/30/2013