Form 22 Subject Statement and Dispute

Sign Out

SUBJECT STATEMENT AND DISPUTE

To add, modify, or remove a statement to the Report referenced below, and/or to place the Report in, or withdraw the
Report from, disputed status, complete the appropriate section(s) below, and click Submit to the Data Bank. You will
receive an on-line confirmation message regarding this transaction. The reporting entity and any queriers who received
a previous version of the Report will receive a copy noting the modifications.
Report Type:
Report Number:
Subject's Name:
Report Maintained Under:

STATE LICENSURE ACTION
5500000034475697
SMITH, JOHN
[X] Title IV
[X] Section 1921
[X] Section 1128E

SUBJECT STATEMENT
As the subject of the referenced report, you have the right to include a statement expressing your view of the action
described in the report. The statement becomes part of the report and is disclosed to authorized queriers. To add a
statement, type the statement in the designated area below exactly as you wish it to appear in the report. To substitute
an existing statement with a new one, modify the statement in the designated area below exactly as you wish it to
appear in the report. (If you have a statement on file, it will appear below.) Your statement must be in English and may
not exceed 4,000 characters, including spaces and punctuation. If you add a statement to the report, it will be
formatted in a block style; paragraph breaks cannot be included.
Note: Patient information is confidential. Do NOT include identifying information (names, addresses, etc.)
about patients or other persons in your statement. All Subject Statements are reviewed by the Data Bank to
determine whether they include individual names, addresses, or telephone numbers. If this information is
discovered, it will be removed and you will be sent an amended version.
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, 0915-0126 and 0915-0331. 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 Statement

There are 4000 characters remaining for the statement.
Spell Check

DISPUTE
You may dispute either the factual accuracy of the action described in the referenced report or whether the report was
submitted in accordance with Data Bank reporting requirements (e.g., was a reportable event). You may NOT dispute
the appropriateness of any action, finding or judgment, or information regarding the facts or circumstances that led to
the reported action. You also must contact the reporting entity or its agent, identified in Section A of the report, to
attempt to resolve disputed issues. (Do not contact the reporting entity for information about Data Bank reporting
requirements or operational procedures.) The report will remain in disputed status until either you take action to elevate
the report for Report Review or you withdraw the report from disputed status.
Information in Data Bank reports can be changed only by the entity that submitted the report or by the Secretary of the
U.S. Department of Health and Human Services following review. The report will remain in the Data Bank unchanged
until the reporting entity or the Secretary changes it.
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, 0915-0126 and 0915-0331. Public reporting burden for this collection of information is estimated
to average 5 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.
Dispute Options
The referenced report is currently NOT in disputed status.
 Check here if you wish to place the referenced report in disputed status. If you wish to add a statement to the




report only and do not wish to place the report in disputed status then do not check the box.

CURRENT ADDRESSES
Your profile will be updated to reflect the addresses below. However, you should be aware that this does not change
your mailing address as reflected in the report filed with the Data Bank.
Email Addresses
The email address you provide will only be used to provide you with notifications that new activity has occurred
concerning this report.
Email Address:

email@address.com

Confirm Email Address:

email@address.com

Add another
Home Address/Address of Record
123 FAKE STREET
Street Address:
Address Line 2:
City:

DENVER

State:
ZIP Code:

CO Colorado

12345



-

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

Work Address
Street Address:

123 FAKE COURT

Address Line 2:

SUITE 100

City:

DENVER

State:
ZIP Code:

CO Colorado

80206



-

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

Certification Data
I certify that I am the individual subject or the subject's duly appointed attorney for such matters
identified in Section B of the referenced report, or that I am the designated employee representing the
organization subject referenced in Section B, and I request that the action(s) above be taken.
Authorized Submitter's Name:
Authorized Submitter's Title:
Authorized Submitter's Phone:
Date:

Ext.
12/03/2012

Submit to Data Bank
Return to Report Response
Options

Sign Out

SUBJECT STATEMENT AND DISPUTE

To add, modify, or remove a statement to the Report referenced below, and/or to place the Report in, or withdraw the
Report from, disputed status, complete the appropriate section(s) below, and click Submit to the Data Bank. You will
receive an on-line confirmation message regarding this transaction. The reporting entity and any queriers who received
a previous version of the Report will receive a copy noting the modifications.
Report Type:
Report Number:
Subject's Name:
Report Maintained Under:

STATE LICENSURE ACTION
5500000034475697
ABC ORGANIZATION
[X] Title IV
[X] Section 1921
[X] Section 1128E

SUBJECT STATEMENT
As the subject of the referenced report, you have the right to include a statement expressing your view of the action
described in the report. The statement becomes part of the report and is disclosed to authorized queriers. To add a
statement, type the statement in the designated area below exactly as you wish it to appear in the report. To substitute
an existing statement with a new one, modify the statement in the designated area below exactly as you wish it to
appear in the report. (If you have a statement on file, it will appear below.) Your statement must be in English and may
not exceed 4,000 characters, including spaces and punctuation. If you add a statement to the report, it will be
formatted in a block style; paragraph breaks cannot be included.
Note: Patient information is confidential. Do NOT include identifying information (names, addresses, etc.)
about patients or other persons in your statement. All Subject Statements are reviewed by the Data Bank to
determine whether they include individual names, addresses, or telephone numbers. If this information is
discovered, it will be removed and you will be sent an amended version.
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, 0915-0126 and 0915-0331. 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 Statement

There are 4000 characters remaining for the statement.
Spell Check

DISPUTE
You may dispute either the factual accuracy of the action described in the referenced report or whether the report was
submitted in accordance with Data Bank reporting requirements (e.g., was a reportable event). You may NOT dispute
the appropriateness of any action, finding or judgment, or information regarding the facts or circumstances that led to
the reported action. You also must contact the reporting entity or its agent, identified in Section A of the report, to
attempt to resolve disputed issues. (Do not contact the reporting entity for information about Data Bank reporting
requirements or operational procedures.) The report will remain in disputed status until either you take action to elevate
the report for Report Review or you withdraw the report from disputed status.
Information in Data Bank reports can be changed only by the entity that submitted the report or by the Secretary of the
U.S. Department of Health and Human Services following review. The report will remain in the Data Bank unchanged
until the reporting entity or the Secretary changes it.
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, 0915-0126 and 0915-0331. Public reporting burden for this collection of information is estimated
to average 5 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.
Dispute Options
The referenced report is currently NOT in disputed status.
 Check here if you wish to place the referenced report in disputed status. If you wish to add a statement to the




report only and do not wish to place the report in disputed status then do not check the box.

CURRENT ADDRESSES
Your profile will be updated to reflect the addresses below. However, you should be aware that this does not change
your mailing address as reflected in the report filed with the Data Bank.
Email Addresses
The email address you provide will only be used to provide you with notifications that new activity has occurred
concerning this report.
Email Address:

email@address.com

Confirm Email Address:

email@address.com

Add another
Work Address
Street Address:

123 FAKE COURT

Address Line 2:

SUITE 100

City:

DENVER

State:
ZIP Code:

CO Colorado

80206



-

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

Certification Data
I certify that I am the individual subject or the subject's duly appointed attorney for such matters
identified in Section B of the referenced report, or that I am the designated employee representing the
organization subject referenced in Section B, and I request that the action(s) above be taken.
Authorized Submitter's Name:
Authorized Submitter's Title:
Authorized Submitter's Phone:
Date:

Ext.
12/03/2012

Submit to Data Bank
Return to Report Response
Options