Form 27 Agent Registration (Renewal & Update)

Entity: ABC (FAIRFAX, VA) | User: admin1234

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RENEW AGENT REGISTRATION

Organization
Information

Print
Registration

Final Steps

Complete this form to renew your registration as an authorized agent to query and/or report to the
NPDB, the HIPDB, or both, on behalf of eligible, registered entities.
All agents must review and sign this registration form to ensure knowledge of and compliance with the confidentiality
requirements of Public Law 99-660, the Health Care Quality Improvement Act of 1986, as amended; Public Law 100-93,
Section 5[b] of the Medicare and Medicaid Patient and Program Protection Act of 1987, as amended by Public Law
101-508, Omnibus Budget Reconciliation Act of 1990; and/or Public Law 104-191, the Health Insurance Portability and
Accountability Act of 1996, as amended; that applies to information submitted to the NPDB-HIPDB. Review each of
these statutes and regulations prior to submitting your agent registration renewal.

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 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.
AGENT IDENTIFICATION INFORMATION
Agent Organization Name:
Department or Office to Which Mail
Should be Addressed:
Street Address:
Address Line 2:
City:
State:
ZIP Code:
Country (if U.S., leave blank):

-

Department Fax Number:
Taxpayer Identification Number (TIN):
AUTHORIZED AGENT REQUIREMENTS
As an agent authorized to report and query the National Practitioner Data Bank (NPDB) and the Healthcare Integrity
and Protection Data Bank (HIPDB) on behalf of an eligible entity, I certify that the organization has read and
understands the provisions of Public Law 99-660, as amended; the NPDB regulation (45 CFR Part 60);
Public Law 100-93, as amended by Public Law 101-508; and/or the HIPDB regulation (45 CFR Part 61),
Public Law 104-191, as amended; and that I will meet and comply with the following requirements:
I am authorized to conduct business in my State.

My facilities are secure to ensure the confidentiality of NPDB-HIPDB information.
I understand and can comply with the technical requirements for electronically reporting to and querying the
NPDB-HIPDB, as provided by the NPDB-HIPDB and/or guidance distributed by the NPDB-HIPDB.
I will use my own password and DBID to report and query on behalf of my NPDB-HIPDB client.
I understand that I must query the NPDB and/or the HIPDB separately for each entity on whose behalf I am
authorized to query. My agreement(s) with the entity(ies) I represent explicitly prohibits me from using information
obtained from the NPDB-HIPDB other than the purpose for which the disclosure was made.
I will not use a single query response for a particular practitioner, provider, or supplier on behalf of more than one
entity.
To my knowledge, the information I am submitting is accurate and truthful.
I will keep registration information concerning my organization in the NPDB-HIPDB up-to-date; and I will delete
NPDB-HIPDB query and report information from my organization's database that I provided or obtained on behalf
of any entity for whom I am no longer acting as agent.
I understand that I must query the NPDB and/or the HIPDB separately for each entity on whose behalf I am
authorized to query. My agreement(s) with the entity(ies) I represent explicitly prohibits me from using information
obtained from the NPDB-HIPDB other than the purpose for which the disclosure was made.
CERTIFYING OFFICIAL
The certifying official is the individual selected and empowered by an agent to certify the legitimacy of registration for
participation in the NPDB and HIPDB.
By completing this registration, the certifying official is agreeing to the following:
The agent being registered satisfies the requirements as specified above.
If he or she does not comply with the stated requirements, his or her status as an authorized agent with the
NPDB-HIPDB may be suspended or revoked by the Government.
Any omission, misrepresentation, or falsification of any information contained in this form or contained in any
communication supplying information to the NPDB-HIPDB to complete or clarify this form may be punishable by
criminal, civil, or other administrative actions including fines, penalties, and/or imprisonment under Federal law.
Notice: 18 U.S.C. §1001 authorizes criminal penalties against whomever in any matter within the jurisdiction of the
executive, legislative, or judicial branch of the Government, knowingly and willfully falsifies, conceals, or covers-up by
any trick, scheme, or writing or document knowing the same to contain any materially false, fictitious, or fraudulent
statement or entry. Individual offenders are subject to fines of up to $250,000 and imprisonment for up to 5
years. Offenders that are organizations are subject to fines of up to $500,000. 18 U.S.C.§3571, Section 3571 (d)
also authorizes fines of up to the greater of twice the gross gain derived by the offender or twice the gross loss
sustained by another as a result of the offense.
Check this box if the certifying official differs from the individual list below.

First Name

Middle Initial Last Name

Name of Certifying Official:
Title of Certifying Official:
Telephone:

Ext.

E-mail Address:

john@test.com

Confirm E-mail Address:

john@test.com

Employee ID:

Contact Us

Entity: AGENT INC (NEW BERLIN, WI) | User: JohnSmith

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UPDATE AGENT PROFILE

To update agent registration information, complete the fields that require a change, then click Submit to
Data Bank.
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.
AGENT IDENTIFICATION INFORMATION
Agent Organization Name:
Department or Office to Which Mail
Should be Addressed:
Street Address:

AGENT INC

123 FAKE STREET

Address Line 2:
City:
State:
ZIP Code:

FAIRFAX
VA Virginia

22033



-

Country (if U.S., leave blank):
Department Fax Number:
Taxpayer Identification Number (TIN):

987654321

AUTHORIZED AGENT REQUIREMENTS
As an agent authorized to report and query the National Practitioner Data Bank (NPDB) on behalf of an eligible entity, I
certify that the organization has read and understands the provisions of Public Law 99-660, as amended; the NPDB
regulation (45 CFR Part 60); Public Law 100-93, as amended by Public Law 101-508; Public Law 104-191, as amended;
and that I will meet and comply with the following requirements:


I am authorized to conduct business in my State.



My facilities are secure to ensure the confidentiality of NPDB information.



I understand and can comply with the technical requirements for electronically reporting to and querying the NPDB,
as provided by the NPDB and/or guidance distributed by the NPDB.



I will use my own password and DBID to report and query on behalf of my NPDB client.



I understand that I must query the NPDB separately for each entity on whose behalf I am authorized to query. My
agreement(s) with the entity(ies) I represent explicitly prohibits me from using information obtained from the NPDB
other than the purpose for which the disclosure was made.



I will not use a single query response for a particular practitioner, provider, or supplier on behalf of more than one
entity.



To my knowledge, the information I am submitting is accurate and truthful.



I will keep registration information concerning my organization in the NPDB up-to-date; and I will delete NPDB
query and report information from my organization's database that I provided or obtained on behalf of any entity for
whom I am no longer acting as agent.



I understand that I must query the NPDB separately for each entity on whose behalf I am authorized to query. My
agreement(s) with the entity(ies) I represent explicitly prohibits me from using information obtained from the NPDB
other than the purpose for which the disclosure was made.

CERTIFYING OFFICIAL
The certifying official is the individual selected and empowered by an agent to certify the legitimacy of registration for
participation in the NPDB.
By completing this registration, the certifying official is agreeing to the following:


The agent being registered satisfies the requirements as specified above.



If he or she does not comply with the stated requirements, his or her status as an authorized agent with the NPDB
may be suspended or revoked by the Government.



Any omission, misrepresentation, or falsification of any information contained in this form or contained in any
communication supplying information to the NPDB to complete or clarify this form may be punishable by criminal,
civil, or other administrative actions including fines, penalties, and/or imprisonment under Federal law.

Notice: 18 U.S.C. §1001 authorizes criminal penalties against whomever in any matter within the jurisdiction of the
executive, legislative, or judicial branch of the Government, knowingly and willfully falsifies, conceals, or covers-up by
any trick, scheme, or writing or document knowing the same to contain any materially false, fictitious, or fraudulent
statement or entry. Individual offenders are subject to fines of up to $250,000 and imprisonment for up to 5 years.
Offenders that are organizations are subject to fines of up to $500,000. 18 U.S.C.§3571, Section 3571 (d) also
authorizes fines of up to the greater of twice the gross gain derived by the offender or twice the gross loss
sustained by another as a result of the offense.






Check this box if the certifying official differs from the individual list below.

First Name

Middle Initial

Last Name

Name of Certifying Official:
Title of Certifying Official:

JOHN
MANAGER

C

SMITH

Telephone:

7035551234

E-mail Address:

john@smith.com

Confirm E-mail Address:

john@smith.com

Ext.

Employee ID:
Submit to Data Bank

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