Form 2 Medical Malpractice Payment

the

DataBank

DCN: 5950000090960752
Process Date: 11/25/2014
Page: 1
of
3
MANN, ANITTA
For authorized use by:
LICENSING BOARD

P.O. Box 10832
Chantilly, VA 20153-0832
http://www.npdb.hrsa.gov

MANN, ANITTA
LICENSING BOARD
MEDICAL MALPRACTICE PAYMENT REPORT
Initial Action
- SETTLEMENT

A. REPORTING
ENTITY

C. INFORMATION
REPORTED

Basis for Initial Action
- FAILURE TO USE ASEPTIC TECHNIQUE
- FAILURE TO DIAGNOSE

Entity Name:
Address:
City, State, Zip:
Country:
Name or Office:
Title or Department:
Telephone:
Entity Internal Report Reference:
Type of Report:

Subject Name:
Other Name(s) Used:
Gender:
Date of Birth:
Organization Name:
Work Address:
City, State, ZIP:
Home Address:
City, State, ZIP:
Deceased:
Social Security Numbers (SSN):
Professional School(s) & Year(s) of Graduation:
Occupation/Field of Licensure (Code):
State License Number, State of Licensure:
Drug Enforcement Administration (DEA) Numbers:
Hospital Affiliation(s):

B. SUBJECT
IDENTIFICATION
INFORMATION
(INDIVIDUAL)

Date of Action: 11/25/2014

LICENSING BOARD
123 CEDAR LANE
ROCKVILLE, MD 20857-0001
JANET DOE
BOARD OFFICIAL
(555) 555-5555
INITIAL
MANN, ANITTA
FEMALE
01/01/1982
LICENSING BOARD
123 CEDAR LANE
ROCKVILLE, MD 20857-0001
5600 FISHERS LN
ROCKVILLE, MD 20852-1750
NO
***-**-1111
UNIVERSITY OF THE FOOT (2006)
PODIATRIST
SL56, MD
AM111111111

Date of Report: 11/25/2014
Relationship of Entity to
This Practitioner: INSURANCE COMPANY - PRIMARY INSURER
PAYMENTS BY THIS PAYER FOR THIS PRACTITIONER
Amount of This Payment
for This Practitioner: $ 1.00
Date of This Payment: 11/25/2014
This Payment Represents: A SINGLE FINAL PAYMENT
Total Amount Paid or to Be Paid by
This Payer for This Practitioner: $ 1.00
Payment Result of: SETTLEMENT
Date of Judgment or Settlement, if Any: 11/25/2014
Adjudicative Body Case Number:
Adjudicative Body Name:

CONFIDENTIAL DOCUMENT - FOR AUTHORIZED USE ONLY

the

DataBank

P.O. Box 10832
Chantilly, VA 20153-0832
http://www.npdb.hrsa.gov

DCN: 5950000090960752
Process Date: 11/25/2014
Page: 2
of
3
MANN, ANITTA
For authorized use by:
LICENSING BOARD

Court File Number:
Description of Judgment or Settlement and Any
Conditions, Including Terms of Payment: DID NOT PROPERLY CARE FOR FOOT.
PAYMENTS BY THIS PAYER FOR OTHER PRACTITIONERS IN THIS CASE
Total Amount Paid or to Be Paid by This Payer for All
Practitioners in This Case:
Number of Practitioners for Whom This Payer Has Paid
or Will Pay in This Case:
PAYMENTS BY OTHERS FOR THIS PRACTITIONER
Has a State Guaranty Fund or State Excess Judgment Fund
Made a Payment for This Practitioner in This Case, or Is Such a
Payment Expected to Be Made?:
Amount Paid or Expected to Be Paid by the State Fund:
Has a Self-Insured Organization and/or Other Insurance
Company/Companies Made Payment(s) for This Practitioner in
This Case, or Is/Are Such Payment(s) Expected to Be Made?:
Amount Paid or Expected to Be Paid by Self-Insured
Organization(s) and/or Other Insurance Company/Companies:
CLASSIFICATION OF ACT(S) OR OMISSION(S)
Patient's Age at Time of Initial Event: UNKNOWN
Patient's Gender: UNKNOWN
Patient Type: UNKNOWN
Description of the Medical Condition With Which the Patient
Presented for Treatment: DID NOT HAVE A GOOD FOOT.
Description of the Procedure Performed: LOOKED AT FOOT.
Nature of Allegation: BEHAVIORAL HEALTH RELATED (100)
Specific Allegation: FAILURE TO USE ASEPTIC TECHNIQUE (100)
Date of Event Associated With Allegation or Incident: 11/24/2014
Specific Allegation: FAILURE TO DIAGNOSE (101)
Date of Event Associated With Allegation or Incident: 11/24/2014
Outcome: EMOTIONAL INJURY ONLY (01)
Description of the Allegations and Injuries or Illnesses Upon
Which the Action or Claim Was Based: PATIENT WAS REALLY UPSET.

D. SUBJECT
STATEMENT

If the subject identified in Section B of this report has submitted a statement, it appears in this section.

E. REPORT STATUS

Unless a box below is checked, the subject of this report identified in Section B has not contested this report.
This report has been disputed by the subject identified in Section B.
At the request of the subject identified in Section B, this report is being reviewed by the Secretary of the
U.S. Department of Health and Human Services to determine its accuracy and/or whether it complies with
reporting requirements. No decision has been reached.
At the request of the subject identified in Section B, this report was reviewed by the Secretary of the U.S.
Department of Health and Human Services and a decision was reached. The subject has requested that
the Secretary reconsider the original decision.

CONFIDENTIAL DOCUMENT - FOR AUTHORIZED USE ONLY

the

DataBank

DCN: 5950000090960752
Process Date: 11/25/2014
Page: 3
of
3
MANN, ANITTA
For authorized use by:
LICENSING BOARD

P.O. Box 10832
Chantilly, VA 20153-0832
http://www.npdb.hrsa.gov

At the request of the subject identified in Section B, this report was reviewed by
the Secretary of the U.S. Department of Health and Human Services. The Secretary’s decision
is shown below:
Date of Original Submission:

11/25/2014

Date of Most Recent Change:

11/25/2014

This report is maintained under the provisions of: Title IV
The information contained in this report is maintained by the National Practitioner Data Bank for restricted use under the
provisions of Title IV of Public Law 99-660, as amended, and 45 CFR Part 60. All information is confidential and may be used only
for the purpose for which it was disclosed. Disclosure or use of confidential information for other purposes is a violation of federal
law. For additional information or clarification, contact the reporting entity identified in Section A.
END OF REPORT

CONFIDENTIAL DOCUMENT - FOR AUTHORIZED USE ONLY