Form 26 Agent Registration (Initial)

the

DataBank

P.O. Box 10832
Chantilly, VA 20153-0832

DCN: 5950000090960789
Page 2 of 2

http://www.npdb.hrsa.gov
I read and understand my responsibilities under:
• Title IV of Public Law 99-660, the Health Care Quality Improvement Act, as amended;
• Public Law 100-93, Section 5[b] of the Medicare and Medicaid Patient and Program Protection Act of 1987, [Section 1921 of the Social
Security Act]; and
• Section 221[a], Public Law 104-191, the Health Insurance Portability and Accountability Act of 1996, more commonly referred to as
Section 1128E of the Social Security Act.
I certify that the entity identified above qualifies under law as specified in the ELIGIBILITY/STATUTORY AUTHORITY section and is eligible to
perform the querying and/or reporting functions. I understand that the entity may be subject to sanctions under Federal statute for failure to
report final adverse actions as required in the statutes and regulations or for the use of information obtained from the NPDB other than the
purposes for which it was provided. I further certify that I am authorized to submit this registration information to the NPDB and that the
information provided is true, correct, and complete. If I become aware that any information in this form is not true, correct, or complete, I agree
to notify the NPDB of this fact immediately. I understand that 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.

______________________________
Signature of Certifying Official

__________________________________
Signature Date (MM-DD-YYYY)

the

DataBank

DCN: 5950000090960789
Page 1 of 1

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

NPDB Certifying Official and Data Bank Administrator Registration

Registrant use only

Section 1 - Registrant Instructions: The Certifying Official/Data Bank Administrator (Registrant) must read the terms below, complete the
appropriate fields, provide a government-issued ID and either provide a work badge or proof-of-affiliation letter on company letterhead before
signing and dating the document in front of the Notary Public.
Summary of Terms: I (the "Registrant"), as the Certifying Official of the health care organization identified in this document, certify that the organization
qualifies under law as specified in the ELIGIBILITY/ STATUTORY AUTHORITY section of the Entity/Agent Registration document and is eligible to
perform querying and/or reporting functions. I understand that the Entity/Authorized Agent may be subject to sanctions under Federal statute for failure
to report final adverse actions as required in the statutes and regulations or for the use of information obtained from the NPDB other than for the
purposes for which it was provided. I am also registering as a Data Bank Administrator for an Entity or Authorized Agent registered or registering with
the NPDB. As a Data Bank Administrator, I am responsible for overseeing the use of the NPDB online services at my organization, identity proofing
applicants who request a user account, establishing and revoking individual user accounts, and maintaining my organization's registration with the
NPDB. By signing below, I acknowledge my acceptance of the Summary of Terms in which I agree to provide complete and accurate responses to
requests for information during the registration process. I further certify that I am authorized to submit this registration information to the NPDB and that
the information provided is true, correct, and complete. If I become aware that any information on this document is not true, correct, or complete, I agree
to notify the NPDB of this fact immediately. I understand that any omission, misrepresentation, or falsification of any information contained in this
document or contained in any communication supplying information to the NPDB to complete or clarify this document may be punishable by criminal,
civil, or administrative actions including fines, penalties, and/or imprisonment under Federal law.
Name (First Name, Middle Initial, Last Name):

Title:

JON MANN

TITLE

Email:

Employee ID:

jonmann@email.gov
Employer/Organization:

Agent
Business Address:

5600 FISHERS LN
ROCKVILLE, MD 20852-1750
Telephone:

(301) 301-3011
Applicant’s Signature and Date*:
_________________________________________________
(*Sign and date in the presence of the Notary Public)

__________
(Date)

Note: Use an ink pen to cross out any mistake, write in the correct information and initial it.

Section 2 - Notary Public Instructions: The Notary Public must record the information below for the Applicant’s government-issued photo
ID for the purpose of identity proofing.

Government-issued ID (Photo, Name, Serial Number, Expiration Date, Address, and Date of Birth Required)

Notary Public use only

Exact Name Listed on ID
Serial Number

Date of Birth

Identification Type

Issuing Authority

Date of Issuance

Expiration Date

____________________________________________________________________
Notary Public:
I hereby certify that on this _______ day of ____________, 20___, in the city of ________________
and in the county of _______________________, _____________________ personally appeared
before me the signer and subject of the above form, who signed or attested the same in my presence,

My Commission Expires In: _______________________
Street Address of Branch or Office: _______________________
Name of Organization Employing Notary: _______________________

Notary Public seal here