National Practitioner Data Bank for Adverse Information on Physicians and Other Health Care Practitioners: 45 CFR Part 60 Regulations and Forms

Forms and Documents

Document Name	Status
Form 44 Other Eligible Entity Attestation Form and Instruction	New
Form 43 Medical Malpractice Payer, Peer Review Organization, or Private Accreditation Organization Attestation Form and Instruction	New
Form 42 Hospital Attestation Form and Instruction	New
Form 41 Health Center Attestation Form and Instruction	New
Form 40 Missing Report from Query Form Form and Instruction	Modified
Form 39 Account Balance Transfer Form and Instruction	Modified
Form 38 Education Request Form and Instruction	Modified
Form 37 Purchase Query Credits Form and Instruction	Modified
Form 36 New Administrator Request Form and Instruction	Modified
Form 35 Account Discrepancy Form and Instruction	Modified
Form 34 Authorized Agent Designation Form and Instruction	Modified
Form 33 Electronic Transfer of Funds (EFT) Authorization Form and Instruction	Modified
Form 32 Agent Registration (Renewal & Update) Form and Instruction	Modified
Form 31 Agent Registration (Initial) Form and Instruction	Modified
Form 30 Reconciling Missing Actions Form and Instruction	Modified
Form 29 Corrective Action Plan (Entity) Form and Instruction	Modified
Form 28 State Licensing Board Attestation Form and Instruction	Modified
Form 27 State Licensing Board Data Request Form and Instruction	Modified
Form 26 Authorized Agent Attestation Form and Instruction	Modified
Form 25 Entity Registration (Renewal & Update) Form and Instruction	Modified
Form 24 Entity Registration (Initial) Form and Instruction	Modified
Form 23 Request for Dispute Resolution Form and Instruction	Modified
Form 22 Subject Statement and Dispute Form and Instruction	Modified
Form 21 Continuous Query Form and Instruction	Modified
Form 20 Self-Query on an Organization Form and Instruction	Modified
Form 19 Self-Query on an Individual Form and Instruction	Modified
Form 18 One Time Query for an Organization Form and Instruction	Modified
Form 17 One Time Query for an Individual Form and Instruction	Modified
Form 16 Health Plan Action Form and Instruction	Modified
Form 15 Government Administrative Form and Instruction	Modified
Form 14 Exclusion/Debarment Form and Instruction	Modified
Form 13 Civil Judgment Form and Instruction	Modified
Form 12 Injunction Form and Instruction	Modified
Form 11 Nolo Contendere (no contest) plea Form and Instruction	Modified
Form 10 Deferred Conviction or Pre-Trial Diversion Form and Instruction	Modified
Form 9 Criminal Conviction (Guilty Plea or Trial) Form and Instruction	Modified
Form 8 Professional Society Form and Instruction	Modified
Form 7 Title IV Clinical Privileges Actions Form and Instruction	Modified
Form 6 Accreditation Form and Instruction	Modified
Form 5 Peer Review Organization Form and Instruction	Modified
Form 4 DEA/Federal Licensure Form and Instruction	Modified
Form 3 State Licensure Form and Instruction	Modified
Form 2 Medical Malpractice Payment Form and Instruction	Modified
Form 1 Correction, Revision to Action, Correction of Revision to Action, Void, Action on Appeal Form and Instruction	Modified
NPDB Supporting Statement A 0126.docx Supporting Statement A	2021-01-22

IC Document Collections

IC ID	Document Title	Status
245415	Other Eligible Entity Attestation Form and Instruction	New
245414	Medical Malpractice Payer, Peer Review Organization, or Private Accreditation Organization Attestation Form and Instruction	New
245413	Hospital Attestation Form and Instruction	New
245412	Health Center Attestation Form and Instruction	New
229942	Missing Report from Query Form Form and Instruction	Modified
229941	Account Balance Transfer Form and Instruction	Modified
229939	Education Request Form and Instruction	Modified
214939	Purchase Query Credits Form and Instruction	Modified
214938	New Administrator Request Form and Instruction	Modified
214937	Account Discrepancy Form and Instruction	Modified
214936	Authorized Agent Designation Form and Instruction	Modified
214935	Electronic Transfer of Funds (EFT) Authorization Form and Instruction	Modified
214934	Agent Registration (Renewal & Update) Form and Instruction	Modified
214933	Agent Registration (Initial) Form and Instruction	Modified
206509	Reconciling Missing Actions Form and Instruction	Modified
206508	Corrective Action Plan (Entity) Form and Instruction	Modified
206507	State Licensing Board Attestation Form and Instruction	Modified
206506	State Licensing Board Data Request Form and Instruction	Modified
206505	Authorized Agent Attestation Form and Instruction	Modified
206504	Entity Registration (Renewal & Update) Form and Instruction	Modified
206503	Entity Registration (Initial) Form and Instruction	Modified
206502	Request for Dispute Resolution Form and Instruction	Modified
206501	Subject Statement and Dispute Form and Instruction	Modified
206500	Continuous Query Form and Instruction	Modified
206499	Self-Query on an Organization Form and Instruction	Modified
206498	Self-Query on an Individual Form and Instruction	Modified
206497	One Time Query for an Organization Form and Instruction	Modified
206496	One Time Query for an Individual Form and Instruction	Modified
206495	Health Plan Action Form and Instruction	Modified
206494	Government Administrative Form and Instruction	Modified
206493	Exclusion/Debarment Form and Instruction	Modified
206492	Civil Judgment Form and Instruction	Modified
206491	Injunction Form and Instruction	Modified
206490	Nolo Contendere (no contest) plea Form and Instruction	Modified
206489	Deferred Conviction or Pre-Trial Diversion Form and Instruction	Modified
206488	Criminal Conviction (Guilty Plea or Trial) Form and Instruction	Modified
206487	Professional Society Form and Instruction	Modified
206486	Title IV Clinical Privileges Actions Form and Instruction	Modified
206485	Accreditation Form and Instruction	Modified
206484	Peer Review Organization Form and Instruction	Modified
206483	DEA/Federal Licensure Form and Instruction	Modified
206482	State Licensure Form and Instruction	Modified
206481	Medical Malpractice Payment Form and Instruction	Modified
206480	Correction, Revision to Action, Correction of Revision to Action, Void, Action on Appeal Form and Instruction	Modified

ICR Details

OMB Control No: 0915-0126	ICR Reference No: 202101-0915-002
Status: Received in OIRA	Previous ICR Reference No: 201801-0915-001
Agency/Subagency: HHS/HSA	Agency Tracking No: 19186
Title: National Practitioner Data Bank for Adverse Information on Physicians and Other Health Care Practitioners: 45 CFR Part 60 Regulations and Forms
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 01/25/2021

	Requested	Previously Approved
Expiration Date	36 Months From Approved	03/31/2021
Responses	7,101,274	6,059,761
Time Burden (Hours)	348,368	326,120
Cost Burden (Dollars)	0	0

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Abstract: The National Practitioner Data Bank (NPDB) is required to receive and release under 45 CFR Part 60 certain adverse data regarding physicians, dentists, and other licensed health care practitioners. Data collected on adverse actions and information relating to the professional competence and conduct of physicians and other health care practitioners will be shared with hospitals, licensing boards, professional societies, and selected health providers. These data will be used to maintain and improve health care and will be obtained from insurers, licensure boards, hospitals, and other providers.

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Authorizing Statute(s): PL: Pub.L. 104 - 101 221 Name of Law: Establishment of the Health Care Fraud and Abuse Data Collection Program
   PL: Pub.L. 99 - 660 402 Name of Law: Health Care Quality Improvement Act of 1986
   US Code: 42 USC 11101 Name of Law: Health Care Quality Improvement Act of 1986
   US Code: 42 USC 1301 Name of Law: Health Care and Abuse Data Collection Program
   US Code: 42 USC 136r-2 Name of Law: 2. Section 1921 of the Social Security Act
   US Code: 42 USC 1320a-7e Name of Law: 3. Section 1128E of the Social Security Act
   PL: Pub.L. 111 - 148 6403 Name of Law: Patient Protection and Affordable Care Act of 2010
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 65834	10/16/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 5220	01/19/2021
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 44

IC Title	Form No.	Form Name
Continuous Query	21	Continuous Query_0915-0126.pdf
Subject Statement and Dispute	22	Subject Statement and Dispute_0915-0126.pdf
Request for Dispute Resolution	23	Request for Dispute Resolution_0915-0126.pdf
Entity Registration (Initial)	24	Entity Registration (Initial)_0915-0126.pdf
Self-Query on an Organization	20	Self-Query on an Organization_0916-0126.pdf
Entity Registration (Renewal & Update)	25	Entity Registration (Renewal & Update)_0915-0126.pdf
Authorized Agent Attestation	26	Authorized Agent Attestation_0915-0126.pdf
State Licensing Board Data Request	27	State Licensing Board Data Request_0915-0126.pdf
State Licensing Board Attestation	28	State Licensing Board Attestation_0915-0126.pdf
Corrective Action Plan (Entity)	29	Corrective Action Plan (Entity)_0915-0126.pdf
Reconciling Missing Actions	30	Reconciling Missing Actions_0915-0126.pdf
Agent Registration (Initial)	31	Agent Registration (Initial)_0915-0126.pdf
One Time Query for an Individual	17	One-Time Query for an Individual_0915-0126.pdf
Agent Registration (Renewal & Update)	32	Agent Registration (Renewal & Update)_0915-0126.pdf
Electronic Transfer of Funds (EFT) Authorization	33	Electronic Funds Transfer (EFT) Authorization_0915-0126.pdf
Authorized Agent Designation	34	Authorized Agent Designation_0915-0126.pdf
Account Discrepancy	35	Account Discrepancy_0915-0126.pdf
New Administrator Request	36	New Administrator Request_0915-0126.pdf
Purchase Query Credits	37	Purchase Query Credits_0915-0126.pdf
Correction, Revision to Action, Correction of Revision to Action, Void, Action on Appeal	1	Correction Revision-to-Action Void Notice of Appeal_0915-0126.pdf
Medical Malpractice Payment	2	Medical Malpractice Payment_0915-0126.pdf
State Licensure	3	State Licensure or Certification_0915-0126.pdf
DEA/Federal Licensure	4	DEA_Federal Licensure_0915-0126.pdf
Peer Review Organization	5	Peer Review Organization_0915-0126.pdf
Accreditation	6	Accreditation Report_0915-0126.pdf
Title IV Clinical Privileges Actions	7	Title IV Clinical Privileges Actions_0915-0126.pdf
Professional Society	8	Professional Society_0915-0126.pdf
Education Request	38	Education Request_0915-0126.pdf
Account Balance Transfer	39	Account Balance Transfer_0915-0126.pdf
Missing Report from Query Form	40	Missing Report from Query_0915-0126.pdf
Criminal Conviction (Guilty Plea or Trial)	9	Criminal Conviction (Guilty Plea or Trial)_0915-0126.pdf
Deferred Conviction or Pre-Trial Diversion	10	Deferred Conviction or Pre-Trial Diversion_0915-0126.pdf
Government Administrative	15	Government Administrative_0915-0126.pdf
Nolo Contendere (no contest) plea	11	Nolo Contendere (no contest plea)_0915-0126.pdf
Injunction	12	Injunction_0915-0126.pdf
Civil Judgment	13	Civil Judgment_0915-0126.pdf
Exclusion/Debarment	14	Exclusion or Debarment_0915-0126.pdf
Health Plan Action	16	Health Plan Action_0915-0126.pdf
One Time Query for an Organization	18	One-Time Query for an Organization_0915-0126.pdf
Self-Query on an Individual	19	Self-Query on an Individual_0915-0126.pdf
Health Center Attestation	41	Health Center Attestation_0915-0126.pdf
Hospital Attestation	42	Hospital Attestation_0915-0126.pdf
Medical Malpractice Payer, Peer Review Organization, or Private Accreditation Organization Attestation	43	Medical Malpractice Payer Attestation_0915-0126.pdf
Other Eligible Entity Attestation	44	Other Eligible Entity Attestation_0915-0126.pdf

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ICR Summary of Burden

	Total Request	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	7,101,274	6,059,761	0	1,041,513	0	0
Annual Time Burden (Hours)	348,368	326,120	0	22,248	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The number of respondents have increased or decreased for some forms causing the increase or decrease in burden.

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Annual Cost to Federal Government: $19,100,000

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 01/25/2021

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