Form 39 Account Balance Transfer

Account Balance Transfer Request

To transfer your account balance with the NPDB to a credit or debit card or Electronic Funds Transfer (EFT) account,
please type or print legibly, in ink, the information requested in Sections A and B.

Section A: Entity Information
Data Bank Identification Number: ________________________________________________
Telephone: Area Code _______ Number _______________________ Extension ___________
Printed Title of Entity Representative: _____________________________________________
Printed Name of Entity Representative: ____________________________________________
Signature of Entity Representative: _______________________________________________
Signature Date: ____________________

Section B: Account Information
Transfer Balance to (check one): ____Credit/Debit Card Account _____Existing EFT Account on File with the NPDB
Amount to be Transferred: $_____________________________________________________
Type of Balance (check one): _______ Debit Balance _______ Credit Balance
Note: If a credit balance is issued, it must be applied to the original account that was debited.
Credit or Debit Card Number: _____________________ Expiration Date (MM/YY): _________
Cardholder’s Name: ____________________________________________________________
Cardholder’s Billing Address: _____________________________________________________
City: _______________________________ State: ______ Zip Code: ______________________
The NPDB is committed to protecting your privacy and your Personally Identifiable Information (PII). In accordance with HHS and
HRSA policy, the NPDB will not accept unencrypted PII via email or fax. When completing this form, please mail to: The NPDB, P.O.
Box 10832, Chantilly, VA 20153-0832. When the account balance transfer has been processed, a billing adjustment notification will
be mailed to your organization.
OMB Number: 0915-0126 Expiration Date: mm/dd/yyyy
Public Burden Statement: The NPDB is a web-based repository of reports containing information on medical malpractice payments
and certain adverse actions related to health care practitioners, providers, and suppliers. Established by Congress in 1986, it is a
workforce tool that prevents practitioners from moving state-to-state without disclosure or discovery of previous damaging
performance. The statutes and regulations that govern and maintain NPDB operations include: Title IV of Public Law 99-660, Health
Care Quality Improvement Act (HCQIA) of 1986, Section 1921 of the Social Security Act, Section 1128E of the Social Security Act,
and Section 6403 of the Patient Protection and Affordable Care Act of 2010. The NPDB regulations implementing these laws are
codified at 45 CFR Part 60. 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 number for this information collection is
0915-0126 and it is valid until mm/dd/yyyy This information collection is voluntary. 45 CFR Section 60.20 provides information on
the confidentiality of the NPDB. Information reported to the NPDB is considered confidential and shall not be disclosed outside of
HHS, except as specified in Sections 60.17, 60.18, and 60.21. Public reporting burden for this collection of information is estimated
to average 5 minutes per response, 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 14N136B,
Rockville, Maryland, 20857 or paperwork@hrsa.gov.