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

OMB 0915-0126

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.

The latest form for National Practitioner Data Bank for Adverse Information on Physicians and Other Health Care Practitioners: 45 CFR Part 60 Regulations and Forms expires 2021-03-31 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form 44 Other Eligible Entity Attestation Form and Instruction
Form 43 Medical Malpractice Payer, Peer Review Organization, or Private Accreditation Organization Attestation Form and Instruction
Form 42 Hospital Attestation Form and Instruction
Form 41 Health Center Attestation Form and Instruction
Form 40 Missing Report from Query Form Form and Instruction
Form 39 Account Balance Transfer Form and Instruction
Form 38 Education Request Form and Instruction
Form 37 Purchase Query Credits Form and Instruction
Form 36 New Administrator Request Form and Instruction
Form 35 Account Discrepancy Form and Instruction
Form 34 Authorized Agent Designation Form and Instruction
Form 33 Electronic Transfer of Funds (EFT) Authorization Form and Instruction
Form 32 Agent Registration (Renewal & Update) Form and Instruction
Form 31 Agent Registration (Initial) Form and Instruction
Form 30 Reconciling Missing Actions Form and Instruction
Form 29 Corrective Action Plan (Entity) Form and Instruction
Form 28 State Licensing Board Attestation Form and Instruction
Form 27 State Licensing Board Data Request Form and Instruction
Form 26 Authorized Agent Attestation Form and Instruction
Form 25 Entity Registration (Renewal & Update) Form and Instruction
Form 24 Entity Registration (Initial) Form and Instruction
Form 23 Request for Dispute Resolution Form and Instruction
Form 22 Subject Statement and Dispute Form and Instruction
Form 21 Continuous Query Form and Instruction
Form 20 Self-Query on an Organization Form and Instruction
Form 19 Self-Query on an Individual Form and Instruction
Form 18 One Time Query for an Organization Form and Instruction
Form 17 One Time Query for an Individual Form and Instruction
Form 16 Health Plan Action Form and Instruction
Form 15 Government Administrative Form and Instruction
Form 14 Exclusion/Debarment Form and Instruction
Form 13 Civil Judgment Form and Instruction
Form 12 Injunction Form and Instruction
Form 11 Nolo Contendere (no contest) plea Form and Instruction
Form 10 Deferred Conviction or Pre-Trial Diversion Form and Instruction
Form 9 Criminal Conviction (Guilty Plea or Trial) Form and Instruction
Form 8 Professional Society Form and Instruction
Form 7 Title IV Clinical Privileges Actions Form and Instruction
Form 6 Accreditation Form and Instruction
Form 5 Peer Review Organization Form and Instruction
Form 4 DEA/Federal Licensure Form and Instruction
Form 3 State Licensure Form and Instruction
Form 2 Medical Malpractice Payment Form and Instruction
Form 1 Correction, Revision to Action, Correction of Revision to Action, Void, Action on Appeal Form and Instruction
NPDB Supporting Statement A - Revised 11062023.docx Supporting Statement A
Other Eligible Entity Attestation Form and Instruction
Medical Malpractice Payer, Peer Review Organization, or Private Accreditation Organization Attestation Form and Instruction
Hospital Attestation Form and Instruction
Health Center Attestation Form and Instruction
Missing Report from Query Form Form and Instruction
Account Balance Transfer Form and Instruction
Education Request Form and Instruction
Purchase Query Credits Form and Instruction
New Administrator Request Form and Instruction
Account Discrepancy Form and Instruction
Authorized Agent Designation Form and Instruction
Electronic Transfer of Funds (EFT) Authorization Form and Instruction
Agent Registration (Renewal & Update) Form and Instruction
Agent Registration (Initial) Form and Instruction
Reconciling Missing Actions Form and Instruction
Corrective Action Plan (Entity) Form and Instruction
State Licensing Board Attestation Form and Instruction
State Licensing Board Data Request Form and Instruction
Authorized Agent Attestation Form and Instruction
Entity Registration (Renewal & Update) Form and Instruction
Entity Registration (Initial) Form and Instruction
Request for Dispute Resolution Form and Instruction
Subject Statement and Dispute Form and Instruction
Continuous Query Form and Instruction
Self-Query on an Organization Form and Instruction
Self-Query on an Individual Form and Instruction
One Time Query for an Organization Form and Instruction
One Time Query for an Individual Form and Instruction
Health Plan Action Form and Instruction
Government Administrative Form and Instruction
Exclusion/Debarment Form and Instruction
Civil Judgment Form and Instruction
Injunction Form and Instruction
Nolo Contendere (no contest) plea Form and Instruction
Deferred Conviction or Pre-Trial Diversion Form and Instruction
Criminal Conviction (Guilty Plea or Trial) Form and Instruction
Professional Society Form and Instruction
Title IV Clinical Privileges Actions Form and Instruction
Accreditation Form and Instruction
Peer Review Organization Form and Instruction
DEA/Federal Licensure Form and Instruction
State Licensure Form and Instruction
Medical Malpractice Payment Form and Instruction
Correction, Revision to Action, Correction of Revision to Action, Void, Action on Appeal Form and Instruction

All Historical Document Collections

202310-0915-003 Approved without change	Revision of a currently approved collection	2023-11-09
202101-0915-002 Approved without change	Revision of a currently approved collection	2021-01-25
201801-0915-001 Approved without change	Revision of a currently approved collection	2018-02-02
201611-0915-002 Approved without change	No material or nonsubstantive change to a currently approved collection	2016-11-08
201502-0915-001 Approved with change	Revision of a currently approved collection	2015-02-11
201405-0915-005 Approved without change	No material or nonsubstantive change to a currently approved collection	2014-05-28
201304-0915-002 Approved without change	Revision of a currently approved collection	2013-04-16
201109-0915-001 Approved without change	No material or nonsubstantive change to a currently approved collection	2011-09-19
201009-0915-005 Approved without change	Revision of a currently approved collection	2010-09-29
201007-0915-002 Withdrawn and continue	Extension without change of a currently approved collection	2010-07-22
200705-0915-002 Approved without change	Extension without change of a currently approved collection	2007-05-15
200401-0915-001 Approved with change	Revision of a currently approved collection	2004-01-28
200207-0915-001 Approved with change	Revision of a currently approved collection	2002-07-25
199902-0915-002 Approved without change	Extension without change of a currently approved collection	1999-02-03
199809-0915-010 Approved without change	No material or nonsubstantive change to a currently approved collection	1998-09-15
199512-0915-003 Approved without change	Extension without change of a currently approved collection	1995-12-15
199503-0915-003 Approved without change	Revision of a currently approved collection	1995-03-27
199212-0915-001 Approved without change	Revision of a currently approved collection	1992-12-21
199207-0915-001 Approved without change	Revision of a currently approved collection	1992-07-16
199102-0915-001 Approved without change	Revision of a currently approved collection	1991-02-28
198912-0915-004 Approved without change	Revision of a currently approved collection	1989-12-28
198906-0915-014 Approved with change	No material or nonsubstantive change to a currently approved collection	1989-06-27
198906-0915-007 Approved with change	No material or nonsubstantive change to a currently approved collection	1989-06-14
198904-0915-011 Approved with change	No material or nonsubstantive change to a currently approved collection	1989-04-10
198811-0915-002 Withdrawn and continue	Revision of a currently approved collection	1988-11-03
198804-0915-002 Approved without change	New collection (Request for a new OMB Control Number)	1988-04-05

OMB Details

Correction, Revision to Action, Correction of Revision to Action, Void, Action on Appeal

Federal Enterprise Architecture: Health - Consumer Health and Safety

Form 1

Correction, Revision to Action, Void, Notice of Appeal.pdf

Fillable Fileable

Form and instruction

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.