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National Practitioner Data Bank: Section 1921 of the Social Security Act

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National Practitioner Data Bank, Section 1921

OMB: 0915-0331

Document [pdf]

Download: pdf | pdf

To submit a query, enter all known subject data.

Explicit Query Form

OMB # 0915-0239 expiration date 10/31/10
OMB # 0915-0126 expiration date 07/31/10
Public Burden Statement: 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 numbers for this project are 0915-0239 (HIPDB) and 0915-0126 (NPDB). Public reporting burden
for this collection of information is estimated to average 5 minutes to complete this form, 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 14-22, Rockville, Maryland, 20857.

SUBJECT INFORMATION
Subject Name:
Last Name

First Name

Middle Name

Suffix (e.g., Jr, III)

Other Names Used (Last Name and First Name Required):
Last Name
First Name
Middle Name

Suffix (e.g., Jr, III)

1.
2.
3.
4.
5.

Gender:
 Male




Birth Date
(MMDDYYYY):
PIN:
Work
Organization
Name:
Organization
Type:

 Female





 Unknown





CHOOSE ONE FROM LIST

Description (if 'Other' was selected above):

ADDRESSES
Click
Work Address

for information on filling out non-U.S. and military addresses.



Street Address:
Address Line 2:
City:
State:

CHOOSE ONE FROM LIST

ZIP Code:



Country (if U.S., leave
blank):
Home Address/Address of
Record
Street Address:
Address Line 2:
City:
State:

CHOOSE ONE FROM LIST

ZIP Code:



Country (if U.S., leave
blank):

SOCIAL SECURITY NUMBERS (SSN) (FORMAT NNNNNNNNN)
1.

INDIVIDUAL TAXPAYER IDENTIFICATION NUMBERS (ITIN) (FORMAT 9NNNNNNNN)
1.

FEDERAL EMPLOYER IDENTIFICATION NUMBERS (FEIN)
1.

NATIONAL PROVIDER IDENTIFIERS (NPI)
1.

DRUG ENFORCEMENT ADMINISTRATION (DEA) NUMBERS
1.

UNIQUE PHYSICIAN IDENTIFICATION NUMBERS (UPIN)
1.

PROFESSIONAL SCHOOLS ATTENDED
School Name:

Year of
Graduation
(Format YYYY):

1.
2.
3.
4.
5.

OCCUPATION AND STATE LICENSURE INFORMATION
(Provide at least one license. Check 'No License' if the subject does not have a State License Number.
Use the Add Additional License/Occupation button to provide more than one license. Up to 60
licenses may be provided.)

1. State License Number:

State of Licensure:

CHOOSE ONE FROM LIST

Occupation/Field of
Licensure:

CHOOSE ONE FROM LIST







No License




Description (complete only if 'Other' is selected above):

Specialty:

CHOOSE ONE FROM LIST



Check this box if you wish to store this subject in your subject database for use in
future queries and/or reports. Duplicate entries in your subject database may result in
duplicate queries.






OMB # 0915-0239 expiration date 10/31/10
OMB # 0915-0126 expiration date 07/31/10

Subj DataBase (Indv) Form

Public Burden Statement: 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 numbers for this project are 0915-0239 (HIPDB) and 0915-0126 (NPDB). Public reporting
burden for this collection of information is estimated to average 5 minutes to complete this form,
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 14-22, Rockville, Maryland, 20857.

SUBJECT INFORMATION
Subject Name:
Last Name

First Name

Middle Name

Suffix (e.g., Jr, III)

Other Names Used (Last Name and First Name Required):
Last Name
First Name
Middle Name

Suffix (e.g., Jr, III)

1.
2.
3.
4.
5.

ENTITY SUBJECT IDENTIFICATION NUMBER
This optional field allows your entity to include a unique number or other reference
information to help you identify this subject. This information is not used by the Data
Banks.
Subject ID:

(e.g., employee number)

Gender:
 Male 




 Female 



 Unknown



Birth Date
(MMDDYYYY):
Work
Organization
Name:
Organization
CHOOSE ONE FROM LIST
Type:
Description (if 'Other' was selected above):



Department:

CHOOSE ONE FROM LIST



ADDRESSES
Click

for information on filling out non-U.S. and military addresses.

Work Address
Street Address:
Address Line 2:
City:
State:

CHOOSE ONE FROM LIST

ZIP Code:



Country (if U.S., leave
blank):
Home Address/Address of
Record
Street Address:
Address Line 2:
City:
State:

CHOOSE ONE FROM LIST

ZIP Code:



Country (if U.S., leave
blank):
Is Subject Deceased?

 No





 Unknown





 Yes--Deceased





Date (MMDDYYYY)

SOCIAL SECURITY NUMBERS (SSN) (FORMAT NNNNNNNNN)
1.

INDIVIDUAL TAXPAYER IDENTIFICATION NUMBERS (ITIN) (FORMAT 9NNNNNNNN)
1.

FEDERAL EMPLOYER IDENTIFICATION NUMBERS (FEIN)
1.

NATIONAL PROVIDER IDENTIFIERS (NPI)

DRUG ENFORCEMENT ADMINISTRATION (DEA) NUMBERS
1.

UNIQUE PHYSICIAN IDENTIFICATION NUMBERS (UPIN)
1.

PROFESSIONAL SCHOOLS ATTENDED
School Name:

Year of
Graduation
(Format YYYY):

1.
2.
3.
4.
5.

1. State License Number:

State of Licensure:

CHOOSE ONE FROM LIST

Occupation/Field of
Licensure:

CHOOSE ONE FROM LIST







No License




Description (complete only if 'Other' is selected above):

Specialty:

CHOOSE ONE FROM LIST



OMB # 0915-0239 expiration date 10/31/10
OMB # 0915-0126 expiration date 07/31/10

Subj Database (Org) Form

SUBJECT INFORMATION
Organization
Name:
Other Organization Names Used:
1.
2.
3.
4.
5.
Click

for information on filling out non-U.S. and military addresses.

Street Address:
Address Line 2:
City:
State:

CHOOSE ONE FROM LIST

ZIP Code:

Country (if U.S., leave
blank):
Organization Type:

CHOOSE ONE FROM LIST

Description (if 'Other' was selected above):

Department:

CHOOSE ONE FROM LIST

FEDERAL EMPLOYER IDENTIFICATION NUMBERS (FEIN)
1.

SOCIAL SECURITY NUMBERS (SSN) (FORMAT NNNNNNNNN)
1.

INDIVIDUAL TAXPAYER IDENTIFICATION NUMBERS (ITIN) (FORMAT 9NNNNNNNN)
1.

PRINCIPAL OFFICERS AND OWNERS
Last Name

First Name

Suffix (e.g., Jr.,
III)

Middle Name

1.
2.
3.
4.
5.
ORGANIZATION STATE LICENSURE INFORMATION
(If no State License, check the 'No License' box.)

1. State License Number:
State of Licensure:

License

c No
d
e
f
g

License

c No
d
e
f
g

License

CHOOSE ONE FROM LIST

3. State License Number:
State of Licensure:

c No
d
e
f
g

CHOOSE ONE FROM LIST

2. State License Number:
State of Licensure:

CHOOSE ONE FROM LIST

DRUG ENFORCEMENT ADMINISTRATION (DEA) NUMBERS

Title

CLINICAL LABORATORY IMPROVEMENT ACT (CLIA) NUMBERS
1.

FEDERAL FOOD AND DRUG ADMINISTRATION (FDA) NUMBERS
1.

NATIONAL PROVIDER IDENTIFIERS (NPI)
1.

MEDICARE PROVIDER/SUPPLIER NUMBERS
1.

INDIVIDUAL SELF-QUERY INSTRUCTIONS
Complete the Individual Self-Query form on-line, review the information entered on
the form for completeness and accuracy, click Continue, and print the formatted copy
of your self-query. Sign the formatted copy in ink and in the presence of a Notary
Public, and mail the notarized copy to the address printed at the top of the page.
DO NOT PRINT OR NOTARIZE THIS FORM. A printable copy will be made available
to you upon transmission of this form.
FEE AND PAYMENT INFORMATION
All individual self-queries are automatically sent to both the NPDB and the HIPDB. An
$8.00 fee per self-query is assessed by the NPDB; an $8.00 fee per self-query is also
assessed by the HIPDB. Fees must be paid by credit card (VISA, MasterCard,
Discover or American Express). Cash and checks are not accepted.
CONFIDENTIALITY OF INFORMATION
Persons and entities that receive confidential information from the NPDB-HIPDB,
either directly or indirectly from another party, must use it solely with respect to the
purpose for which it was provided. Any person who violates the confidentiality
provisions of the Data Bank(s) shall be subject to a civil penalty for each
violation.
In compliance with the Privacy Act, the results of an individual self-query are sent only
to the practitioner's home or work address as certified on the self-query form.
Individual health care practitioners who obtain information about themselves from the
NPDB-HIPDB are permitted to share that information with anyone they choose.

OMB # 0915-0239 expiration date 10/31/10
OMB # 0915-0126 expiration date 07/31/10
Public Burden Statement: 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 numbers for this project are 0915-0239
(HIPDB) and 0915-0126 (NPDB). Public reporting burden for this collection of
information is estimated to average 25 minutes to complete this form, 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 14-22, Rockville, Maryland, 20857.

SUBJECT INFORMATION
Subject Name:
Last Name

First Name

Middle Name

Suffix (e.g., Jr, III)

Other Names Used (Last Name and First Name Required):
Last Name
First Name
Middle Name

Suffix (e.g., Jr, III)

1.
2.
3.
4.
5.

Gender:
 Male 




 Female



Birth Date
(MMDDYYYY):
Work
Organization
Name:
Organization
CHOOSE ONE FROM LIST
Type:
Description (if 'Other' was selected above):



HOME OR WORK ADDRESS
Enter the address (home or work) to which you would like your response sent:
Note: If specifying a work address, be sure to include the employer name in the first line of the address.
Street Address:
Address Line 2:
City:
State:

CHOOSE ONE FROM LIST

ZIP Code:



Country (if U.S., leave
blank):
Telephone:

Ext.

SOCIAL SECURITY NUMBERS (SSN) (FORMAT NNNNNNNNN)
1.

INDIVIDUAL TAXPAYER IDENTIFICATION NUMBERS (ITIN) (FORMAT 9NNNNNNNN)
1.

FEDERAL EMPLOYER IDENTIFICATION NUMBERS (FEIN)
1.

NATIONAL PROVIDER IDENTIFIERS (NPI)
1.

DRUG ENFORCEMENT ADMINISTRATION (DEA) NUMBERS
1.

UNIQUE PHYSICIAN IDENTIFICATION NUMBERS (UPIN)
1.

PROFESSIONAL SCHOOLS ATTENDED
School Name:

Year of
Graduation
(Format YYYY):

1.
2.
3.
4.
5.

1. State License Number:
State of Licensure:
Occupation/Field of

OR
CHOOSE ONE FROM LIST









No License

Licensure:

CHOOSE ONE FROM LIST



Description (complete only if 'Other' is selected above):

Specialty:

CHOOSE ONE FROM LIST



REPORT PASSWORD PREFERENCE
Once your self-query request is processed, the Data Banks will send a response to the address
specified. The self-query response will consist of either a notification that no information exists in the
Data Bank(s), or a copy of all information concerning you that has been submitted by eligible reporting
entities.
You must select below whether to include in this self-query response a Report Password that will allow
you to access the Report Response Service. The service allows you to add, modify, or remove a
Subject Statement, initiate or withdraw a dispute or request for Secretarial Review, or modify your
address as maintained by the Data Banks. If you are the subject of a report, you will be assigned a
unique, confidential password to access the Report Response Service. If you plan to share your
self-query results with another person or organization, such as a State licensing board (i.e., a third
party), you may wish to omit password information from the self-query results.






I wish to have my Report Password displayed on my self-query results. This option is
recommended for individuals who do not plan to share their self-query results with a third
party.







I wish to have my Report Password omitted from my self-query results. This option is
recommended for individuals who plan to share their self-query results with a third party.

PAYMENT INFORMATION
The fee per self-query is $16.00, payable by credit card only. Individual self-queries are automatically
sent to the NPDB and the HIPDB ($8.00 is assessed by the NPDB and $8.00 by the HIPDB). Please
enter a valid credit card number (VISA, MasterCard, Discover or American Express) and expiration date.
Your credit card will not be charged until the NPDB-HIPDB receives and processes your notarized selfquery. Your signature on this form indicates consent to pay this fee.
Credit Card Number:
Expiration Date:






Credit Card Data Security
Month  / Year 

Check here if your credit card billing information is the same as the Subject Name and Home or
Work Address entered above; otherwise, enter the billing information for this credit card below. This
information is required to process this self-query.

Cardholder's Name:
Cardholder's Billing Address:
Address Line 2:
City:

State:
ZIP Code:

CHOOSE ONE FROM LIST



Country (if U.S., leave blank):
 Continue without credit card information. If you choose this option, be sure to write your credit




card information on the formatted copy of your self-query, or your self-query will be rejected.

DATA BANKS NEWSLETTER
If you would like to receive the Data Banks e-newsletter, send an email to
enewsletter-sq-subscribe@npdb-hipdb.hrsa.gov. View the latest e-newsletter.
We do not share e-mail addresses provided to us through our web site with other parties. You will have the opportunity to
opt out of future messages with each e-mail you receive from the NPDB-HIPDB.

OMB # 0915-0239 expiration date 10/31/10
OMB # 0915-0126 expiration date 07/31/10

Self-Query Org Form

Public Burden Statement: 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 numbers for this project are 0915-0239
(HIPDB) and 0915-0126 (NPDB). Public reporting burden for this collection of
information is estimated to average 25 minutes to complete this form, 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 14-22, Rockville, Maryland, 20857.

SUBJECT INFORMATION
Organization
Name:
Other Organization Names Used:
1.
2.
3.
4.
5.
Click

for information on filling out non-U.S. and military addresses.

Street Address:
Address Line 2:
City:
State:

CHOOSE ONE FROM LIST

ZIP Code:

Country (if U.S., leave
blank):
Organization Type:

CHOOSE ONE FROM LIST

Description (if 'Other' was selected above):

FEDERAL EMPLOYER IDENTIFICATION NUMBERS (FEIN)
1.

SOCIAL SECURITY NUMBERS (SSN) (FORMAT NNNNNNNNN)
1.

INDIVIDUAL TAXPAYER IDENTIFICATION NUMBERS (ITIN) (FORMAT 9NNNNNNNN)
1.

ORGANIZATION STATE LICENSURE INFORMATION
(If no State License, check the 'No License' box.)

1. State License Number:
State of Licensure:

License

c No
d
e
f
g

License

c No
d
e
f
g

License

CHOOSE ONE FROM LIST

3. State License Number:
State of Licensure:

c No
d
e
f
g

CHOOSE ONE FROM LIST

2. State License Number:
State of Licensure:

CHOOSE ONE FROM LIST

DRUG ENFORCEMENT ADMINISTRATION (DEA) NUMBERS
1.

CLINICAL LABORATORY IMPROVEMENT ACT (CLIA) NUMBERS
1.

FEDERAL FOOD AND DRUG ADMINISTRATION (FDA) NUMBERS

NATIONAL PROVIDER IDENTIFIERS (NPI)
1.

MEDICARE PROVIDER/SUPPLIER NUMBERS
1.

CERTIFICATION
I certify that I am authorized to request this information and that I am a representative of the
organization described in Section A of this form. I further certify that the information on this form is true
and complete.
Authorized Submitter's Name:
Authorized Submitter's Title:
Authorized Submitter's Phone:

Ext.

j
k
l
m
n

I wish to have my Report Password displayed on my self-query results. This option is
recommended for organizations that do not plan to share their self-query results with a third
party.
I wish to have my Report Password omitted from my self-query results. This option is
recommended for organizations that plan to share their self-query results with a third party.

PAYMENT INFORMATION
The fee per organization self-query is $8.00, payable by credit card only. Organization self-queries are
sent only to the HIPDB. Please enter a valid credit card number (VISA, MasterCard, Discover or
American Express) and expiration date. Your credit card will not be charged until the NPDB-HIPDB
receives and processes your notarized self-query. Your signature on this form indicates consent to pay
this fee.
Credit Card Number:
Expiration Date:
c
d
e
f
g

Credit Card Data Security
Month

/ Year

Cardholder's Name:
Cardholder's Billing Address:
Address Line 2:
City:
State:
ZIP Code:

CHOOSE ONE FROM LIST

Country (if U.S., leave blank):
c Continue
d
e
f
g

without credit card information. If you choose this option, be sure to write your credit
card information on the formatted copy of your self-query, or your self-query will be rejected.

SUBJECT STATEMENT AND DISPUTE

National Practitioner Data Bank
Healthcare Integrity and Protection Data Bank

To add, modify, or remove a statement to the report referenced below, and/or to place the report in, or
withdraw the report from, disputed status, complete the appropriate section(s) below, and click Submit
To Data Bank(s). You will receive an on-line confirmation message regarding this transaction. The
reporting entity and any queriers who received a previous version of the report will receive a copy
noting the modifications.
Report Type:
Report Number:
Subject's Name:
Report Maintained Under:

STATE LICENSURE ACTION
7930000052539805
MOOSE, JOHN
[X] Title IV (NPDB)
[X] Section 1128E (HIPDB)

SUBJECT STATEMENT

As the subject of the referenced report, you have the right to include a statement expressing your view
of the action described in the report. The statement becomes part of the report and is disclosed to
authorized queriers. To add a statement, type the statement in the designated area below exactly as you
wish it to appear in the report. To substitute an existing statement with a new one, modify the statement
in the designated area below exactly as you wish it to appear in the report. (If you have a statement on
file, it will appear below.) Your statement must be in English and may not exceed 4,000 characters,
including spaces and punctuation. If you add a statement to the report, it will be formatted in a block
style; paragraph breaks cannot be included.
Note:Patient information is confidential. Do NOT include identifying information (names,
addresses, etc.) about patients or other persons in your statement. All Subject Statements are
reviewed by the Data Banks to determine whether they include individual names, addresses, or
telephone numbers. If this information is discovered, it will be removed and you will be sent an
amended version.
OMB # 0915-0239 expiration date 10/31/10
OMB # 0915-0126 expiration date 07/31/10
Public Burden Statement: 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 numbers for this project are 0915-0239 (HIPDB) and 0915-0126 (NPDB). Public reporting burden
for this collection of information is estimated to average 45 minutes to complete this form, 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 14-22, Rockville, Maryland, 20857.
Subject Statement

There are 4000 characters remaining for the statement.
DISPUTE
You may dispute either the factual accuracy of the action described in the referenced report or whether
the report was submitted in accordance with Data Bank reporting requirements (e.g., was a reportable
event). You may NOT dispute the appropriateness of any action, finding or judgment, or information
regarding the facts or circumstances that led to the reported action. You also must contact the reporting
entity or its agent, identified in Section A of the report, to attempt to resolve disputed issues. (Do not
contact the reporting entity for information about Data Bank reporting requirements or operational
procedures.) The report will remain in disputed status until either you take action to elevate the report for
Secretarial Review or you withdraw the report from disputed status.
Information in Data Bank reports can be changed only by the entity that submitted the report or by the
Secretary of the U.S. Department of Health and Human Services following review. The report will remain
in the Data Bank(s) unchanged until the reporting entity or the Secretary changes it.
OMB # 0915-0239 expiration date 10/31/10
OMB # 0915-0126 expiration date 07/31/10
Public Burden Statement: 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 numbers for this project are 0915-0239 (HIPDB) and 0915-0126 (NPDB). Public reporting burden
for this collection of information is estimated to average 5 minutes to complete this form, 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 14-22, Rockville, Maryland, 20857.
The referenced report is currently NOT in disputed status.
Check here if you wish to place the referenced report in disputed status. If you wish to add a
statement to the report only and do not wish to place the report in disputed status then do not check the
box.
c
d
e
f
g

address. You may update the addresses that the Data Bank(s) have on file below. However, this does
not change your addresses as reflected in the report filed with the Data Bank(s). Only the entity that
originally submitted the report can modify or correct information provided in the report. You should
contact the entity identified in Section A of the report and request that it make the address correction.
Home Address/Address of Record
Street Address:
Address Line 2:
City:
State:
ZIP Code:

CHOOSE ONE FROM LIST

Country (if U.S., leave blank):

Work Address
Street Address:

123 MAIN STREET

Address Line 2:
City:

FAIRFAX

State:
ZIP Code:

VA Virginia

22033

Country (if U.S., leave blank):

CERTIFICATION
I certify that I am the individual subject identified in Section B of the referenced report, or that I am the
designated employee representing the organization subject referenced in Section B, and I request that
the action(s) above be taken.
Authorized Submitter's Name:
Authorized Submitter's Title:
Authorized Submitter's Phone:
Date (MMDDYYYY):

Ext.
03032009

REQUEST FOR SECRETARIAL REVIEW

National Practitioner Data Bank
Healthcare Integrity and Protection Data Bank

At your request, the report identified below has been placed in disputed status. All queriers who
previously received the report are notified that the information they received from the National
Practitioner Data Bank (NPDB) and/or the Healthcare Integrity and Protection Data Bank (HIPDB) is in
dispute. The reporting entity, identified in Section A, also has been notified.
OMB # 0915-0239 expiration date 10/31/10
OMB # 0915-0126 expiration date 07/31/10
Public Burden Statement: 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 numbers for this project are 0915-0239 (HIPDB) and 0915-0126 (NPDB). Public reporting burden
for this collection of information is estimated to average 8 hours to complete the activities associated
with this form, 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 14-22, Rockville, Maryland, 20857.
Report Type:
Report Number:
Subject's Name:
Report Maintained Under:

STATE LICENSURE ACTION
7930000052539805
MOOSE, JOHN
[X] Title IV (NPDB)
[X] Section 1128E (HIPDB)

REQUESTING SECRETARIAL REVIEW
Before requesting a review by the Secretary of the U.S. Department of Health and Human Services
(HHS), you must first attempt to resolve the disagreement with the reporting entity. If your disagreement
cannot be resolved through discussions with the reporting entity (e.g., the reporting entity declines to
change the report), you may then request that the Secretary review the report for accuracy.
Please be advised that the Secretary will review your case only to determine the following:
z
z

Whether a report should have been filed in accordance with reporting regulations, and if so,
If the information contained in the report is a factually accurate reflection of the action
taken and the reasons the action was taken are specified in relevant documents.

The Secretary will not review the merits of a medical malpractice claim in the case of a payment or the
appropriateness of, or basis for, an adverse action or judgment or conviction. The Secretary can only
determine if the action was reportable and if the report accurately describes the action and the reasons
the action was taken. The Secretary cannot review the extent to which entities followed due process
guidelines. Due process issues must be resolved between the subject and the reporter.
As part of the Secretarial Review process, you should submit to the Data Banks documentation that
supports your position that the reporting entity's information is inaccurate. Documentation must relate
directly to the facts in dispute and substantially contribute to a determination of the factual accuracy of
the report. Documentation may not exceed 10 pages, including attachments and exhibits. Click Help for
examples of acceptable documentation.
You must also submit proof that you attempted to resolve the disagreement with the reporting entity, but

were unsuccessful (e.g., a copy of your correspondence to the reporting entity and the entity's response,
if any).
To proceed with your request for Secretarial Review, follow the instructions below and click Continue.
Otherwise, click Return to Report Response Options at the bottom of this page.
Do not print this page. A printable copy of your request will be provided after submission.
Below is the Subject Statement that you submitted in reference to the specified report. To change this
statement, click Return to Report Response Options at the bottom of the page, then click Statement
and Dispute. Once you are satisfied with your Subject Statement, return to this screen to continue
processing your request for Secretarial Review.
COMMENTS TO SECRETARY
Comments directed to the Secretary must be entered below. Enter a clear and brief statement
describing which facts are in dispute, what you believe to be the correct facts, and, if appropriate, why
you believe the report should not have been filed. Your comments must be in English and may not
exceed 4,000 characters, including spaces and punctuation. These comments are to the Secretary
and do not replace the Subject Statement that you may have previously submitted. These
comments will not be disclosed as part of your report.

There are 4000 characters remaining for the comments.
j
k
l
m
n

I have attempted to resolve my dispute with the reporting entity and, after 30 days, have received no
response.
OR

j
k
l
m
n

I have attempted to resolve my dispute with the reporting entity; however, the entity has declined to
correct or void the report.

CURRENT ADDRESSES
Future correspondence from the Data Bank(s) will be mailed to the address specified. Note: If you
provide both your home and work addresses, the Data Bank(s) will send correspondence to your home
address. You may update the addresses that the Data Bank(s) have on file below. However, this does
not change your addresses as reflected in the report filed with the Data Bank(s). Only the entity that
originally submitted the report can modify or correct information provided in the report. You should
contact the entity identified in Section A of the report and request that it make the address correction.

Home Address/Address of Record
Street Address:
Address Line 2:
City:
State:
ZIP Code:

CHOOSE ONE FROM LIST

Country (if U.S., leave blank):

Work Address
Street Address:

123 MAIN STREET

Address Line 2:
City:

FAIRFAX

State:
ZIP Code:

VA Virginia

22033

Country (if U.S., leave blank):

Ext.
03032009

Entity: TEST ENTITY (FAIRFAX, VA)
Complete this form to select an authorized agent who can query and/or report on your
behalf. Specify (1) the last four digits of the agent's Data Bank Identification Number, (2)
the Agent Organization Name, City, State, ZIP Code, and Country (if applicable), (3)
whether to allow the agent to query or report, (4) whether query and/or report responses
will be routed to the agent or the entity, and (5) whether the agent's or the entity's EFT
account will be charged when EFT is the method of payment used for a query submission.
Once the data provided here is validated, you will be instructed to print the Agent
Designation Request for your records. This document will serve as the sole record of your
request.
OMB # 0915-0239 expiration date 10/31/10
OMB # 0915-0126 expiration date 07/31/10
Public Burden Statement: 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 numbers for this project are 0915-0239 (HIPDB) and 0915-0126 (NPDB). Public reporting burden
for this collection of information is estimated to average 15 minutes to complete this form, 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 14-22, Rockville, Maryland, 20857.
AGENT INFORMATION
Data Bank Identification Number
(last 4 digits):
Agent Organization Name:
City:
State:
ZIP Code:

CHOOSE ONE FROM LIST

Country (if U.S., leave blank):

CONFIGURATION
I authorize my agent to submit the following transactions on my behalf:
c Query
d
e
f
g
c Proactive Disclosure Service (PDS)
d
e
f
g
c Report
d
e
f
g
I authorize my agent to use my entity's EFT account to pay for queries submitted on my entity's behalf:
NOTE: When an entity designates an authorized agent to query and/or report on behalf of the entity,
the entity is ultimately responsible for payment (even if EFT charges are directed to that
agent). Payment may also be made by credit card at the time of querying, regardless of EFT routing
assignment.
j
k
l
m
n

Yes

j
k
l
m
n

Route responses to my agent's submission to:
j Only my entity
k
l
m
n
j Only my agent
k
l
m
n
j Both my entity and my agent
k
l
m
n
Return responses to my entity via:
m
n IQRS
j
k
l
m
n ITP
j
k
l
m
n QRXS
j
k
l

CERTIFICATION
I certify that I am authorized to designate the authorized agent identified above to report to
and/or query the NPDB-HIPDB on my behalf.
Name of Certifying Official:
Title of Certifying Official:
Telephone:
Certification Date (MMDDYYYY):

Ext.
03282008

Entity: TEST ENTITY (FAIRFAX, VA)
Complete this form to modify an authorized agent who can query and/or report on your
behalf. Specify (1) whether query and/or report responses will be routed to the agent or
the entity, and (2) whether the agent's or the entity's EFT account will be charged when
EFT is the method of payment used for a query submission. Once the data provided here
is validated, you will be instructed to print the Agent Designation Request for your
records. This document will serve as the sole record of your request.
OMB # 0915-0239 expiration date 10/31/10
OMB # 0915-0126 expiration date 07/31/10
Public Burden Statement: 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 numbers for this project are 0915-0239 (HIPDB) and 0915-0126 (NPDB). Public reporting burden
for this collection of information is estimated to average 5 minutes to complete this form, 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 14-22, Rockville, Maryland, 20857.
AGENT INFORMATION
Agent Organization Name:
Address:
City, State, Zip

TEST AGENT
123 MAPLE STREET
FAIRFAX, VA 22033

CONFIGURATION
I authorize my agent to submit the following transactions on my behalf:
b Query
c
d
e
f
g
c Proactive Disclosure Service (PDS)
d
e
f
g
b Report
c
d
e
f
g
I authorize my agent to use my entity's EFT account to pay for queries submitted on my entity's behalf:
NOTE: When an entity designates an authorized agent to query and/or report on behalf of the entity,
the entity is ultimately responsible for payment (even if EFT charges are directed to that
agent). Payment may also be made by credit card at the time of querying, regardless of EFT routing
assignment.
i Yes
j
k
l
m
n
j No
k
l
m
n
Route responses to my agent's submission to:
j Only my entity
k
l
m
n
j Only my agent
k
l
m
n
i Both my entity and my agent
j
k
l
m
n
Return responses to my entity via:
i
j
k
l
m
n

IQRS

j
k
l
m
n
j
k
l
m
n

ITP
QRXS

Ext.
03282008

Complete this form to authorize payment of user fees directly from your bank account.
Limit your responses to the number of characters, including spaces and punctuation,
specified in parentheses for each field.
OMB # 0915-0239 expiration date 10/31/10
OMB # 0915-0126 expiration date 07/31/10
Public Burden Statement: 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 numbers for this project are 0915-0239 (HIPDB) and
0915-0126 (NPDB). Public reporting burden for this collection of information is estimated to
average 15 minutes to complete this form, 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 14-22, Rockville, Maryland, 20857.
ACCOUNT INFORMATION
Bank Routing Number (9 digits):
Bank Account Number (max 17 digits):
Bank Account Type:

j Checking
k
l
m
n
j Savings
k
l
m
n

Bank routing information can be found on your check. See picture below.

CERTIFICATION

Name of Certifying Official:
Title of Certifying Official:
Telephone:

Ext.

Certification Date (MMDDYYYY):

11182008

National Practitioner Data Bank
Healthcare Integrity and Protection Data Bank
ACCOUNT DISCREPANCY
If you cannot reconcile your credit card account statement or Electronic Funds Transfer (EFT) account statement, and
determine that your account should be reviewed, please provide the information requested below. Type or print legibly in
ink. Numbers in parentheses indicate the maximum number of characters including spaces and punctuation allowed per field.
OMB # 0915-0239 expiration date 08/31/07
OMB # 0915-0126 expiration date 05/31/07
Public Burden Statement: 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 numbers for this project are
0915-0239 (HIPDB) and 0915-0126 (NPDB). Public reporting burden for this collection of information is estimated to
average 15 minutes to complete this form, 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 14-22, Rockville, Maryland, 20857.
Data Bank Identification Number (DBID) (15): |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
Telephone: Area Code (3) _____________ Number (7) _________________________ Extension (5) _________________
Printed Name of Entity Representative (40): ______________________________________________________________
Signature of Entity Representative: ______________________________________________________________
Signature Date: _____________________________________
Credit Card Number (if applicable): |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
Credit Card Expiration Date (MM/YY): |___|___|___|___|
Dollar Amount of the Suspected Error(s): $ _______________
Please provide an explanation of your discrepancy and include the Data Bank Control Number (DCN), if applicable:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Attach a copy of your credit card statement or EFT account statement and the charge receipt. Highlight the charge(s) that you
believe you were charged in error.
For additional information, visit the NPDB-HIPDB Web site at www.npdb-hipdb.hrsa.gov. If you need assistance, contact the
NPDB-HIPDB Customer Service Center by e-mail at help@npdb-hipdb.hrsa.gov or by phone at 1-800–767–6732
(TDD 703-802-9395). Information Specialists are available to speak with you weekdays from 8:30 a.m. to 6:00 p.m.
(5:30 p.m. on Fridays) Eastern Time. The NPDB-HIPDB Customer Service Center is closed on all Federal holidays.

July 2008

1 of 1

NPDB-00958.05.00

File Type	application/pdf
File Title	https://www.npdb-hipdb.hrsa.gov/servlet/QueryInputServlet?FORM_
Author	herrk
File Modified	2009-11-20
File Created	2009-10-19