hipdb_eauth_001

Instructions for Registering as an NPDB-HIPDB Certifying Official and Data Bank Administrator

1. Click your browser’s Print button or select File>Print… from the menu to send this document to a local printer. Do not close the window that contains this document until you have made sure that the document printed in its entirety.

2. Make sure you have read the Summary of Terms section of the NPDB-HIPDB Certifying Official and Data Bank Administrator Registration document.

3. Do not sign the document yourself yet; a Notary Public must witness your signature as described below.

4. Take the NPDB-HIPDB Certifying Official and Data Bank Administrator Registration document and the credentials listed below to a person certified by a State or Federal Government as being authorized to confirm identities (such as Notary Public), that uses a stamp, seal, or other mechanism to authenticate their identity confirmation.

Credentials to Present to the Notary Public:
You must present the following credentials to the Notary that proves your identity and affiliation with your healthcare organization for which you are certifying to the NPDB-HIPDB:

1. One form of ID must be a valid State or Federal government-issued photo ID. Forms of acceptable ID are as follows: A state-issued photo ID (with a serial number) such as a driver’s license, Passport from country of citizenship, federal, state or local government agency (must have name, date of birth, gender, height, eye color and address), US military ID, Certificate of U.S. Citizenship, Certificate of Naturalization, permanent or unexpired temporary resident card, Native American tribal document, or Canadian driver’s license.

AND

2. The work badge issued by your organization OR a signed letter on company letterhead from an authorized official in your organization attesting to your affiliation with the healthcare organization for which you are certifying.

5. Sign and date the NPDB-HIPDB Certifying Official and Data Bank Administrator Registration document in the presence of the Notary Public who will complete his/her section of the document.

6. If you are submitting this paperwork as part of a new registration (or re-registration) of your healthcare organization, the following items must be mailed to the NPDB-HIPDB for processing:

1. The original, notarized NPDB-HIPDB Certifying Official and Data Bank Administrator Registration document

AND

A photocopy of your work badge or the original authorization letter (whichever you presented to the Notary).

2. Your healthcare organization’s registration document (i.e., the NPDB-HIPDB Entity Registration or Agent Registration document).

5. Mail all registration documents to:

National Practitioner Data Bank - Healthcare Integrity and Protection Data Bank

P.O. Box 10832

Chantilly, VA 20153-0832

Note: Faxed or scanned copies will not be accepted.

5. If you are replacing a Certifying Official and Data Bank Administrator for an organization that is currently registered with the NPDB-HIPDB, then please indicate so on the registration document in the field provided. In this case, send only the original, notarized NPDB-HIPDB Certifying Official and Data Bank Administrator Registration document AND a photocopy of your work badge or the original authorization letter (whichever you presented to the Notary) to the address above.

6. The NPDB-HIPDB will process the registration documents and if the registration is approved, you shall receive confirmation via e-mail with instructions on how to proceed.

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.

S ummary of Terms: You (the "Registrant"), as the Certifying Official of the healthcare 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 the 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 or the HIPDB other than the purposes for which it was provided. You are also registering as a Data Bank Administrator for an Entity or Authorized Agent registered or registering with the NPDB-HIPDB. As a Data Bank Administrator, you are responsible for overseeing the use of the NPDB-HIPDB online services at your organization, identity proofing applicants who request a user account, establishing and revoking individual user accounts, and maintaining your organization’s registration with the NPDB-HIPDB. By signing below, you acknowledge your acceptance of the Summary of Terms in which you 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 NIPDB-HIPDB 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-HIPDB 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-HIPDB to complete or clarify document may be punishable by criminal, civil, or other administrative actions including fines, penalties, and/or imprisonment under Federal law.

Name (First Name, Middle Initial, Last Name):	Title: A re you replacing a registered Certifying Official/ Data Bank Administrator? Yes No
Employer/Organization:	Employee ID:
Business Address:	Telephone:
E-mail:
Registrant’s Signature and Date*: ___________ ______________________________________ __________ (*Sign and date in the presence of the Notary Public) (Date)

S ection 2 – Notary Public Instructions: Record the information below for the Registrant’s government-issued photo ID for the purpose of identity proofing. In addition, you must verify that the Registrant presented either a c urrent work badge or a proof of affiliation letter on company letterhead.

Government-issued ID (Photo, Name, Serial Number, Expiration Date, Address, and Date of Birth Required)	Organization Affiliation (check one)
Exact Name Listed on ID	T he Registrant presented his/her work badge as proof of organizational affiliation. OR The Registrant presented an original copy of a P roof of Organizational Affiliation letter on company letterhead as proof of organizational affiliation.
Date of Birth
Serial Number
Expiration Date
Identification Type
Date of Issuance
Issuing Authority

N

Notary Public seal here

otary 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 section, who signed or attested the same in my presence, and presented one government-issued form of photo ID as proof of his or her identity. In addition, I have reviewed the Registrant’s work badge or an original copy of the Registrant’s organizational affiliation letter on company letterhead submitted as proof of organizational affiliation.

My Commission Expires In*: _______________________

Street Address of Branch or Office: _______________________

Name of Organization Employing Notary: _______________________

* If commission does not expire, indicate "does not expire" in this field.