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Make sure you have read the Summary of Terms of the Investigative Search Registration document.
Do not sign the registration document yourself yet; a Notary Public must witness your signature as described below.
Take the Investigative Search 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 organization for which you are
registering with the NPDB-HIPDB:
One form of ID must be a valid State or Federal government-issued photo ID (that is not a work badge). 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, 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
A work badge issued by the federal, state or local government agency (must have name, date of birth, gender, height, eye color and address) OR a signed letter on official agency letterhead from an authorized official in your organization attesting to your affiliation with the agency for which you are registering with the NPDB-HIPDB as an Investigator Search user.
Sign and date the Investigative Search Registration document in the presence of the Notary Public who will complete his/her section of the document.
Send the original, notarized Investigative Search Registration document with a photocopy of your work badge or the original authorization letter (whichever you presented to the Notary) 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.
NPDB-HIPDB will process the registration request and notify you of the results. If the registration request is approved, you shall receive confirmation via the postal mail with instructions on how to log into the system.
Section
1 – Registrant Instructions:
The Investigative Search user (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") are registering to be an
Investigative Search user for an organization that is registered or
actively registering with the NPDB-HIPDB. As an Investigative Search
user, you are responsible for performing searches on both individuals
and organizations to determine if there is any prior criminal or
fraudulent behavior that has been reported to the HIPDB. By signing
below, you acknowledge your acceptance of the Summary of Terms in
which you agree to provide complete and accurate responses to request
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 this 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: |
Employer/Organization:
|
Employee ID: |
Business Address:
|
Telephone: |
E-mail: |
Name of Your Agency’s NPDB-HIPDB Data Bank Administrator: |
Registrant’s Signature and Date*:
(*Sign and date in the presence of the Notary Public) (Date) |
Note: Use an ink pen to cross out any mistake, write in the correct information and initial it.
S
ection
2 – Notary Public Instructions:
The Notary Public must 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
p
resented
either a current 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
OR The
Registrant presented an original copy of a P |
Date
of Birth |
|
Serial
Number |
|
Expiration Date |
|
Identification Type |
|
Date of Issuance |
|
Issuing Authority |
N
Notary
Public seal here
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.
File Type | application/msword |
File Title | Instructions for the HHS PKI Certificates Request Form |
Author | RigneyK |
Last Modified By | Kathy |
File Modified | 2010-06-11 |
File Created | 2010-06-11 |