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

ICR 202401-0906-003

OMB: 0906-0081

Federal Form Document

Forms and Documents

Document Name	Status
Form 44 Other Eligible Entity Attestation Form and Instruction	Modified
Form 43 Medical Malpractice Payer, Peer Review Organization, or Private Accreditation Organization Attestation Form and Instruction	Modified
Form 42 Hospital Attestation Form and Instruction	Modified
Form 41 Health Center Attestation Form and Instruction	Modified
Form 40 Missing Report from Query Form Form and Instruction	Modified
Form 39 Account Balance Transfer Form and Instruction	Modified
Form 38 Education Request Form and Instruction	Modified
Form 37 Purchase Query Credits Form and Instruction	Modified
Form 36 New Administrator Request Form and Instruction	Modified
Form 35 Account Discrepancy Form and Instruction	Modified
Form 34 Authorized Agent Designation Form and Instruction	Modified
Form 33 Electronic Transfer of Funds (EFT) Authorization Form and Instruction	Modified
Form 32 Agent Registration (Renewal & Update) Form and Instruction	Modified
Form 31 Agent Registration (Initial) Form and Instruction	Modified
Form 30 Reconciling Missing Actions Form and Instruction	Modified
Form 29 Corrective Action Plan (Entity) Form and Instruction	Modified
Form 28 State Licensing Board Attestation Form and Instruction	Modified
Form 27 State Licensing Board Data Request Form and Instruction	Modified
Form 26 Authorized Agent Attestation Form and Instruction	Modified
Form 25 Entity Registration (Renewal & Update) Form and Instruction	Modified
Form 24 Entity Registration (Initial) Form and Instruction	Modified
Form 23 Request for Dispute Resolution Form and Instruction	Modified
Form 22 Subject Statement and Dispute Form and Instruction	Modified
Form 21 Continuous Query Form and Instruction	Modified
Form 20 Self-Query on an Organization Form and Instruction	Modified
Form 19 Self-Query on an Individual Form and Instruction	Modified
Form 18 One Time Query for an Organization Form and Instruction	Modified
Form 17 One Time Query for an Individual Form and Instruction	Modified
Form 16 Health Plan Action Form and Instruction	Modified
Form 15 Government Administrative Form and Instruction	Modified
Form 14 Exclusion/Debarment Form and Instruction	Modified
Form 13 Civil Judgment Form and Instruction	Modified
Form 12 Injunction Form and Instruction	Modified
Form 11 Nolo Contendere (no contest) plea Form and Instruction	Modified
Form 10 Deferred Conviction or Pre-Trial Diversion Form and Instruction	Modified
Form 9 Criminal Conviction (Guilty Plea or Trial) Form and Instruction	Modified
Form 8 Professional Society Form and Instruction	Modified
Form 7 Title IV Clinical Privileges Actions Form and Instruction	Modified
Form 6 Accreditation Form and Instruction	Modified
Form 5 Peer Review Organization Form and Instruction	Modified
Form 4 DEA/Federal Licensure Form and Instruction	Modified
Form 3 State Licensure Form and Instruction	Modified
Form 2 Medical Malpractice Payment Form and Instruction	Modified
Form 1 Correction, Revision to Action, Correction of Revision to Action, Void, Action on Appeal Form and Instruction	Modified
NPDB Supporting Statement A - Revised 11062023.docx Supporting Statement A	2023-11-08

IC Document Collections

IC ID	Document Title	Status
245415	Other Eligible Entity Attestation Form and Instruction	Modified
245414	Medical Malpractice Payer, Peer Review Organization, or Private Accreditation Organization Attestation Form and Instruction	Modified
245413	Hospital Attestation Form and Instruction	Modified
245412	Health Center Attestation Form and Instruction	Modified
229942	Missing Report from Query Form Form and Instruction	Modified
229941	Account Balance Transfer Form and Instruction	Modified
229939	Education Request Form and Instruction	Modified
214939	Purchase Query Credits Form and Instruction	Modified
214938	New Administrator Request Form and Instruction	Modified
214937	Account Discrepancy Form and Instruction	Modified
214936	Authorized Agent Designation Form and Instruction	Modified
214935	Electronic Transfer of Funds (EFT) Authorization Form and Instruction	Modified
214934	Agent Registration (Renewal & Update) Form and Instruction	Modified
214933	Agent Registration (Initial) Form and Instruction	Modified
206509	Reconciling Missing Actions Form and Instruction	Modified
206508	Corrective Action Plan (Entity) Form and Instruction	Modified
206507	State Licensing Board Attestation Form and Instruction	Modified
206506	State Licensing Board Data Request Form and Instruction	Modified
206505	Authorized Agent Attestation Form and Instruction	Modified
206504	Entity Registration (Renewal & Update) Form and Instruction	Modified
206503	Entity Registration (Initial) Form and Instruction	Modified
206502	Request for Dispute Resolution Form and Instruction	Modified
206501	Subject Statement and Dispute Form and Instruction	Modified
206500	Continuous Query Form and Instruction	Modified
206499	Self-Query on an Organization Form and Instruction	Modified
206498	Self-Query on an Individual Form and Instruction	Modified
206497	One Time Query for an Organization Form and Instruction	Modified
206496	One Time Query for an Individual Form and Instruction	Modified
206495	Health Plan Action Form and Instruction	Modified
206494	Government Administrative Form and Instruction	Modified
206493	Exclusion/Debarment Form and Instruction	Modified
206492	Civil Judgment Form and Instruction	Modified
206491	Injunction Form and Instruction	Modified
206490	Nolo Contendere (no contest) plea Form and Instruction	Modified
206489	Deferred Conviction or Pre-Trial Diversion Form and Instruction	Modified
206488	Criminal Conviction (Guilty Plea or Trial) Form and Instruction	Modified
206487	Professional Society Form and Instruction	Modified
206486	Title IV Clinical Privileges Actions Form and Instruction	Modified
206485	Accreditation Form and Instruction	Modified
206484	Peer Review Organization Form and Instruction	Modified
206483	DEA/Federal Licensure Form and Instruction	Modified
206482	State Licensure Form and Instruction	Modified
206481	Medical Malpractice Payment Form and Instruction	Modified
206480	Correction, Revision to Action, Correction of Revision to Action, Void, Action on Appeal Form and Instruction	Modified