Changes to Forms from 2007-2010

0915-0126_Form Changes From 2007 to 2010.docx

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

Changes to Forms from 2007-2010

OMB: 0915-0126

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Entity Registration:

  • Added new question in the Existing DBID section: “Is your organization already registered with the Data Banks?” The question is answered with a Yes/No radio button selection.

  • Entity Administrator section removed

Agent Registration:

  • Entity Administrator section removed

Entity Registration Update:

  • No changes

Agent Registration Update:

  • No changes

Entity Registration Renewal:

  • No changes

Agent Registration Renewal:

  • No changes

Initial AAR:

  • No changes

Correction AAR:

  • No changes

Correction Legacy AAR:

  • No changes

Revision to Action AAR:

  • No changes

Explicit Query:

  • No changes

Subject Database (Individual):

  • No changes

Subject Database (Organization):

  • No changes

Self Query (Individual):

  • Removed Report Password Preference section

  • Removed Payment Information section

Self Query (Organization):

  • Removed Report Password Preference section

  • Removed Payment Information section

Subject Dispute:

  • Added Home Address fields (Street Address, Address Line 2, City, State, ZIP, Country)

  • Added Work Address fields (Street Address, Address Line 2, City, State, ZIP, Country)

Secretarial Review:

  • Added Home Address fields (Street Address, Address Line 2, City, State, ZIP, Country)

  • Added Work Address fields (Street Address, Address Line 2, City, State, ZIP, Country)

Authorized Agent Designation:

  • New input: “Return responses to my entity via:” with 3 radio button options

Authorized Agent Designation Update:

  • New input: “Return responses to my entity via:” with 3 radio button options

Electronic Funds Transfer Authorization:

  • No changes

Account Discrepancy Form:

  • No changes

Initial Accreditation:

  • No changes

Accreditation Correction:

  • No changes

Accreditation Revision:

  • No changes

QIO Initial (now called Peer Review Organization Initial):

  • No changes

QIO Correction (now called Peer Review Organization Correction):

  • No changes

QIO Revision (now called Peer Review Organization Revision):

  • No changes



File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorMatt Bianchetti
File Modified0000-00-00
File Created2021-02-02

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