Download:
pdf |
pdfTo submit a query, enter all known subject data.
Explicit Query (Individual)
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.
2.
3.
4.
INDIVIDUAL TAXPAYER IDENTIFICATION NUMBERS (ITIN) (FORMAT 9NNNNNNNN)
1.
2.
3.
4.
FEDERAL EMPLOYER IDENTIFICATION NUMBERS (FEIN)
1.
2.
3.
4.
NATIONAL PROVIDER IDENTIFIERS (NPI)
1.
2.
3.
4.
DRUG ENFORCEMENT ADMINISTRATION (DEA) NUMBERS
1.
2.
3.
4.
UNIQUE PHYSICIAN IDENTIFICATION NUMBERS (UPIN)
1.
2.
3.
4.
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:
OR
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.
To submit a query, enter all known subject data.
Explicit Query (Organization)
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
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.
2.
3.
4.
SOCIAL SECURITY NUMBERS (SSN) (FORMAT NNNNNNNNN)
1.
2.
3.
4.
INDIVIDUAL TAXPAYER IDENTIFICATION NUMBERS (ITIN) (FORMAT 9NNNNNNNN)
1.
2.
3.
4.
ORGANIZATION STATE LICENSURE INFORMATION
(If no State License, check the 'No License' box.)
1. State License Number:
State of Licensure:
License
OR
c No
d
e
f
g
License
OR
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:
OR
CHOOSE ONE FROM LIST
DRUG ENFORCEMENT ADMINISTRATION (DEA) NUMBERS
1.
2.
3.
4.
CLINICAL LABORATORY IMPROVEMENT ACT (CLIA) NUMBERS
1.
2.
3.
4.
5.
6.
FEDERAL FOOD AND DRUG ADMINISTRATION (FDA) NUMBERS
1.
2.
3.
4.
5.
6.
NATIONAL PROVIDER IDENTIFIERS (NPI)
1.
2.
3.
4.
MEDICARE PROVIDER/SUPPLIER NUMBERS
1.
2.
3.
4.
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.
c
d
e
f
g
Subject Database (Individual)
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.
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:
CHOOSE ONE FROM LIST
State:
ZIP Code:
-
Country (if U.S., leave
blank):
Home Address/Address of
Record
Street Address:
Address Line 2:
City:
CHOOSE ONE FROM LIST
State:
ZIP Code:
-
Country (if U.S., leave
blank):
Is Subject Deceased?
No
Unknown
Yes--Deceased
Date (MMDDYYYY)
SOCIAL SECURITY NUMBERS (SSN) (FORMAT NNNNNNNNN)
1.
2.
3.
4.
INDIVIDUAL TAXPAYER IDENTIFICATION NUMBERS (ITIN) (FORMAT 9NNNNNNNN)
1.
2.
3.
4.
FEDERAL EMPLOYER IDENTIFICATION NUMBERS (FEIN)
1.
2.
3.
4.
NATIONAL PROVIDER IDENTIFIERS (NPI)
1.
2.
3.
4.
DRUG ENFORCEMENT ADMINISTRATION (DEA) NUMBERS
1.
2.
3.
4.
UNIQUE PHYSICIAN IDENTIFICATION NUMBERS (UPIN)
1.
2.
3.
4.
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:
OR
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
Subject Database (Organization)
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
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:
CHOOSE ONE FROM LIST
State:
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.
2.
3.
4.
SOCIAL SECURITY NUMBERS (SSN) (FORMAT NNNNNNNNN)
1.
2.
3.
4.
INDIVIDUAL TAXPAYER IDENTIFICATION NUMBERS (ITIN) (FORMAT 9NNNNNNNN)
1.
2.
3.
4.
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
OR
c No
d
e
f
g
License
OR
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:
OR
CHOOSE ONE FROM LIST
DRUG ENFORCEMENT ADMINISTRATION (DEA) NUMBERS
Title
1.
2.
3.
4.
CLINICAL LABORATORY IMPROVEMENT ACT (CLIA) NUMBERS
1.
2.
3.
4.
5.
6.
FEDERAL FOOD AND DRUG ADMINISTRATION (FDA) NUMBERS
1.
2.
3.
4.
5.
6.
NATIONAL PROVIDER IDENTIFIERS (NPI)
1.
2.
3.
4.
MEDICARE PROVIDER/SUPPLIER NUMBERS
1.
2.
3.
4.
National Practitioner Data Bank
Healthcare Integrity and Protection Data Bank
SUBJECT INFORMATION
Subject
Information
Output Options
Payment
Information
Final Steps
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
Print
Self-Query
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:
n Male n
j
k
l
m
j Female
k
l
m
Birth Date
(MMDDYYYY):
Work
Organization
Name:
Organization
CHOOSE ONE FROM LIST
Type:
Description (if 'Other' was selected above):
6
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:
6
-
Country (if U.S., leave
blank):
Telephone:
Ext.
SOCIAL SECURITY NUMBERS (SSN) (FORMAT NNNNNNNNN)
1.
2.
3.
4.
INDIVIDUAL TAXPAYER IDENTIFICATION NUMBERS (ITIN) (FORMAT 9NNNNNNNN)
1.
2.
3.
4.
FEDERAL EMPLOYER IDENTIFICATION NUMBERS (FEIN)
1.
2.
3.
4.
NATIONAL PROVIDER IDENTIFIERS (NPI)
1.
2.
3.
4.
DRUG ENFORCEMENT ADMINISTRATION (DEA) NUMBERS
1.
2.
3.
4.
UNIQUE PHYSICIAN IDENTIFICATION NUMBERS (UPIN)
1.
2.
3.
4.
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:
OR
c
d
e
f
g
No License
State of Licensure:
CHOOSE ONE FROM LIST
Occupation/Field of
Licensure:
CHOOSE ONE FROM LIST
6
6
Description (complete only if 'Other' is selected above):
Specialty:
CHOOSE ONE FROM LIST
6
Return to Previous Page
National Practitioner Data Bank
Healthcare Integrity and Protection Data Bank
SUBJECT INFORMATION
Subject
Information
Output Options
Payment
Information
Final Steps
ORGANIZATION SELF-QUERY INSTRUCTIONS
Complete the Organization 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 organization 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 selfquery 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 organization self-query are sent
only to the organization's address as certified on the self-query form. Health care
organizations that 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
Print
Self-Query
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:
6
-
Country (if U.S., leave
blank):
Organization Type:
CHOOSE ONE FROM LIST
Description (if 'Other' was selected above):
FEDERAL EMPLOYER IDENTIFICATION NUMBERS (FEIN)
1.
2.
3.
4.
SOCIAL SECURITY NUMBERS (SSN) (FORMAT NNNNNNNNN)
1.
2.
3.
4.
INDIVIDUAL TAXPAYER IDENTIFICATION NUMBERS (ITIN) (FORMAT 9NNNNNNNN)
1.
2.
3.
4.
ORGANIZATION STATE LICENSURE INFORMATION
(If no State License, check the 'No License' box.)
6
1. State License Number:
State of Licensure:
OR
CHOOSE ONE FROM LIST
2. State License Number:
State of Licensure:
State of Licensure:
CHOOSE ONE FROM LIST
c No
d
e
f
g
License
c No
d
e
f
g
License
6
OR
CHOOSE ONE FROM LIST
License
6
OR
3. State License Number:
c No
d
e
f
g
6
DRUG ENFORCEMENT ADMINISTRATION (DEA) NUMBERS
1.
2.
3.
4.
CLINICAL LABORATORY IMPROVEMENT ACT (CLIA) NUMBERS
1.
2.
3.
4.
5.
6.
FEDERAL FOOD AND DRUG ADMINISTRATION (FDA) NUMBERS
1.
2.
3.
4.
5.
6.
NATIONAL PROVIDER IDENTIFIERS (NPI)
1.
2.
3.
4.
MEDICARE PROVIDER/SUPPLIER NUMBERS
1.
2.
3.
4.
CERTIFICATION
I certify that I am authorized to submit this transaction and that all information is true and correct to the
best of my knowledge.
Authorized Submitter's Name:
Authorized Submitter's Title:
Authorized Submitter's Phone:
Date:
Ext.
11/18/2009
Return to Previous Page
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
7930000059491279
PAUL, GEORGE
[ ] Title IV (NPDB)
[X] Section 1921 (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.
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:
Address Line 2:
City:
State:
ZIP Code:
CHOOSE ONE FROM LIST
-
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.
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
7930000059491279
PAUL, GEORGE
[ ] Title IV (NPDB)
[X] Section 1921 (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.
I have attempted to resolve my dispute with the reporting entity and, after 30 days, have received no
response.
OR
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:
Address Line 2:
City:
State:
ZIP Code:
CHOOSE ONE FROM LIST
-
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.
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
No
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:
j IQRS
k
l
m
n
j ITP
k
l
m
n
j QRXS
k
l
m
n
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
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
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 [email protected] 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 | NPDB-HIPDB-2 Updated |
| File Modified | 2010-05-26 |
| File Created | 2010-05-26 |