hipdb_eauth_005

Instructions for Registering as an NPDB-HIPDB Self-Querier

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 form until you have made sure that the document printed in its entirety.

2. Make sure you have read the Summary of Terms of the NPDB-HIPDB Self-Querier Registration document.

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

4. Take the NPDB-HIPDB Self-Querier Registration document and one form of identification (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 one valid State or Federal government-issued photo ID to the Notary that proves your identity for which you are registering with the NPDB-HIPDB. 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) ID, 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.

5. Sign and date the NPDB-HIPDB Self-Querier Registration document in the presence of the Notary Public who will complete his/her section of the form.

6. Mail the completed, notarized form 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 NPDB-HIPDB approves your request, you will receive an email confirmation with login information to your new account.

NPDB-HIPDB Self-Querier Registration

Section 1 – Registrant Instructions: The Authorized User (Registrant) must read the terms below, complete the appropriate fields, and provide a government-issued ID before signing and dating the form in front of the Notary Public.

S ummary of Terms: You (the "Registrant") are applying to be a registered user of the NPDB-HIPDB system. 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 NPDB-HIPDB and that the information provided is true, correct, and complete. If I become aware that any information in 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:
Employer/Organization:	Telephone:
Business Address:	E-mail:
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.

Government-issued ID (Photo, Name, Serial Number, Expiration Date, Address, and Date of Birth Required)

Exact Name Listed on ID

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.

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.