hipdb_eauth_006

Instructions for Registering as an NPDB-HIPDB User

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 section of the NPDB-HIPDB User Registration document.

3. Do not sign the form yourself yet; your NPDB-HIPDB Entity/Authorized Agent Data Bank Administrator must witness your signature as described below.

4. Take the NPDB-HIPDB User Registration document and one or two forms of non-expired ID described below to your Data Bank Administrator. Forms of acceptable ID are as follows:

• ID (1): A current work badge that contains a photograph, serial number, the name of the organization for which you work, and an expiration date. If the work badge has this information, you do not need to supply a second form of ID.

• ID (2): If you do not have a current work badge, or your work badge does not have a photo, serial number, name of the organization or an expiration date, you must supply a second form of government-issued photo ID such as a driver’s license, passport, military ID, or a federal agency badge. In addition, the Data Bank Administrator must confirm your employment with your organization through an enterprise records check.

5. Complete, sign and date Section 1 of the NPDB-HIPDB User Registration document in the presence of your Data Bank Administrator who will complete Section 2 of the form and mail the original copy to NPDB-HIPDB for you. Note: Faxed or scanned copies will not be accepted.

6. If your Data Bank Administrator approves your request, you will receive an email confirmation with login information to your new account.

NPDB-HIPDB User Registration

Section 1 - Registrant Instructions: The User (Registrant) must read the terms below, provide proof of identity, and then sign and date the form in front of a designated NPDB-HIPDB Data Bank Administrator. A second, government-issued ID is only required if the work badge does not have a photo, serial number, organization name or expiration date.

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 on this form 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 form or contained in any communication supplying information to the NPDB-HIPDB to complete or clarify this form 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:	Employee ID:
Employer/Organization:	Telephone:
Business Address:	E-mail:
Registrant’s Signature and Date*: ___________ _____________________________________________ __________ (*Sign and date in the presence of the NPDB-HIPDB Administrator) (Date)
Note: Use an ink pen to cross out any mistake, write in the correct information and initial it.

S ection 2 - NPDB-HIPDB Data Bank Administrator Instructions: You must record the information below for the Registrant’s work badge for the purpose of identity proofing and employment verification. If the work badge does not have a photo or any of the required fields below, you must record the information from a government-issued photo ID as well as verify the Registrant’s employment records. Send the original, completed 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.

Work Badge (Photo ID)	If the work badge supplied by the Registrant is not available or is not sufficient, complete the column to the right.	Government Issued Photo ID
Exact Name Listed on ID		Exact Name Listed on ID
Date of Birth		Date of Birth
Serial Number		Serial Number
Name of Organization Listed on ID		Expiration Date
Date of Issuance		Identification Type
Expiration Date		Date of Issuance
		Issuing Authority
		Employment Verification (check box)
		The Registrant’s employment has been verified through an enterprise records check.

On this ______ day of ________________, 20___, the Registrant listed above personally appeared before me and signed this registration document in my presence, at which time I reviewed the above-referenced identification credentials, including those containing photographs, and confirmed that: (a) the identification credentials do not appear to have been altered, forged or modified; (b) the picture(s) and name on the Photo ID(s) matched the appearance and name of the individual identified as the Registrant; and (c) the Registrant is the holder of the identification credentials presented. In addition, I have verified the Registrant’s employment by checking his/her work badge or through an enterprise records check.

_______________________________ _ ______________________________________
NPDB-HIPDB Administrator Printed Name NPDB-HIPDB Administrator’s Signature