hipdb_eauth_007

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 of the NPDB-HIPDB User 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 User Registration document and the documents 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 the following credentials to the Notary that proves your identity and affiliation with your healthcare organization for which you are registering with the NPDB-HIPDB:

1. One form of ID must be a valid State or Federal government-issued photo ID. 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.

AND

2. The work badge issued by your organization OR a signed letter on company letterhead from an authorized official in your organization attesting to your affiliation with the healthcare organization for which you are registering with the NPDB-HIPDB.

5. Sign and date the User 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 your NPDB-HIPDB Entity/Authorized Agent Data Bank Administrator who will process it. Note: Faxed or scanned copies will not be accepted.

7. 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 (Notarization Required)

Section 1 – Registrant Instructions: The Authorized User (Registrant) must read the terms below, complete the appropriate fields, provide a government-issued ID and either provide a work badge or proof of affiliation letter on company letterhead 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:	Employee ID:
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. In addition, you must verify that the Registrant p resented either a current work badge or a proof of affiliation letter on company letterhead.

Government-issued ID (Photo, Name, Serial Number, Expiration Date, Address, and Date of Birth Required)	Organization Affiliation (check one)
Exact Name Listed on ID	T he Registrant presented his/her work badge as proof of organizational affiliation. OR The Registrant presented an original copy of a P roof of Organizational Affiliation letter on company letterhead as proof of organizational affiliation.
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. In addition, I have reviewed the Registrant’s work badge or an original copy of the Registrant’s organizational affiliation letter on company letterhead submitted as proof of organizational affiliation.

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.

Section 3 - NPDB-HIPDB Data Bank Administrator Instructions: Send the original, completed document 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.