1 60.9: Licensure Actions

Report Input Form

https://www.npdb-hipdb.hrsa.gov/servlet/WebInputServlet?AAC_COD...

STATE LICENSURE

Individual Subject: Initial Report

Please provide as much of the following information as possible. Failure to provide sufficient
information to permit identification of a single subject will result in the report being rejected,
necessitating resubmission.
Do not print this page. A printable copy of your report submission will be provided after submission.
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 the forms,
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:
Birth
Date(MMDDYYYY):
Work Organization
Name:

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Male

Female

Unknown

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Organization Type:
Description (if 'Other' was selected above):

ADDRESSES
Click

for information on filling out non-U.S. and military addresses.

Work Address
Street Address:
Address Line 2:
City:
State:
ZIP Code:

-

Country (if U.S., leave
blank):
Home Address/Address of
Record
Street Address:
Address Line 2:
City:
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)

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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
The form will suggest medical schools as you type. Please choose the matching
school or enter the complete school name.
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

No License

State of Licensure:
Occupation/Field of
Licensure:

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Description (complete only if 'Other' is selected above):

Specialty:

HEALTH CARE ENTITIES WITH WHICH THE SUBJECT IS AFFILIATED OR ASSOCIATED
Inclusion of an affiliated/associated health care entity in this report does not imply complicity in the
reported action.
for information on filling out non-U.S. and military addresses.

Click
1.

Name of
Affiliated/Associated
Health Care Entity:
Street Address:
Address Line 2:
City:
State:
ZIP Code:

-

Country (if U.S., leave
blank):
Nature of Subject's
Relationship to Affiliate:
Other Description (complete only if 'Other' is selected above):

ADVERSE ACTION INFORMATION
BASIS FOR ACTION
Select a category and then choose a basis for action code that best describes the reason for the
action. Click Add Additional Basis For Action to provide up to 5 basis for action selections. View a
complete basis for action list.
1.

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Non-Compliance With Requirements
Criminal Conviction or Adjudication
Confidentiality, Consent or Disclosure Violations
Misconduct or Abuse
Fraud, Deception, or Misrepresentation

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Unsafe Practice or Substandard Care
Improper Supervision or Allowing Unlicensed Practice
Improper Prescribing, Dispensing, Administering Medication/Drug Violation
Other

Name of Agency or
Program that Took the
Adverse Action Specified in
This Report:
Date Action Was Taken
(MMDDYYYY):
Date Action Became
Effective (MMDDYYYY):
Length of Action:

Permanent

Indefinite/Unspecified

Specific Period
Years:
Months:
Days:
Is Reinstatement Automatic
Yes
at Completion of Adverse
Yes, with conditions (requires a Revision to Action Report when status
Action Period?
changes)
No
Total Amount of Monetary Penalty, Assessment and/or Restitution or fine (Format
NNNNN.NN):
Note: If no amount, leave this field blank.
$
Is the Adverse Action Specified in This Report Based on the Subject's Professional
Competence or Conduct, Which Adversely Affected, or Could Have Adversely Affected, the
Health or Welfare of the Patient?
Yes
No
Description of Subject's Act(s) or Omission(s) or Other Reasons for Action(s) Taken and
Description of Action(s) Taken by Reporting Entity
Note: Do not reference any personal identification
information (e.g., names) of anyone other than the subject
of this report. The description must include sufficient
specificity to enable a knowledgeable reviewer to determine
clearly the circumstances of the action(s) or surrender.
Refer to Reporting, Submitting a Factually-Sufficient
Narrative, for detailed information.

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There are 4000 characters remaining for the description.
Is the Action on Appeal?

Yes

No

Unknown

Date of Appeal (MMDDYYYY):

ENTITY INTERNAL REPORT REFERENCE
This optional field allows your entity to include an internal file number or other reference information to
help you identify this report in your files. This information is not used by the Data Banks, but it will be
provided on copies of the report sent to queriers.
Entity Internal Report Reference (e.g., claim
number):

CUSTOMER USE
This optional field may be used by the submitter to identify this transaction. This information is
returned without modification and only appears on the response returned to your organization.
Customer Use:

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:

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Authorized Submitter's Phone:
Date:

Ext.
11/02/2010

Send e-mail notification when this and any future responses are available.
Check this box if you wish to add/update 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. You will be notified of potential duplicate entries prior to completing
this subject entry.

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