National Practitioner Data Bank for Adverse Information on Physicians and Other Health Care Practitioners: Regulations and Forms

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 0915-0126 NPDB For NPDB Forms	Form	Removed	Available
Form NPDB Identity Proo NPDB Identity Proofing Forms	Form and Instruction	Removed	Available
Form 30 Account Discrepancy	Form and Instruction	New	Available
Form 29 Authorized Agent Designation	Form and Instruction	New	Available
Form 28 Electronic Transfer of Funds (ETF) Authorization	Form and Instruction	New	Available
Form 27 Agent Registration (Renewal & Update)	Form and Instruction	New	Available
Form 26 Agent Registration (Initial)	Form and Instruction	New	Available
Form 25 Entity Registration (Renewal & Update)	Form and Instruction	New	Available
Form 24 Entity Registration (Initial)	Form and Instruction	New	Available
Form 23 Request for Secretarial Review	Form and Instruction	New	Available
Form 22 Subject Statement and Dispute	Form and Instruction	New	Available
Form 21 Continuous Query	Form and Instruction	New	Available
Form 20 Self-Query on an Organization	Form and Instruction	New	Available
Form 19 Self-Query on an Individual	Form and Instruction	New	Available
Form 18 One Time Query for an Organization	Form and Instruction	New	Available
Form 17 One Time Query for an Individual	Form and Instruction	New	Available
Form 16 Health Plan Action	Form and Instruction	New	Available
Form 15 Government Administrative	Form and Instruction	New	Available
Form 14 Exclusion/Debarment	Form and Instruction	New	Available
Form 13 Civil Judgement	Form and Instruction	New	Available
Form 12 Injunction	Form and Instruction	New	Available
Form 11 Nolo Contendere (no contest) plea	Form and Instruction	New	Available
Form 10 Deferred Conviction or Pre-Trial Diversion	Form and Instruction	New	Available
Form 9 Criminal Conviction (Guilty Plea or Trial)	Form and Instruction	New	Available
Form 8 Professional Society	Form and Instruction	New	Available
Form 7 Title IV Clinical Privileges Actions	Form and Instruction	New	Available
Form 6 Accreditation	Form and Instruction	New	Available
Form 5 Peer Review Organization	Form and Instruction	New	Available
Form 4 DEA/Federal Licensure	Form and Instruction	New	Available
Form 3 State Licensure	Form and Instruction	New	Available
Form 2 Medical Malpractice Payment	Form and Instruction	New	Available
Form 1 Correction, Revision to Action, Correction of Revision to Action, Void, Action on Appeal	Form and Instruction	New	Available
Form 3 60.10: Adverse Actions - Peer Review Organizations	Form and Instruction	Removed	Available
Form 1 60.9: Licensure Actions	Form and Instruction	Removed	Available
Form 2 60.10: Adverse Actions - Private Accreditation	Form and Instruction	Removed	Available
0915-0126_Form Changes From 2007 to 2010_Revision.9.1.10.doc	Supplementary Document	Uploaded 2010-09-07	Available
Supporting Statement.docx	Supporting Statement A	Uploaded 2013-04-16	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
6361	National Practitioner Data Bank for Adverse Information on Physicians and Other Health Care Pract	Form	Removed	NPDB Forms
6361	National Practitioner Data Bank for Adverse Information on Physicians and Other Health Care Pract	Form and Instruction	Removed	NPDB Identity Proofing Forms
206509	Account Discrepancy	Form and Instruction	New	Account Discrepancy
206508	Authorized Agent Designation	Form and Instruction	New	Authorized Agent Designation
206507	Electronic Transfer of Funds (ETF) Authorization	Form and Instruction	New	Electronic Transfer of Funds (ETF) Authorization
206506	Agent Registration (Renewal & Update)	Form and Instruction	New	Agent Registration (Renewal & Update)
206505	Agent Registration (Initial)	Form and Instruction	New	Agent Registration (Initial)
206504	Entity Registration (Renewal & Update)	Form and Instruction	New	Entity Registration (Renewal & Update)
206503	Entity Registration (Initial)	Form and Instruction	New	Entity Registration (Initial)
206502	Request for Secretarial Review	Form and Instruction	New	Request for Secretarial Review
206501	Subject Statement and Dispute	Form and Instruction	New	Subject Statement and Dispute
206500	Continuous Query	Form and Instruction	New	Continuous Query
206499	Self-Query on an Organization	Form and Instruction	New	Self-Query on an Organization
206498	Self-Query on an Individual	Form and Instruction	New	Self-Query on an Individual
206497	One Time Query for an Organization	Form and Instruction	New	One Time Query for an Organization
206496	One Time Query for an Individual	Form and Instruction	New	One Time Query for an Individual
206495	Health Plan Action	Form and Instruction	New	Health Plan Action
206494	Government Administrative	Form and Instruction	New	Government Administrative
206493	Exclusion/Debarment	Form and Instruction	New	Exclusion/Debarment
206492	Civil Judgment	Form and Instruction	New	Civil Judgement
206491	Injunction	Form and Instruction	New	Injunction
206490	Nolo Contendere (no contest) plea	Form and Instruction	New	Nolo Contendere (no contest) plea
206489	Deferred Conviction or Pre-Trial Diversion	Form and Instruction	New	Deferred Conviction or Pre-Trial Diversion
206488	Criminal Conviction (Guilty Plea or Trial)	Form and Instruction	New	Criminal Conviction (Guilty Plea or Trial)
206487	Professional Society	Form and Instruction	New	Professional Society
206486	Title IV Clinical Privileges Actions	Form and Instruction	New	Title IV Clinical Privileges Actions
206485	Accreditation	Form and Instruction	New	Accreditation
206484	Peer Review Organization	Form and Instruction	New	Peer Review Organization
206483	DEA/Federal Licensure	Form and Instruction	New	DEA/Federal Licensure
206482	State Licensure	Form and Instruction	New	State Licensure
206481	Medical Malpractice Payment	Form and Instruction	New	Medical Malpractice Payment
206480	Correction, Revision to Action, Correction of Revision to Action, Void, Action on Appeal	Form and Instruction	New	Correction, Revision to Action, Correction of Revision to Action, Void, Action on Appeal
199299	Section 1921 forms	Form and Instruction	Removed	60.10: Adverse Actions - Peer Review Organizations
199299	Section 1921 forms	Form and Instruction	Removed	60.9: Licensure Actions
199299	Section 1921 forms	Form and Instruction	Removed	60.10: Adverse Actions - Private Accreditation

ICR Details

OMB Control No: 0915-0126	ICR Reference No: 201304-0915-002
Status: Historical Active	Previous ICR Reference No: 201109-0915-001
Agency/Subagency: HHS/HSA	Agency Tracking No: 19186
Title: National Practitioner Data Bank for Adverse Information on Physicians and Other Health Care Practitioners: Regulations and Forms
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 05/28/2013
Retrieve Notice of Action (NOA)	Date Received in OIRA: 04/16/2013
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2016	36 Months From Approved	12/31/2013
Responses	1,696,115	0	3,720,492
Time Burden (Hours)	265,978	0	324,823
Cost Burden (Dollars)	0	0	16,732,083

---

Abstract: The National Practitioner Data Bank (NPDB) is required to receive and release under 45 CFR Part 60 certain adverse data regarding physicians, dentists, and other licensed health care practitioners. Data collected on adverse actions and information relating to the professional competence and condcut of physicians and other health care practitioners will be shared with hospitals, licensing boards, professional societies, and selected health providers. These data will be used to maintain and improve health care and will be obtained from insurers, licensure boards, hospitals, and other providers.

---

Authorizing Statute(s): PL: Pub.L. 104 - 101 221 Name of Law: Establishment of the Health Care Fraud and Abuse Data Collection Program
   PL: Pub.L. 99 - 660 402 Name of Law: Health Care Quality Improvement Act of 1986
   US Code: 42 USC 11101 Name of Law: Health Care Quality Improvement Act of 1986
   US Code: 42 USC 1301 Name of Law: Health Care and Abuse Data Collection Program
   US Code: 42 USC 136r-2 Name of Law: 2. Section 1921 of the Social Security Act
   US Code: 42 USC 1320a-7e Name of Law: 3. Section 1128E of the Social Security Act
   PL: Pub.L. 111 - 148 6403 Name of Law: Patient Protection and Affordable Care Act of 2010
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 1214	01/08/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 20929	04/08/2013
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 30

table that charts list of burden

IC Title	Form No.	Form Name
Account Discrepancy	30	Account Discrepancy
Accreditation	6	Accreditation
Agent Registration (Initial)	26	Agent Registration (Initial)
Agent Registration (Renewal & Update)	27	Agent Registration (Renewal & Update)
Authorized Agent Designation	29	Authorized Agent Designation
Civil Judgment	13	Civil Judgement
Continuous Query	21	Continuous Query
Correction, Revision to Action, Correction of Revision to Action, Void, Action on Appeal	1	Correction, Revision to Action, Correction of Revision to Action, Void, Action on Appeal
Criminal Conviction (Guilty Plea or Trial)	9	Criminal Conviction (Guilty Plea or Trial)
DEA/Federal Licensure	4	DEA/Federal Licensure
Deferred Conviction or Pre-Trial Diversion	10	Deferred Conviction or Pre-Trial Diversion
Electronic Transfer of Funds (ETF) Authorization	28	Electronic Transfer of Funds (ETF) Authorization
Entity Registration (Initial)	24	Entity Registration (Initial)
Entity Registration (Renewal & Update)	25	Entity Registration (Renewal & Update)
Exclusion/Debarment	14	Exclusion/Debarment
Government Administrative	15	Government Administrative
Health Plan Action	16	Health Plan Action
Injunction	12	Injunction
Medical Malpractice Payment	2	Medical Malpractice Payment
National Practitioner Data Bank for Adverse Information on Physicians and Other Health Care Pract	NPDB Identity Proofing Forms, 0915-0126 NPDB Forms	NPDB Identity Proofing Forms ,   NPDB Forms
Nolo Contendere (no contest) plea	11	Nolo Contendere (no contest) plea
One Time Query for an Individual	17	One Time Query for an Individual
One Time Query for an Organization	18	One Time Query for an Organization
Peer Review Organization	5	Peer Review Organization
Professional Society	8	Professional Society
Request for Secretarial Review	23	Request for Secretarial Review
Section 1921 forms	2, 1, 3	60.10: Adverse Actions - Private Accreditation ,   60.9: Licensure Actions ,   60.10: Adverse Actions - Peer Review Organizations
Self-Query on an Individual	19	Self-Query on an Individual
Self-Query on an Organization	20	Self-Query on an Organization
State Licensure	3	State Licensure
Subject Statement and Dispute	22	Subject Statement and Dispute
Title IV Clinical Privileges Actions	7	Title IV Clinical Privileges Actions

---

ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	1,696,115	3,720,492	0	-2,027,059	2,682	0
Annual Time Burden (Hours)	265,978	324,823	0	-60,857	2,012	0
Annual Cost Burden (Dollars)	0	16,732,083	0	-16,732,083	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: There are currently a total of 469,844 hours in the OMB inventory for both data banks (323,694 hours for the NPDB and 146,190 hours for the HIPDB). This request will be 265,978 hours. The result of the HIPDB-NPDB merger alleviates duplication and streamlines internal operations, resulting in a decrease of burden to users by 203,866 hours

---

Annual Cost to Federal Government: $18,041,000

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 04/16/2013

---