Form 14 Exclusion/Debarment

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

14.Exclusion_Debarment

Exclusion/Debarment

OMB: 0915-0126

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Entity: TEST ENTITY (FAIRFAX, VA) | User: user

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REPORT INPUT FORM
EXCLUSION/DEBARMENT
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 05/31/14
OMB # 0915-0126 expiration date 12/31/13
OMB # 0915-0331 expiration date 12/31/13
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), 0915-0126 (NPDB) and 0915-0331
(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.
PRACTITIONER INFORMATION
We have pre-populated the practitioner information from the most recent report. Please
review all pre-populated information for accuracy.
Personal Information
Practitioner Name
Last Name
SMITH

First Name
JOHN

Add another name used

Gender
 Male 





 Female 



 Unknown




Birth Date (MMDDYYYY)
05051950

Is Subject Deceased?
 No






 Unknown





 Yes





Middle Name

Suffix (Jr, III)

Home Address/Address of Record
Street Address:
Address Line 2:
City:
CHOOSE ONE FROM LIST

State:
ZIP Code:



-

Country:
(if U.S., leave blank)

Work Information
here if the practitioner's work information is the same as your organization.

 Check





Organization
Name:

GENERAL HOSPITAL

Type:

Click

301 General/Acute Care Hospital



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

Address
Street Address:

123 FAKE STREET

Address Line 2:
City:

FAIRFAX

State:

VA Virginia

ZIP Code:

22030



-

Country:
(if U.S., leave blank)

Social Security Numbers (SSN)
*****2333
Add another SSN

Edit

Individual Taxpayer Identification Numbers (ITIN)
Add another ITIN

Federal Employer Identification Numbers (FEIN)
Add another FEIN

National Provider Identifiers (NPI)
Add another NPI

Drug Enforcement Administration (DEA) Numbers
Add another DEA Number

Unique Physician Identification Numbers (UPIN)
Add another UPIN

Professional Schools Attended
The form will suggest schools as you type. Please choose the matching school or enter the
complete school name.
Year of
School Name:
Graduation (YYYY)
Add another Professional School

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:

123ABC

State of Licensure:

AL Alabama

Occupation/Field of
Licensure:

Physician (MD)

Aerospace Medicine
Specialty:
Add Additional License/Occupation

OR







No License





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. Click
for information on filling out non-U.S. and military
addresses.
Name of
Affiliated/Associated
Health Care Entity:
Address
Street Address:
Address Line 2:
City:
CHOOSE ONE FROM LIST

State:
ZIP Code:



-

Country:
(if U.S., leave blank)
Nature of Subject's
Relationship to
Affiliate:
Add another Affiliate

CHOOSE ONE FROM LIST



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. 
 Criminal Conviction









Other
Clear

Add Additional Basis for Action

Adverse Action Information
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
Is Reinstatement Automatic at Completion of Adverse Action Period?
 Yes




 Yes, with conditions (requires a Revision to Action Report when status changes)




 No




Is the Action on Appeal?
 Yes




 No




 Unknown





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.

There are 4000 characters remaining for the description.
Spell Check

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 Bank, 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: DEVELOPER
Authorized Submitter's Title:

DEVELOPER

Authorized Submitter's Phone: 7035551212
Date:

Ext.

01/31/2013







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.

Submit to Data Bank

Validate Without Submitting

Store as a Draft

Return to Options

Entity: TEST ENTITY (FAIRFAX, VA) | User: user

Sign Out

REPORT INPUT FORM
EXCLUSION/DEBARMENT
Report Correction
To submit a correction to previously submitted report DCN 7930000076905924, complete all
necessary modifications in the form below, and press Submit to Data Bank.
The report entered here will replace the original report, so please ensure that all known data is entered
in its entirety. Failure to provide sufficient information to permit identification of a single subject may
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 05/31/14
OMB # 0915-0126 expiration date 12/31/13
OMB # 0915-0331 expiration date 12/31/13
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), 0915-0126 (NPDB) and 0915-0331
(NPDB). Public reporting burden for this collection of information is estimated to average 15 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.
PRACTITIONER INFORMATION
Personal Information
Practitioner Name
Last Name
SMITH

First Name
JOHN

Add another name used

Gender
 Male 





 Female 



 Unknown




Birth Date (MMDDYYYY)
05051950

Is Subject Deceased?
 No






 Unknown





 Yes





Home Address/Address of Record

Middle Name

Suffix (Jr, III)

Street Address:
Address Line 2:
City:
State:

CHOOSE ONE FROM LIST

ZIP Code:



-

Country:
(if U.S., leave blank)

Work Information
 Check here if the practitioner's work information is the same as your organization.




Organization
Name:

GENERAL HOSPITAL

Type:

Click

301 General/Acute Care Hospital



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

Address
Street Address:

123 FAKE STREET

Address Line 2:
City:

FAIRFAX

State:

VA Virginia

ZIP Code:

22030



-

Country:
(if U.S., leave blank)

Social Security Numbers (SSN)
*****2333
Add another SSN

Edit

Individual Taxpayer Identification Numbers (ITIN)
Add another ITIN

Federal Employer Identification Numbers (FEIN)

Add another FEIN

National Provider Identifiers (NPI)
Add another NPI

Drug Enforcement Administration (DEA) Numbers
Add another DEA Number

Unique Physician Identification Numbers (UPIN)
Add another UPIN

Professional Schools Attended
The form will suggest schools as you type. Please choose the matching school or enter the
complete school name.
Year of
School Name:
Graduation (YYYY)
Add another Professional School

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:

123ABC

State of Licensure:

AL Alabama

Occupation/Field of
Licensure:

Physician (MD)

Aerospace Medicine
Specialty:
Add Additional License/Occupation

OR







No License






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. Click
addresses.
Name of
Affiliated/Associated
Health Care Entity:

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

Address
Street Address:
Address Line 2:
City:
State:

CHOOSE ONE FROM LIST

ZIP Code:



-

Country:
(if U.S., leave blank)
Nature of Subject's
Relationship to
Affiliate:
Add another Affiliate

CHOOSE ONE FROM LIST



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.







Criminal Conviction
 Conviction






Relating to Controlled Substances

 Conviction





Relating to Fraud

 Conviction





Relating to Obstruction of an Investigation

 Conviction





Relating to Patient Abuse or Neglect

 Criminal





Conviction - Not Classified

 Felony





Conviction Relating to Controlled Substance Violations

 Felony





Conviction Relating to Health Care Fraud

 Program-Related










Other
Clear

Conviction

Add Additional Basis for Action

Adverse Action Information
Name of Agency or Program that Took
the Adverse Action Specified in This
Report:

AGENCY

Date Action Was Taken:
(MMDDYYYY)

01012013

Date Action Became Effective:
(MMDDYYYY)

01022013

Length of Action:
 Permanent




 Indefinite/Unspecified





 Specific





Period
Is Reinstatement Automatic at Completion of Adverse Action Period?
 Yes




 Yes, with conditions (requires a Revision to Action Report when status changes)




 No





Is the Action on Appeal?
 Yes




 No





 Unknown





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.
DESCRIPTION OF SUBJECT'S ACTS

There are 3971 characters remaining for the description.
Spell Check

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 Bank, 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: DEVELOPER
Authorized Submitter's Title:

DEVELOPER

Authorized Submitter's Phone: 7035551212
Date:







Ext.

01/31/2013

Send e-mail notification when this and any future responses are available.

Submit to Data Bank

Validate Without Submitting

Store as a Draft

Return to Options

Entity: MALPRACTICE ENTITY (FAIRFAX, VA) | User: user

REPORT INPUT FORM

EXCLUSION/DEBARMENT

Organization 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 05/31/14
OMB # 0915-0126 expiration date 12/31/13
OMB # 0915-0331 expiration date 12/31/13
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), 0915-0126 (NPDB) and 0915-0331
(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

Sign Out

Organization Information
Organization Name

Add another name used

Click

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

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

-

Country:
(if U.S., leave
blank)

Type
Organization Type:

Federal Employer Identification Numbers (FEIN)

Add another FEIN

Social Security Numbers (SSN)

Add another SSN

Individual Taxpayer Identification Numbers (ITIN)

Add another ITIN

Drug Enforcement Administration (DEA) Numbers

Add another DEA Number

Clinical Laboratory Improvement Act (CLIA) Numbers

Add another CLIA Number

Federal Food and Drug Administration (FDA) Numbers

Add another FDA Number

National Provider Identifiers (NPI)

Add another NPI

Medicare Provider/Supplier Numbers

Add another Medicare Provider/Supplier Number

Organization State Licensure Information
(If no State License, check the 'No License' box.)
State License
Number:
State of Licensure:

OR

No License

Add another License

Principal Officers and Owners
Last Name

First Name

Middle Name

Add another Principal Officer or Owner

Suffix

Title

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. Click
for information on filling out non-U.S. and military
addresses.
Name of
Affiliated/Associated
Health Care Entity:
Address
Street Address:
Address Line 2:
City:
State:
ZIP Code:

-

Country:
(if U.S., leave
blank)

Nature of Subject's
Relationship to
Affiliate:
Add another Affiliate

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.

Criminal Conviction
Other
Clear
Add Additional Basis for Action

Adverse Action Information
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
Is Reinstatement Automatic at Completion of Adverse Action Period?
Yes
Yes, with conditions (requires a Revision to Action Report when status changes)
No
Is the Action on Appeal?
Yes
No
Unknown
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.

There are 4000 characters remaining for the description.

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 Bank, 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:
Authorized Submitter's Phone:
Date:

Ext.
02/01/2013

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.

Entity: MALPRACTICE ENTITY (FAIRFAX, VA) | User: user

REPORT INPUT FORM

EXCLUSION/DEBARMENT

Report Correction

To submit a correction to previously submitted report DCN 7930000076906052, complete all
necessary modifications in the form below, and press Submit to Data Bank.
The report entered here will replace the original report, so please ensure that all known data is entered
in its entirety. Failure to provide sufficient information to permit identification of a single subject may
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 05/31/14
OMB # 0915-0126 expiration date 12/31/13
OMB # 0915-0331 expiration date 12/31/13
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), 0915-0126 (NPDB) and 0915-0331
(NPDB). Public reporting burden for this collection of information is estimated to average 15 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

Sign Out

Organization Information
Organization Name

Add another name used

Click

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

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

-

Country:
(if U.S., leave
blank)

Type
Organization Type:

Federal Employer Identification Numbers (FEIN)

Add another FEIN

Social Security Numbers (SSN)

Add another SSN

Individual Taxpayer Identification Numbers (ITIN)

Add another ITIN

Drug Enforcement Administration (DEA) Numbers

Add another DEA Number

Clinical Laboratory Improvement Act (CLIA) Numbers

Add another CLIA Number

Federal Food and Drug Administration (FDA) Numbers

Add another FDA Number

National Provider Identifiers (NPI)

Add another NPI

Medicare Provider/Supplier Numbers

Add another Medicare Provider/Supplier Number

Organization State Licensure Information
(If no State License, check the 'No License' box.)
State License
Number:
State of Licensure:

OR

No License

Add another License

Principal Officers and Owners
Last Name

First Name

Middle Name

Add another Principal Officer or Owner

Suffix

Title

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. Click
for information on filling out non-U.S. and military
addresses.
Name of
Affiliated/Associated
Health Care Entity:
Address
Street Address:
Address Line 2:
City:
State:
ZIP Code:

-

Country:
(if U.S., leave
blank)

Nature of Subject's
Relationship to
Affiliate:
Add another Affiliate

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.

Criminal Conviction
Conviction Relating to Controlled Substances
Conviction Relating to Fraud
Conviction Relating to Obstruction of an Investigation
Conviction Relating to Patient Abuse or Neglect
Criminal Conviction - Not Classified
Felony Conviction Relating to Controlled Substance Violations
Felony Conviction Relating to Health Care Fraud
Program-Related Conviction

Other
Clear
Add Additional Basis for Action

Adverse Action Information
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
Is Reinstatement Automatic at Completion of Adverse Action Period?
Yes
Yes, with conditions (requires a Revision to Action Report when status changes)
No
Is the Action on Appeal?
Yes
No
Unknown
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.
TEST

There are 3996 characters remaining for the description.
Spell Check

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 Bank, 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:
Authorized Submitter's Phone:
Date:

Ext.
02/01/2013

Send e-mail notification when this and any future responses are available.


File Typeapplication/pdf
Authorhannonn
File Modified2013-03-22
File Created2013-03-22

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