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pdfEntity: MALPRACTICE ENTITY (FAIRFAX, VA) | User: JohnAdmin
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ENTITY REGISTRATION
Eligibility/Statutory Authority
You are responsible for verifying your organization's legal obligation or eligibility under the following applicable
laws and regulation.
Title IV of Public Law 99-660, the Health Care Quality Improvement Act of 1986, as amended;
Public Law 100-93, Section 5[b] of the Medicare and Medicaid Patient and Program Protection Act of
1987, [Section 1921 of the Social Security Act]; and
Section 221[a], Public Law 104-191, the Health Insurance Portability and Accountability Act of 1996,
more commonly referred to as Section 1128E of the Social Security Act.
Final Regulations, NPDB (includes Section 1921 and Section 1128E)
Please respond to the questions following this page to determine your organization's eligibility and statutory
authority. You may wish to seek advice from legal counsel before completing this questionnaire. Review each
of these statutes and regulations prior to submitting your entity registration.
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Entity: MALPRACTICE ENTITY (FAIRFAX, VA) | User: JohnAdmin
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VERIFY USERS
Verify Users
Organization
Information
Eligibility
Questionnaire
Organization
Certifications
Print
Registration
Final Steps
Select an action for each user. Users marked "Keep" will need to have their identity and organizational
affiliation verified. Users marked "Delete" will be deleted upon the Data Bank's approval of the
entity renewal. After selecting an action for each user, click Continue.
Action
User ID
Name
Last Login
JOHN SMITH
OCT 18, 2012 10:45AM
Keep
Delete
1PMuser
Keep
Delete
RDON
RON DON
AUG 03, 2012 02:26PM
Keep
Delete
aaronh
Aaron
SEP 11, 2012 04:30PM
Keep
Delete
batchqryUser
TEST DEVELOPER
AUG 22, 2011 03:19PM
Keep
Delete
jdoe1
JOHN DOE
AUG 23, 2011 12:33PM
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Entity: MALPRACTICE ENTITY (FAIRFAX, VA) | User: JohnAdmin
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VERIFY USERS
Verify Users
Organization
Information
Eligibility
Questionnaire
Organization
Certifications
Print
Registration
Final Steps
The following user account(s) will remain active and will be required to complete identity proofing:
User ID
Name
1PMuser
JOHN SMITH
OCT 18, 2012 10:45AM
RDON
RON DON
AUG 03, 2012 02:26PM
aaronh
Aaron
SEP 11, 2012 04:30PM
TEST DEVELOPER
AUG 22, 2011 03:19PM
JOHN DOE
AUG 23, 2011 12:33PM
batchqryUser
jdoe1
Last Login
If these selections are correct, click Continue. Otherwise click Return to Previous Page to modify your selections.
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Entity: MALPRACTICE ENTITY (FAIRFAX, VA) | User: JohnAdmin
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ENTITY REGISTRATION
Verify Users
Organization
Information
Eligibility
Questionnaire
Organization
Certifications
Print
Registration
Final Steps
Complete this form with information about your organization and click Continue.
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
collection of information unless it displays a currently valid OMB control number. The OMB control numbers f
this project are 0915-0239 , 0915-0126 and 0915-0331. Public reporting burden for this collection of informatio
estimated to average 1 hour to complete this form, including the time for reviewing instructions, searching exi
data sources, and completing and reviewing the collection of information. Send comments regarding this bur
estimate or any other aspect of this collection of information, including suggestions for reducing this burden,
HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14-22, Rockville, Maryland, 20857.
Entity Identification Information
Name of Entity:
Department or Office to Which Mail
Should be Addressed:
Street Address:
Address Line 2:
City:
State:
Zip:
-
Country:
(if U.S., leave blank)
Department Fax Number:
Taxpayer Identification Number (TIN):
National Crime Information Center
Originating Agency Identifier (ORI):
(For law enforcement only)
Ownership of the Entity:
To select this ownership, you must be a public sector organization that is a component of, authorized by
and under the direct authority of a State government. Receiving funding from a State Agency is not
sufficient to select this ownership. If you are funded by, but not a component of a State government,
select another category that more accurately describes your organization's ownership.
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Entity: MALPRACTICE ENTITY (FAIRFAX, VA) | User: JohnAdmin
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ENTITY REGISTRATION
Verify Users
Organization
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Eligibility
Questionnaire
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Registration
Final Steps
Eligibility/Statutory Authority
Change
You have indicated that your organization is a State Government Agency.
RESULTS: Statutory Authority and Requirements
Based on your answers, your organization is eligible to register with the Data Bank under the following statutory
authority functions. Certain agencies and organizations may qualify under more than one function per statute.
Your organization must comply with all regulatory requirements associated with Data Bank eligibility, including, but
not limited to the associated querying and reporting requirements listed below.
Statutory Authority
Function
Title IV
State Practitioner Licensing Board Other than Medical/Dental Examiners Optional
No Requirement
Section 1921
State Authority Responsible for Licensing or Certification of Health Care
Optional
Practitioners, Entities, Providers, or Suppliers
Mandatory
Section 1128E
State Authority Responsible for Licensing or Certification of Health Care
Optional
Practitioners, Entities, Providers, or Suppliers
Mandatory
Do the Statutory Authority selections accurately describe your organization?
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Querying
Reporting
Entity: MALPRACTICE ENTITY (FAIRFAX, VA) | User: JohnAdmin
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ENTITY REGISTRATION
Verify Users
Organization
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Eligibility
Questionnaire
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Registration
Final Steps
Entity Primary and Additional Functions
Choose a primary function that best describes the health care related function or service your
organization performs. You can select one primary function and up to two additional functions.
If an appropriate description does not appear on the list, select "Other" and describe the function.
Category:
Primary Function:
Add additional function
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ENTITY REGISTRATION
Verify Users
Organization
Information
Eligibility
Questionnaire
Organization
Certifications
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Registration
Query Option
Based on your selections you are eligible by law to query the Data Bank, if you choose.
Allow users to query
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Final Steps
Entity: MALPRACTICE ENTITY (FAIRFAX, VA) | User: JohnAdmin
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ENTITY REGISTRATION
Verify Users
Organization
Information
Eligibility
Questionnaire
Organization
Certifications
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Registration
Final Steps
Point Of Contact For Reports
A report point of contact is applicable only if the entity is eligible under law to submit
reports. You may designate an individual or office to be the point of contact to be included on
all reports submitted by your organization to the NPDB. If your entity does not designate a point of contact,
the submitter of each individual report will be listed as the point of contact for that report.
Name or Office:
Title or Department:
Telephone
Ext:
Certifying Official
The certifying official is the individual selected and empowered by an entity to certify the
legitimacy of registration for participation in the NPDB.
By completing this registration, the certifying official is agreeing to the following:
The entity being registered qualifies under law as specified in the ELIGIBILITY/STATUTORY
AUTHORITY section and is eligible to perform the requested querying and/or reporting functions.
The entity may be subject to sanctions under Federal statute for failure to report final adverse actions
as required in the statutes and regulations, or for the use of information obtained from the NPDB other
than the purposes for which it was provided.
He or she is authorized to submit this registration information to the NPDB and that the information
provided is true, correct, and complete.
He or she will notify the NPDB immediately if he or she becomes aware that any information in this
form is not true, correct, or complete.
Any omission, misrepresentation, or falsification of any information contained in this form or contained
in any communication supplying information to the NPDB 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.
Note: The name entered below must match the name on the certifying official's Government-issued ID or
the registration will be rejected.
Check this box if the certifying official differs from the individual listed below.
First Name
Middle Initial Last Name
Name of Certifying Official:
Title of Certifying Official:
Telephone:
E-mail Address:
Confirm E-mail Address:
Employee ID:
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Ext:
Entity: MALPRACTICE ENTITY (FAIRFAX, VA) | User: JohnAdmin
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PRINT REGISTRATION
Verify Users
Organization
Information
Eligibility
Questionnaire
Organization
Certifications
Print
Registration
Final Steps
In order for the Data Bank to successfully process your registration, you must complete the following steps:
1. Print your Registration document. You may wish to print an additional copy for your records.
2. Once you have finished printing your copies, press Continue.
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| File Type | application/pdf |
| File Title | Entity Registration |
| Author | hannonn |
| File Modified | 2012-11-28 |
| File Created | 2012-11-28 |