Form 30 Account Discrepancy

National Practitioner Data Bank

Healthcare Integrity and Protection Data Bank

ACCOUNT DISCREPANCY
If you cannot reconcile your credit card account statement or Electronic Funds Transfer (EFT) account statement, and
determine that your account should be reviewed, please provide the information requested below. Type or print legibly in
ink. Numbers in parentheses indicate the maximum number of characters including spaces and punctuation allowed per
field.
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) and 0915-0126 (NPDB) and 0915-0331 (NPDB). Public reporting burden for this collection of information
is estimated to average 15 minutes to complete this form, 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.
Data Bank Identification Number (DBID) (15): |
Telephone: Area Code (3)

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Number (7)

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Extension (5)

Printed Name of Entity Representative (40):
Signature of Entity Representative:
Signature Date:
Credit Card Number (if applicable): |
Credit Card Expiration Date (MM/YY): |

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Dollar Amount of the Suspected Error(s): $

Please provide an explanation of your discrepancy and include the Data Bank Control Number (DCN), if applicable:

Attach a copy of your credit card statement or EFT account statement and the charge receipt. Highlight the charge(s) that
you believe you were charged in error.
The Data Bank is committed to protecting your privacy and your Personally Identifiable Information (PII). In accordance with
HHS and HRSA policy, the Data Bank will not accept unencrypted PII via email or fax. When completing this form, please
mail to: The Data Bank, P.O. Box 10832, Chantilly, VA 20153-0832.
For additional information, visit the Data Bank Web site at http://www.npdb-hipdb.hrsa.gov. If you need assistance, contact
the Data Bank Customer Service Center by email at [email protected] or by phone at 1-800–767–6732
(TDD 703-802-9395). Information Specialists are available to speak with you weekdays from 8:30 a.m. to 6:00 p.m.
(5:30 p.m. on Fridays) Eastern Time. The Data Bank Customer Service Center is closed on all Federal holidays.
January 2012

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NPDB-00958.05.02