Information Collection Request

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

ICR 201502-0915-001 · OMB 0915-0126 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Form 37 ReconcilingMissingActionForm Form and Instruction New Available
Form 36 Corrective Action Plan (Entity) Form and Instruction New Available
Form 35 LicensingBoardAttestation Form and Instruction New Available
Form 34 ReportingDiscrepancyLetter Form and Instruction New Available
Form 33 LicensingBoardDataRequest Form and Instruction New Available
Form 32 HospitalRegistrationRenewal Form and Instruction New Available
Form 31 HospitalRegistrationInitial Form and Instruction New Available
Form 30 Account Discrepancy Form and Instruction Modified Available
Form 29 Authorized Agent Designation Form and Instruction Modified Available
Form 28 Electronic Transfer of Funds (ETF) Authorization Form and Instruction Modified Available
Form 27 Agent Registration (Renewal & Update) Form and Instruction Modified Available
Form 26 Agent Registration (Initial) Form and Instruction Modified Available
Form 25 Entity Registration (Renewal & Update) Form and Instruction Modified Available
Form 24 Entity Registration (Initial) Form and Instruction Modified Available
Form 23 Request for Secretarial Review Form and Instruction Modified Available
Form 22 Subject Statement and Dispute Form and Instruction Modified Available
Form 21 Continuous Query Form and Instruction Modified Available
Form 20 Self-Query on an Organization Form and Instruction Modified Available
Form 19 Self-Query on an Individual Form and Instruction Modified Available
Form 18 One Time Query for an Organization Form and Instruction Modified Available
Form 17 One Time Query for an Individual Form and Instruction Modified Available
Form 16 Health Plan Action Form and Instruction Modified Available
Form 15 Government Administrative Form and Instruction Modified Available
Form 14 Exclusion/Debarment Form and Instruction Modified Available
Form 13 Civil Judgment Form and Instruction Modified Available
Form 12 Injunction Form and Instruction Modified Repair queued
Form 11 Nolo Contendere (no contest) plea Form and Instruction Modified Available
Form 10 Deferred Conviction or Pre-Trial Diversion Form and Instruction Modified Available
Form 9 Criminal Conviction (Guilty Plea or Trial) Form and Instruction Modified Available
Form 8 Professional Society Form and Instruction Modified Available
Form 7 Title IV Clinical Privileges Actions Form and Instruction Modified Available
Form 6 Accreditation Form and Instruction Modified Available
Form 5 Peer Review Organization Form and Instruction Modified Available
Form 4 DEA/Federal Licensure Form and Instruction Modified Available
Form 3 State Licensure Form and Instruction Modified Available
Form 2 Medical Malpractice Payment Form and Instruction Modified Available
Form 1 Correction, Revision to Action, Correction of Revision to Action, Void, Action on Appeal Form and Instruction Modified Available
SSA 0126.docx Supporting Statement A Uploaded 2015-03-30 Available
IC Document Collections
IC IDCollectionTypeStatusForm
214939 ReconcilingMissingActionForm Form and Instruction New
214938 Corrective Action Plan (Entity) Form and Instruction New
214937 LicensingBoardAttestation Form and Instruction New
214936 ReportingDiscrepancyLetter Form and Instruction New
214935 LicensingBoardDataRequest Form and Instruction New
214934 HospitalRegistrationRenewal Form and Instruction New
214933 HospitalRegistrationInitial Form and Instruction New
206509 Account Discrepancy Form and Instruction Modified
206508 Authorized Agent Designation Form and Instruction Modified
206507 Electronic Transfer of Funds (ETF) Authorization Form and Instruction Modified
206506 Agent Registration (Renewal & Update) Form and Instruction Modified
206505 Agent Registration (Initial) Form and Instruction Modified
206504 Entity Registration (Renewal & Update) Form and Instruction Modified
206503 Entity Registration (Initial) Form and Instruction Modified
206502 Request for Secretarial Review Form and Instruction Modified
206501 Subject Statement and Dispute Form and Instruction Modified
206500 Continuous Query Form and Instruction Modified
206499 Self-Query on an Organization Form and Instruction Modified
206498 Self-Query on an Individual Form and Instruction Modified
206497 One Time Query for an Organization Form and Instruction Modified
206496 One Time Query for an Individual Form and Instruction Modified
206495 Health Plan Action Form and Instruction Modified
206494 Government Administrative Form and Instruction Modified
206493 Exclusion/Debarment Form and Instruction Modified
206492 Civil Judgment Form and Instruction Modified
206491 Injunction Form and Instruction Modified
206490 Nolo Contendere (no contest) plea Form and Instruction Modified
206489 Deferred Conviction or Pre-Trial Diversion Form and Instruction Modified
206488 Criminal Conviction (Guilty Plea or Trial) Form and Instruction Modified
206487 Professional Society Form and Instruction Modified
206486 Title IV Clinical Privileges Actions Form and Instruction Modified
206485 Accreditation Form and Instruction Modified
206484 Peer Review Organization Form and Instruction Modified
206483 DEA/Federal Licensure Form and Instruction Modified
206482 State Licensure Form and Instruction Modified
206481 Medical Malpractice Payment Form and Instruction Modified
206480 Correction, Revision to Action, Correction of Revision to Action, Void, Action on Appeal Form and Instruction Modified
ICR Details
0915-0126 201502-0915-001
Historical Active 201405-0915-005
HHS/HSA 19186
National Practitioner Data Bank for Adverse Information on Physicians and Other Health Care Practitioners: Regulations and Forms
Revision of a currently approved collection   No
Regular
Approved with change 03/30/2015
Retrieve Notice of Action (NOA) 02/11/2015
  Inventory as of this Action Requested Previously Approved
03/31/2018 36 Months From Approved 05/31/2016
5,012,335 0 1,696,115
278,753 0 265,978
0 0 0

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.

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
  
None

Not associated with rulemaking

  79 FR 72690 12/08/2014
80 FR 7481 02/10/2015
No

37
IC Title Form No. Form Name
Deferred Conviction or Pre-Trial Diversion 10 Deferred Conviction or Pre-Trial Diversion
Nolo Contendere (no contest) plea 11 Nolo Contendere (no contest) plea
Injunction 12 Injunction
Civil Judgment 13 Civil Judgment
Exclusion/Debarment 14 Exclusion/Debarment
Government Administrative 15 Government Administrative
Health Plan Action 16 Health Plan Action
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
Self-Query on an Individual 19 Self-Query on an Individual
Self-Query on an Organization 20 Self-Query on an Organization
Continuous Query 21 Continuous Query
Subject Statement and Dispute 22 Subject Statement and Dispute
Request for Secretarial Review 23 Request for Secretarial Review
Entity Registration (Initial) 24 Entity Registration (Initial)
Entity Registration (Renewal & Update) 25 Entity Registration (Renewal & Update)
Agent Registration (Initial) 26 Agent Registration (Initial)
Agent Registration (Renewal & Update) 27 Agent Registration (Renewal & Update)
Electronic Transfer of Funds (ETF) Authorization 28 Electronic Transfer of Funds (ETF) Authorization
Authorized Agent Designation 29 Authorized Agent Designation
Account Discrepancy 30 Account Discrepancy
HospitalRegistrationInitial 31 31 HospitalRegistrationInitial
HospitalRegistrationRenewal 32 HospitalRegistrationRenewal
LicensingBoardDataRequest 33 LicensingBoardDataRequest
ReportingDiscrepancyLetter 34 ReportingDiscrepancyLetter
LicensingBoardAttestation 35 LicensingBoardAttestation
Corrective Action Plan (Entity) 36 Corrective Action Plan (Entity)
Accreditation 6 Accreditation
Title IV Clinical Privileges Actions 7 Title IV Clinical Privileges Actions
Professional Society 8 Professional Society
Criminal Conviction (Guilty Plea or Trial) 9 Criminal Conviction (Guilty Plea or Trial)
Correction, Revision to Action, Correction of Revision to Action, Void, Action on Appeal 1 Correction, Revision to Action, Correction of Revision to Action, Void, Notice of Appeal
Medical Malpractice Payment 2 Medical Malpractice Payment
State Licensure 3 State Licensure
DEA/Federal Licensure 4 DEA/Federal Licensure
Peer Review Organization 5 Peer Review Organization
ReconcilingMissingActionForm 37 ReconcilingMissingActionForm

  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 5,012,335 1,696,115 0 3,316,220 0 0
Annual Time Burden (Hours) 278,753 265,978 0 12,775 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
Miscellaneous Actions
Yes
Miscellaneous Actions
The total burden hours increased by approximately 9,700 hours and the total number of respondents increased by approximately 3.3 million respondents since our last approved burden. In the previous submission, we only counted individual transactions that were manually processed through the IQRS system. We did not account for batch transactions that were processed through an automated system called QRXS because there is no direct user burden. This time, we decided to include the number of batch queries and reports due to the large volume of automated transactions. For this reason, the burden table provides a more complete picture of our respondent numbers because it reflects manual (IQRS) and automatic (QRXS) transactions.

$20,500,000
No
No
Yes
No
No
Uncollected
Jodi Duckhorn 301 443-1984

  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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
02/11/2015