Form 24 Entity Registration (Initial)

the

DataBank

P.O. Box 10832
Chantilly, VA 20153-0832
http://www.npdb.hrsa.gov

Entity Registration Instructions
1. Make note of the DBID and User ID below. After your registration has been successfully processed you will use these
values in addition to your password to log in to the Integrated Querying and Reporting Service (IQRS).
Data Bank Identification Number: 429700000107580

User ID: jonmann158

2. Sign the Entity Registration document.
3. Make sure you have read the Summary of Terms section of the NPDB Certifying Official and Data Bank Administrator
Registration document.
4. Do not sign the document yourself yet; a Notary Public must witness your signature as described below.
5. Take the NPDB Certifying Official and Data Bank Administrator Registration document and the credentials listed below to
a person certified by a State or Federal Government as being authorized to confirm identities (such as Notary Public),
that uses a stamp, seal, or other mechanism to authenticate their identity confirmation.
Credentials to Present to the Notary Public:
You must present a valid State or Federal government-issued photo ID. Forms of acceptable ID are as follows: A stateissued photo ID (with a serial number) such as a driver's license, Passport from country of citizenship, federal, state or
local government agency (must have name, date of birth, gender, height, eye color and address), US military ID,
Certificate of U.S. Citizenship, Certificate of Naturalization, permanent or unexpired temporary resident card, Native
American tribal document, or Canadian driver's license.
6. Sign and date the registration document in the presence of the Notary Public who will complete his/her section of the
document.
7. The following 4 items must be mailed to the Data Bank for processing (faxed/scanned copies will not be accepted):
A. The signed Entity Registration document.
B. The original notarized NPDB Certifying Official and Data Bank Administrator Registration document.
C. Proof-of-affiliation with your health care organization for which you are certifying to the NPDB. You must provide one
of the following:
(1) A photocopy of the work badge issued by your organization. The badge must contain a photograph and the
name of the organization for which you work.
(2) Proof-of-Affiliation document signed by a duly authorized representative for your organization attesting to your
affiliation with the health care organization for which you are certifying.
D. A photocopy of your organization's license to conduct business in your state OR articles of incorporation.
8. Mail the document(s) to one of the following addresses:
Regular Mail:
The Data Bank
P.O. Box 10832
Chantilly, VA 20153-0832

Overnight Mail:
The Data Bank
4094 Majestic Lane, PMB-332
Fairfax, VA 22033

9. The Data Bank will process the registration documents and if the registration is approved, you shall receive confirmation
via e-mail with instructions on how to proceed.

Registration Checklist
Signatures on all documents must be original (Photocopied, stamped, or computer-generated signatures are not
accepted)
All of the 4 documents listed must be sent to the Data Bank before your registration can be processed.
Entity Registration document
• Signed and dated by the Certifying Official
• Current and accurate organization identification information
Organizational Documentation
• Copy of your organization's license to conduct business in your state OR articles of incorporation
NPDB Certifying Official and Data Bank Administrator Registration
• Must be notarized with a stamp or seal on the document
• Government-issued ID fields must be completed
Proof of Organizational Affiliation documents with a copy of a work badge OR a letter signed by a duly authorized
representative of your organization
If a work badge is used, it must contain:
• Name of the individual
• Photo of the individual
• Name of the organization
If a letter is used, it must be signed by a duly authorized representative of your organization who can attest to your
employment (for example, a member of your human resources department or another manager or official in your
organization)
The Certifying Official and Data Bank Administrator may not sign their own Proof-of-affiliation letter for the account

Mail the document(s) to one of the following addresses:
Regular Mail:

Overnight Mail:

The Data Bank
P.O. Box 10832
Chantilly, VA 20153-0832

The Data Bank
4094 Majestic Lane, PMB-332
Fairfax, VA 22033

the

DataBank

DCN: 5950000090960789
Page 1 of 2

P.O. Box 10832
Chantilly, VA 20153-0832
http://www.npdb.hrsa.gov

Entity Registration
A. ENTITY IDENTIFICATION INFORMATION
Name of Entity:
Street Address:
City, State, Zip:
Taxpayer Identification Number:
Ownership of the Entity:
Primary Function of the Entity:

FOOT CARE BOARD
5600 FISHERS LN
ROCKVILLE, MD 20852-1750
123456789
State Government Agency
Health Care Practitioner Licensing Board or Authority

B. ELIGIBILITY/STATUTORY AUTHORITY
NPDB - Title IV

Function/Service:
Querying: Optional

NPDB - Section 1921

Function/Service:

Querying: Optional
NPDB - Section 1128E

Function/Service:

Querying: Optional
Query Preference:
C. POINT OF CONTACT FOR REPORTS
Name or Office:
Title or Department:
Telephone:

NPDB Only
ANITTA MANN
TITLE
(301) 301-3011

D. CERTIFYING OFFICIAL/ENTITY ADMINISTRATOR
JON MANN
Name:
Title:
TITLE
Telephone:
(301) 301-3011
Email Address:
[email protected]
Certification Date:
12/09/2014

State Practitioner Licensing Board Other than
Medical/Dental Examiners
Reporting: No Requirement
State Licensing or Certification Authority Responsible for
Licensing or Certifying Health Care Practitioners, Entities,
Providers, or Suppliers
Reporting: Mandatory
State Licensing or Certification Authority Responsible for
Licensing or Certifying Health Care Practitioners, Entities,
Providers, or Suppliers
Reporting: No Requirement

the

DataBank

P.O. Box 10832
Chantilly, VA 20153-0832

DCN: 5950000090960789
Page 2 of 2

http://www.npdb.hrsa.gov
I read and understand my responsibilities under:
• Title IV of Public Law 99-660, the Health Care Quality Improvement Act, 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.
I certify that the entity identified above qualifies under law as specified in the ELIGIBILITY/STATUTORY AUTHORITY section and is eligible to
perform the querying and/or reporting functions. I understand that 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. I further certify that I am authorized to submit this registration information to the NPDB and that the
information provided is true, correct, and complete. If I become aware that any information in this form is not true, correct, or complete, I agree
to notify the NPDB of this fact immediately. I understand that 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.

______________________________
Signature of Certifying Official

__________________________________
Signature Date (MM-DD-YYYY)

the

DataBank

DCN: 5950000090960789
Page 1 of 1

P.O. Box 10832
Chantilly, VA 20153-0832
http://www.npdb.hrsa.gov

NPDB Certifying Official and Data Bank Administrator Registration

Registrant use only

Section 1 - Registrant Instructions: The Certifying Official/Data Bank Administrator (Registrant) must read the terms below, complete the
appropriate fields, provide a government-issued ID and either provide a work badge or proof-of-affiliation letter on company letterhead before
signing and dating the document in front of the Notary Public.
Summary of Terms: I (the "Registrant"), as the Certifying Official of the health care organization identified in this document, certify that the organization
qualifies under law as specified in the ELIGIBILITY/ STATUTORY AUTHORITY section of the Entity/Agent Registration document and is eligible to
perform querying and/or reporting functions. I understand that the Entity/Authorized Agent 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 for the
purposes for which it was provided. I am also registering as a Data Bank Administrator for an Entity or Authorized Agent registered or registering with
the NPDB. As a Data Bank Administrator, I am responsible for overseeing the use of the NPDB online services at my organization, identity proofing
applicants who request a user account, establishing and revoking individual user accounts, and maintaining my organization's registration with the
NPDB. By signing below, I acknowledge my acceptance of the Summary of Terms in which I agree to provide complete and accurate responses to
requests for information during the registration process. I further certify that I am authorized to submit this registration information to the NPDB and that
the information provided is true, correct, and complete. If I become aware that any information on this document is not true, correct, or complete, I agree
to notify the NPDB of this fact immediately. I understand that any omission, misrepresentation, or falsification of any information contained in this
document or contained in any communication supplying information to the NPDB to complete or clarify this document may be punishable by criminal,
civil, or administrative actions including fines, penalties, and/or imprisonment under Federal law.
Name (First Name, Middle Initial, Last Name):

Title:

JON MANN

TITLE

Email:

Employee ID:

[email protected]
Employer/Organization:

FOOT CARE BOARD
Business Address:

5600 FISHERS LN
ROCKVILLE, MD 20852-1750
Telephone:

(301) 301-3011
Applicant’s Signature and Date*:
_________________________________________________
(*Sign and date in the presence of the Notary Public)

__________
(Date)

Note: Use an ink pen to cross out any mistake, write in the correct information and initial it.

Section 2 - Notary Public Instructions: The Notary Public must record the information below for the Applicant’s government-issued photo
ID for the purpose of identity proofing.

Government-issued ID (Photo, Name, Serial Number, Expiration Date, Address, and Date of Birth Required)

Notary Public use only

Exact Name Listed on ID
Serial Number

Date of Birth

Identification Type

Issuing Authority

Date of Issuance

Expiration Date

____________________________________________________________________
Notary Public:
I hereby certify that on this _______ day of ____________, 20___, in the city of ________________
and in the county of _______________________, _____________________ personally appeared
before me the signer and subject of the above form, who signed or attested the same in my presence,

My Commission Expires In: _______________________
Street Address of Branch or Office: _______________________
Name of Organization Employing Notary: _______________________

Notary Public seal here