Form 30 Account Discrepancy

Account Discrepancy
If you cannot reconcile your credit or debit 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 # 0915-0126 expiration date 05/31/16
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 number for this
project is 0915-0126. 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 10-29, Rockville, Maryland, 20857.
Data Bank Identification Number (15): | | | | | | | | | | | | | | | |
Telephone: Area Code (3)

Number (7)

Extension (5)

Printed Name of Entity Representative (40):
Signature of Entity Representative:
Signature Date:
Credit or Debit Card Number: | | | | | | | | | | | | | | | | | Exp. Date (MM/YY): | | | | |
(if applicable)
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 or debit 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.

NPDB Assistance
For additional information or assistance, please contact the NPDB Customer Service Center at:
1-800-767-6732
Outside the U.S.: 1-703-802-9380
TT/TDD: 1-703-802-9395
Fax: 1-703-803-1964

May 2013

Email: [email protected]
Online: http://www.npdb.hrsa.gov
Open: Mon. - Thurs. 8:30 a.m. - 6:00 p.m. ET,
Fri. 8:30 a.m. - 5:30 p.m. ET
Closed: Federal holidays
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NPDB-00958.06.01