National Practitioner Data Bank (NPDB) Attestation of Reports by Hospitals, Medical Malpractice Payers, Health Plans, and Certain Other Health Care Entities

Documents and Forms

Document Name Document Type
Form 1 National Practitioner Data Bank (NPDB) Attestation of Reports by Hospitals, Medical Malpractice Payers, Health Plans, and Certain Other Health Care Entities Form and Instruction
1 Form - Agent Attestation.pdf Form - Agent Attestation.pdf Form and Instruction
2 Form - Health Center Attestation and Add Site.pdf Form - Health Center Attestation and Add Site.pdf Form and Instruction
3 Form - Hospital Attestation.pdf Form - Hospital Attestation.pdf Form and Instruction
4 Form - Medical Malpractice Payer Attestation.pdf Form - Medical Malpractice Payer Attestation.pdf Form and Instruction
5 Form - Other Eligible Entity Attestation.pdf Form - Other Eligible Entity Attestation.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	National Practitioner Data Bank (NPDB) Attestation of Reports by Hospitals, Medical Malpractice Payers, Health Plans, and Certain Other Health Care Entities	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	Form - Agent Attestation.pdf	Form - Agent Attestation.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	2	Form - Health Center Attestation and Add Site.pdf	Form - Health Center Attestation and Add Site.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	3	Form - Hospital Attestation.pdf	Form - Hospital Attestation.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	4	Form - Medical Malpractice Payer Attestation.pdf	Form - Medical Malpractice Payer Attestation.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	5	Form - Other Eligible Entity Attestation.pdf	Form - Other Eligible Entity Attestation.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 11,600	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	11,600	4,865	6,735
Annual IC Time Burden (Hours)	11,600	4,865	6,735
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.