Form 36 New Administrator Request_0915-0126

NPDB

NATIONAL PRACTITIONER DATA BANK

OMS Number: 0915-0126 Expiration Date: mrn!dd/yyyy

Public Burden Statement: The NPDB is a web-based repository of reports containing information on medical malpractice
payments and certain adverse actions related to health care practitioners, providers, and suppliers. Established by
Congress in 1986, it is a workforce tool that prevents practitioners from moving state-to-state without disclosure or
discovery of previous damaging performance. The statutes and regulations that govern and maintain NPDB operations
include: Title IV of Public law 99-660, Health Care Quality Improvement Act (HCQIA) of 1986, Section 1921 of the Social
Security Act, Section 1128E of the Social Security Act, and Section 6403 of the Patient Protection and Affordable Care Act
of 2010. The NPDB regulations implementing these laws are codified at 45 CFR Part 60. 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 information collection is 0915-0126 and it is valid until XX/XX/202X. This
information collection is voluntary. 45 CFR Section 60.20 provides information on the confidentiality of the NPDB.
Information reported to the NPDB is considered confidential and shall not be disclosed outside of HHS, except as
specified in Sections 60.17, 60.18, and 60.21. Public reporting burden for this collection of information is estimated to
average .08 hours per response, 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 14N1368, Rockville, Maryland, 20857 or [email protected].

New Administrator Request
Instructions: This form must be signed by a manager or HR representative in your organization (the Duly
Authorized Representative). Once completed, scan the form, attach it to an email, and send it to
[email protected], or fax the request to 1-703-803-1964.

Organization Information
legal Organization Name:

OtherNarnesUsed(DBA): _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Address:

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Tax Identification Number:

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Data Bank Identification Number (DBID) (if a v a i l a b l e ) : - - - - - - - - - - - - - - - - - - ­
Former Administrator Name:

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New Administrator's Information
Full legal Name (First, Ml, L a s t ) : - - - - - - - - - - - - - - - - - - - - - - - - - - ­

Title:

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Em a i I Address: _ _ _ _ _ _ _ _ _ _ _ _ _ Phone:_ _ _ _ _ _ _ _ _ _ _ Ext: _ _ _ _ __

Current Work Address:

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NPDB User Account ID: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Duly Authorized Organization Representative (HR Representative or Management Personnel)
Full Legal Name (First, Ml, L a s t ) : - - - - - - - - - - - - - - - - - - - - - - - - - - ­
Title:

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Certification
As a Duly Authorized Representative, I attest that _ _ _ _ _ _ _ _ _ _ is authorized to access the
NEW ADMINISTRATOR NAME

NPDB system as an account adm inistrator for _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
ORGANIZATION NAME

Signature of Duly Authorized Representative:-------------- Date: _ _ _ __