Form 35 Account Discrepancy_0915-0126

Refund Request (Account Discrepancy Form)

OMB Number: 0915-0126 Expiration Date: mm/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 XXJXX/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 .25 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].
Requests for credits should be made within 60 days of the query submission. Ifyou suspect that your bill is incorrect, or you need more
information about a transaction, you should complete this form. Requests are usually responded to within 5-7 business days of receipt.
Note: Fields with an asterisk (") are required in order to ensure an accurate response; the information will not be used for any other purpose.

Name'
First and Las1 Name

Phone Number •
Phone Number

0810 or Self-Query Order ID*
DBID or Self· Query Order ID

Dollar Amount*

I

S0.00

DCN(s) or Bill Reference Number(s)*
DCN(s) or Bill Reference Numberfs)

Please provide an explanation for your request•
Provide an explanalion for your request

-