32 Agent Registration (Renewal & Update)_0915-0126

National Practitioner Data Bank for Adverse Information on Physicians and Other Health Care Practitioners: 45 CFR Part 60 Regulations and Forms

Agent Registration (Renewal & Update)_0915-0126

OMB: 0915-0126

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State Changes
Label

PDF Name

OMB Number: 09150126 Expiration Date:
mm/dd/yyyy

Agent
Registration

I am authorized by my Agent
organization to serve Registration
as the certifying
official

Item Type
Modal

Trigger
When the user selects the link the modal
is displayed with the public burden
statement content.

Check Box Selecting the checkbox hides the fields for
the Certifying Official’s Information (First
Name, Middle Name, Last Name, Suffix,
Title, Phone, Extension, Email Address,
Employee ID).


File Typeapplication/pdf
File TitleAgent Registration(Renewal Update)
SubjectNPDB forms
AuthorHealth Resources and Services Administration
File Modified2020-11-19
File Created2020-08-25

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