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

Forms and Documents

Document	Type	Status	Availability
Form 44 Other Eligible Entity Attestation	Form and Instruction	Modified	Repair queued
Form 43 Medical Malpractice Payer, Peer Review Organization, or Private Accreditation Organization Attestation	Form and Instruction	Modified	Missing upstream
Form 42 Hospital Attestation	Form and Instruction	Modified	Repair queued
Form 41 Health Center Attestation	Form and Instruction	Modified	Repair queued
Form 40 Missing Report from Query Form	Form and Instruction	Modified	Repair queued
Form 39 Account Balance Transfer	Form and Instruction	Modified	Repair queued
Form 38 Education Request	Form and Instruction	Modified	Repair queued
Form 37 Purchase Query Credits	Form and Instruction	Modified	Repair queued
Form 36 New Administrator Request	Form and Instruction	Modified	Repair queued
Form 35 Account Discrepancy	Form and Instruction	Modified	Repair queued
Form 34 Authorized Agent Designation	Form and Instruction	Modified	Repair queued
Form 33 Electronic Transfer of Funds (EFT) Authorization	Form and Instruction	Modified	Repair queued
Form 32 Agent Registration (Renewal & Update)	Form and Instruction	Modified	Repair queued
Form 31 Agent Registration (Initial)	Form and Instruction	Modified	Repair queued
Form 30 Reconciling Missing Actions	Form and Instruction	Modified	Repair queued
Form 29 Corrective Action Plan (Entity)	Form and Instruction	Modified	Repair queued
Form 28 State Licensing Board Attestation	Form and Instruction	Modified	Repair queued
Form 27 State Licensing Board Data Request	Form and Instruction	Modified	Repair queued
Form 26 Authorized Agent Attestation	Form and Instruction	Modified	Repair queued
Form 25 Entity Registration (Renewal & Update)	Form and Instruction	Modified	Repair queued
Form 24 Entity Registration (Initial)	Form and Instruction	Modified	Repair queued
Form 23 Request for Dispute Resolution	Form and Instruction	Modified	Repair queued
Form 22 Subject Statement and Dispute	Form and Instruction	Modified	Repair queued
Form 21 Continuous Query	Form and Instruction	Modified	Repair queued
Form 20 Self-Query on an Organization	Form and Instruction	Modified	Repair queued
Form 19 Self-Query on an Individual	Form and Instruction	Modified	Repair queued
Form 18 One Time Query for an Organization	Form and Instruction	Modified	Repair queued
Form 17 One Time Query for an Individual	Form and Instruction	Modified	Repair queued
Form 16 Health Plan Action	Form and Instruction	Modified	Repair queued
Form 15 Government Administrative	Form and Instruction	Modified	Repair queued
Form 14 Exclusion/Debarment	Form and Instruction	Modified	Repair queued
Form 13 Civil Judgment	Form and Instruction	Modified	Repair queued
Form 12 Injunction	Form and Instruction	Modified	Repair queued
Form 11 Nolo Contendere (no contest) plea	Form and Instruction	Modified	Repair queued
Form 10 Deferred Conviction or Pre-Trial Diversion	Form and Instruction	Modified	Repair queued
Form 9 Criminal Conviction (Guilty Plea or Trial)	Form and Instruction	Modified	Repair queued
Form 8 Professional Society	Form and Instruction	Modified	Repair queued
Form 7 Title IV Clinical Privileges Actions	Form and Instruction	Modified	Missing upstream
Form 6 Accreditation	Form and Instruction	Modified	Repair queued
Form 5 Peer Review Organization	Form and Instruction	Modified	Repair queued
Form 4 DEA/Federal Licensure	Form and Instruction	Modified	Repair queued
Form 3 State Licensure	Form and Instruction	Modified	Repair queued
Form 2 Medical Malpractice Payment	Form and Instruction	Modified	Repair queued
Form 1 Correction, Revision to Action, Correction of Revision to Action, Void, Action on Appeal	Form and Instruction	Modified	Repair queued
NPDB Supporting Statement A - Revised 11062023.docx	Supporting Statement A	Uploaded 2023-11-08	Repair queued

IC Document Collections

IC ID	Collection	Type	Status	Form
245415	Other Eligible Entity Attestation	Form and Instruction	Modified
245414	Medical Malpractice Payer, Peer Review Organization, or Private Accreditation Organization Attestation	Form and Instruction	Modified
245413	Hospital Attestation	Form and Instruction	Modified
245412	Health Center Attestation	Form and Instruction	Modified
229942	Missing Report from Query Form	Form and Instruction	Modified
229941	Account Balance Transfer	Form and Instruction	Modified
229939	Education Request	Form and Instruction	Modified
214939	Purchase Query Credits	Form and Instruction	Modified
214938	New Administrator Request	Form and Instruction	Modified
214937	Account Discrepancy	Form and Instruction	Modified
214936	Authorized Agent Designation	Form and Instruction	Modified
214935	Electronic Transfer of Funds (EFT) Authorization	Form and Instruction	Modified
214934	Agent Registration (Renewal & Update)	Form and Instruction	Modified
214933	Agent Registration (Initial)	Form and Instruction	Modified
206509	Reconciling Missing Actions	Form and Instruction	Modified
206508	Corrective Action Plan (Entity)	Form and Instruction	Modified
206507	State Licensing Board Attestation	Form and Instruction	Modified
206506	State Licensing Board Data Request	Form and Instruction	Modified
206505	Authorized Agent Attestation	Form and Instruction	Modified
206504	Entity Registration (Renewal & Update)	Form and Instruction	Modified
206503	Entity Registration (Initial)	Form and Instruction	Modified
206502	Request for Dispute Resolution	Form and Instruction	Modified
206501	Subject Statement and Dispute	Form and Instruction	Modified
206500	Continuous Query	Form and Instruction	Modified
206499	Self-Query on an Organization	Form and Instruction	Modified
206498	Self-Query on an Individual	Form and Instruction	Modified
206497	One Time Query for an Organization	Form and Instruction	Modified
206496	One Time Query for an Individual	Form and Instruction	Modified
206495	Health Plan Action	Form and Instruction	Modified
206494	Government Administrative	Form and Instruction	Modified
206493	Exclusion/Debarment	Form and Instruction	Modified
206492	Civil Judgment	Form and Instruction	Modified
206491	Injunction	Form and Instruction	Modified
206490	Nolo Contendere (no contest) plea	Form and Instruction	Modified
206489	Deferred Conviction or Pre-Trial Diversion	Form and Instruction	Modified
206488	Criminal Conviction (Guilty Plea or Trial)	Form and Instruction	Modified
206487	Professional Society	Form and Instruction	Modified
206486	Title IV Clinical Privileges Actions	Form and Instruction	Modified
206485	Accreditation	Form and Instruction	Modified
206484	Peer Review Organization	Form and Instruction	Modified
206483	DEA/Federal Licensure	Form and Instruction	Modified
206482	State Licensure	Form and Instruction	Modified
206481	Medical Malpractice Payment	Form and Instruction	Modified
206480	Correction, Revision to Action, Correction of Revision to Action, Void, Action on Appeal	Form and Instruction	Modified

ICR Details

OMB Control No: 0915-0126	ICR Reference No: 202310-0915-003
Status: Received in OIRA	Previous ICR Reference No: 202101-0915-002
Agency/Subagency: HHS/HSA	Agency Tracking No: 19186
Title: National Practitioner Data Bank for Adverse Information on Physicians and Other Health Care Practitioners: 45 CFR Part 60 Regulations and Forms
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 11/09/2023

	Requested	Previously Approved
Expiration Date	36 Months From Approved	04/30/2024
Responses	8,114,604	7,101,274
Time Burden (Hours)	374,258	348,368
Cost Burden (Dollars)	0	0

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Abstract: The National Practitioner Data Bank (NPDB) is required to receive and release under 45 CFR Part 60 certain adverse data regarding physicians, dentists, and other licensed health care practitioners. Data collected on adverse actions and information relating to the professional competence and conduct of physicians and other health care practitioners will be shared with hospitals, licensing boards, professional societies, and selected health providers. These data will be used to maintain and improve health care and will be obtained from insurers, licensure boards, hospitals, and other providers.

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Authorizing Statute(s): US Code: 42 USC 11101 Name of Law: Health Care Quality Improvement Act of 1986
   US Code: 42 USC 1301 Name of Law: Health Care and Abuse Data Collection Program
   US Code: 42 USC 136r-2 Name of Law: 2. Section 1921 of the Social Security Act
   US Code: 42 USC 1320a-7e Name of Law: 3. Section 1128E of the Social Security Act
   PL: Pub.L. 111 - 148 6403 Name of Law: Patient Protection and Affordable Care Act of 2010
   PL: Pub.L. 104 - 101 221 Name of Law: Establishment of the Health Care Fraud and Abuse Data Collection Program
   PL: Pub.L. 99 - 660 402 Name of Law: Health Care Quality Improvement Act of 1986
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 57118	08/22/2023
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 76770	11/07/2023
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 44

IC Title	Form No.	Form Name
Account Balance Transfer	39	Account Balance Transfer.pdf
Account Discrepancy	35	Account Discrepancy.pdf
Accreditation	6	Accreditation.pdf
Agent Registration (Initial)	31	Agent Registration (Initial).pdf
Agent Registration (Renewal & Update)	32	Agent Registration (Renewal & Update).pdf
Authorized Agent Attestation	26	Authorized Agent Attestation.pdf
Authorized Agent Designation	34	Authorized Agent Designation.pdf
Civil Judgment	13	Civil Judgment.pdf
Continuous Query	21	Continuous Query
Correction, Revision to Action, Correction of Revision to Action, Void, Action on Appeal	1	Correction Revision-to-Action Void Notice of Appeal
Corrective Action Plan (Entity)	29	Corrective Action Plan (Entity).pdf
Criminal Conviction (Guilty Plea or Trial)	9	Criminal Conviction (Guilty Plea or Trial).pdf
DEA/Federal Licensure	4	DEA_Federal Licensure.pdf
Deferred Conviction or Pre-Trial Diversion	10	Deferred Conviction or Pre-Trial Diversion.pdf
Education Request	38	Education Request.pdf
Electronic Transfer of Funds (EFT) Authorization	33	Electronic Funds Transfer (EFT) Authorization.pdf
Entity Registration (Initial)	24	Entity Registration (Initial).pdf
Entity Registration (Renewal & Update)	25	Entity Registration (Renewal & Update).pdf
Exclusion/Debarment	14	Exclusion or Debarment.pdf
Government Administrative	15	Government Administrative.pdf
Health Center Attestation	41	Health Center Attestation.pdf
Health Plan Action	16	Health Plan Action.pdf
Hospital Attestation	42	Hospital Attestation.pdf
Injunction	12	Injunction.pdf
Medical Malpractice Payer, Peer Review Organization, or Private Accreditation Organization Attestation	43	Medical Malpractice Payer Attestation.pdf
Medical Malpractice Payment	2	Medical Malpractice Payment.pdf
Missing Report from Query Form	40	Missing Report from Query.pdf
New Administrator Request	36	New Administrator Request.pdf
Nolo Contendere (no contest) plea	11	Nolo Contendere (no contest plea).pdf
One Time Query for an Individual	17	One-Time Query for an Individual.pdf
One Time Query for an Organization	18	One-Time Query for an Organization.pdf
Other Eligible Entity Attestation	44	Other Eligible Entity Attestation.pdf
Peer Review Organization	5	Peer Review Organization.pdf
Professional Society	8	Professional Society.pdf
Purchase Query Credits	37	Purchase Query Credits.pdf
Reconciling Missing Actions	30	Reconciling Missing Actions.pdf
Request for Dispute Resolution	23	Request for Dispute Resolution.pdf
Self-Query on an Individual	19	Self-Query on an Individual.pdf
Self-Query on an Organization	20	Self-Query on an Organization.pdf
State Licensing Board Attestation	28	State Licensing Board Attestation.pdf
State Licensing Board Data Request	27	State Licensing Board Data Request.pdf
State Licensure	3	State Licensure or Certification.pdf
Subject Statement and Dispute	22	Subject Statement and Dispute.pdf
Title IV Clinical Privileges Actions	7	Title IV Clinical Privileges Actions.pdf

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ICR Summary of Burden

	Total Request	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	8,114,604	7,101,274	0	1,013,330	0	0
Annual Time Burden (Hours)	374,258	348,368	0	25,890	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The increase is mainly attributable to the higher use of Query forms (i.e., Continuous Query, Self-Query on an Individual, One-Time Query for an Individual, and One-time Query for an Organization). For items where there is a burden reduction, it is typically due to a reduction in the number of people responding based off responses received in prior years.

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Annual Cost to Federal Government: $23,600,000

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 11/09/2023

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