OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

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

ICR 202401-0906-003 · OMB 0906-0081 · Active

Forms and Documents
DocumentTypeStatusAvailability
Form 44 Other Eligible Entity Attestation Form and Instruction Modified Available
Form 43 Medical Malpractice Payer, Peer Review Organization, or Private Accreditation Organization Attestation Form and Instruction Modified Repair queued
Form 42 Hospital Attestation Form and Instruction Modified Available
Form 41 Health Center Attestation Form and Instruction Modified Repair queued
Form 40 Missing Report from Query Form Form and Instruction Modified Available
Form 39 Account Balance Transfer Form and Instruction Modified Available
Form 38 Education Request Form and Instruction Modified Available
Form 37 Purchase Query Credits Form and Instruction Modified Available
Form 36 New Administrator Request Form and Instruction Modified Available
Form 35 Account Discrepancy Form and Instruction Modified Available
Form 34 Authorized Agent Designation Form and Instruction Modified Available
Form 33 Electronic Transfer of Funds (EFT) Authorization Form and Instruction Modified Available
Form 32 Agent Registration (Renewal & Update) Form and Instruction Modified Available
Form 31 Agent Registration (Initial) Form and Instruction Modified Available
Form 30 Reconciling Missing Actions Form and Instruction Modified Available
Form 29 Corrective Action Plan (Entity) Form and Instruction Modified Repair queued
Form 28 State Licensing Board Attestation Form and Instruction Modified Available
Form 27 State Licensing Board Data Request Form and Instruction Modified Repair queued
Form 26 Authorized Agent Attestation Form and Instruction Modified Available
Form 25 Entity Registration (Renewal & Update) Form and Instruction Modified Available
Form 24 Entity Registration (Initial) Form and Instruction Modified Available
Form 23 Request for Dispute Resolution Form and Instruction Modified Available
Form 22 Subject Statement and Dispute Form and Instruction Modified Available
Form 21 Continuous Query Form and Instruction Modified Available
Form 20 Self-Query on an Organization Form and Instruction Modified Available
Form 19 Self-Query on an Individual Form and Instruction Modified Available
Form 18 One Time Query for an Organization Form and Instruction Modified Available
Form 17 One Time Query for an Individual Form and Instruction Modified Available
Form 16 Health Plan Action Form and Instruction Modified Available
Form 15 Government Administrative Form and Instruction Modified Repair queued
Form 14 Exclusion/Debarment Form and Instruction Modified Available
Form 13 Civil Judgment Form and Instruction Modified Available
Form 12 Injunction Form and Instruction Modified Available
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 Available
Form 9 Criminal Conviction (Guilty Plea or Trial) Form and Instruction Modified Available
Form 8 Professional Society Form and Instruction Modified Available
Form 7 Title IV Clinical Privileges Actions Form and Instruction Modified Available
Form 6 Accreditation Form and Instruction Modified Available
Form 5 Peer Review Organization Form and Instruction Modified Available
Form 4 DEA/Federal Licensure Form and Instruction Modified Repair queued
Form 3 State Licensure Form and Instruction Modified Available
Form 2 Medical Malpractice Payment Form and Instruction Modified Available
Form 1 Correction, Revision to Action, Correction of Revision to Action, Void, Action on Appeal Form and Instruction Modified Available
NPDB Supporting Statement A - Revised 11062023.docx Supporting Statement A Uploaded 2023-11-08 Available
IC Document Collections
IC IDCollectionTypeStatusForm
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
StatusActive
Agency/SubagencyHHS/HRSA
OMB Control No0906-0081
Type of Information CollectionRevision of a currently approved collection
Previous ICR Reference No202101-0915-002
Agency Tracking No19186
Date Submitted to OIRA2024-01-12
Requested Expiration Date1969-12-31