New Administrator Request

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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].
Organization Information
Legal Organization Name:
Other Names Used (DBA):
Address:
Tax Identification Number (TIN):
Data Bank Identification Number (DBID) (if available):
Former Administrator Name:

_

New Administrator’s Information
Full Legal Name (First, MI, Last):
Title:
Email:
Current Work Address:

Phone:

Ext:

Duly Authorized Organization Representative (HR Representative or Management Personnel)
Full Legal Name (First, MI, Last):
Title:
Email:
Current Work Address:

Phone:

Ext:

Certification
As a Duly Authorized Representative, I attest that
NPDB system as an account administrator for

is authorized to access the
.

Signature of Duly Authorized Representative: _______________________________Date:______________
OMB Number: 0906-0081 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 0906-0081 and it is valid until mm/dd/yyyy. 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 5 minutes 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
Information Collection Clearance Officer, 5600 Fishers Lane, Room 13N82, Rockville, Maryland, 20857.