OMB control number

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

OMB 0906-0081 · HHS/HRSA.

OMB 0906-0081

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.

The latest form for National Practitioner Data Bank for Adverse Information on Physicians and Other Health Care Practitioners: 45 CFR Part 60 Regulations and Forms expires 2027-01-31 and is listed under ICR 202401-0906-003.

Latest Forms, Documents, and Supporting Material

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

All Historical Document Collections

Historical document collections
Reference	Filing	Received	Concluded	Action
202401-0906-003	Revision of a currently approved collection	2024-01-12		Approved without change

OMB Details

Correction, Revision to Action, Correction of Revision to Action, Void, Action on Appeal

Federal Enterprise Architecture: Health - Consumer Health and Safety

Information collection instruments
Form	Name	Electronic access	Type
Form 1	Correction Revision-to-Action Void Notice of Appeal	Fillable Fileable	Form and instruction

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.