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Federal forms, ICRs, and supporting documents

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.

View the official OMB control history on Reginfo.gov.

Latest Forms, Documents, and Supporting Material

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

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