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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 0915-0126 · HHS/HSA.

OMB 0915-0126

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 2021-03-31 and is listed under ICR 201801-0915-001.

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
DocumentType
Form 44 Other Eligible Entity AttestationForm and Instruction
Form 43 Medical Malpractice Payer, Peer Review Organization, or Private Accreditation Organization AttestationForm and Instruction
Form 42 Hospital AttestationForm and Instruction
Form 41 Health Center AttestationForm and Instruction
Form 40 Missing Report from Query FormForm and Instruction
Form 39 Account Balance TransferForm and Instruction
Form 38 Education RequestForm and Instruction
Form 37 Purchase Query CreditsForm and Instruction
Form 36 New Administrator RequestForm and Instruction
Form 35 Account DiscrepancyForm and Instruction
Form 34 Authorized Agent DesignationForm and Instruction
Form 33 Electronic Transfer of Funds (EFT) AuthorizationForm and Instruction
Form 32 Agent Registration (Renewal & Update)Form and Instruction
Form 31 Agent Registration (Initial)Form and Instruction
Form 30 Reconciling Missing ActionsForm and Instruction
Form 29 Corrective Action Plan (Entity)Form and Instruction
Form 28 State Licensing Board AttestationForm and Instruction
Form 27 State Licensing Board Data RequestForm and Instruction
Form 26 Authorized Agent AttestationForm and Instruction
Form 25 Entity Registration (Renewal & Update)Form and Instruction
Form 24 Entity Registration (Initial)Form and Instruction
Form 23 Request for Dispute ResolutionForm and Instruction
Form 22 Subject Statement and DisputeForm and Instruction
Form 21 Continuous QueryForm and Instruction
Form 20 Self-Query on an OrganizationForm and Instruction
Form 19 Self-Query on an IndividualForm and Instruction
Form 18 One Time Query for an OrganizationForm and Instruction
Form 17 One Time Query for an IndividualForm and Instruction
Form 16 Health Plan ActionForm and Instruction
Form 15 Government AdministrativeForm and Instruction
Form 14 Exclusion/DebarmentForm and Instruction
Form 13 Civil JudgmentForm and Instruction
Form 12 InjunctionForm and Instruction
Form 11 Nolo Contendere (no contest) pleaForm and Instruction
Form 10 Deferred Conviction or Pre-Trial DiversionForm and Instruction
Form 9 Criminal Conviction (Guilty Plea or Trial)Form and Instruction
Form 8 Professional SocietyForm and Instruction
Form 7 Title IV Clinical Privileges ActionsForm and Instruction
Form 6 AccreditationForm and Instruction
Form 5 Peer Review OrganizationForm and Instruction
Form 4 DEA/Federal LicensureForm and Instruction
Form 3 State LicensureForm and Instruction
Form 2 Medical Malpractice PaymentForm and Instruction
Form 1 Correction, Revision to Action, Correction of Revision to Action, Void, Action on 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
202310-0915-003 Revision of a currently approved collection 2023-11-09 Approved without change
202101-0915-002 Revision of a currently approved collection 2021-01-25 Approved without change
201801-0915-001 Revision of a currently approved collection 2018-02-02 Approved without change
201611-0915-002 No material or nonsubstantive change to a currently approved collection 2016-11-08 Approved without change
201502-0915-001 Revision of a currently approved collection 2015-02-11 Approved with change
201405-0915-005 No material or nonsubstantive change to a currently approved collection 2014-05-28 Approved without change
201304-0915-002 Revision of a currently approved collection 2013-04-16 Approved without change
201109-0915-001 No material or nonsubstantive change to a currently approved collection 2011-09-19 Approved without change
201009-0915-005 Revision of a currently approved collection 2010-09-29 Approved without change
201007-0915-002 Extension without change of a currently approved collection 2010-07-22 Withdrawn and continue
200705-0915-002 Extension without change of a currently approved collection 2007-05-15 Approved without change
200401-0915-001 Revision of a currently approved collection 2004-01-28 Approved with change
200207-0915-001 Revision of a currently approved collection 2002-07-25 Approved with change
199902-0915-002 Extension without change of a currently approved collection 1999-02-03 Approved without change
199809-0915-010 No material or nonsubstantive change to a currently approved collection 1998-09-15 Approved without change
199512-0915-003 Extension without change of a currently approved collection 1995-12-15 Approved without change
199503-0915-003 Revision of a currently approved collection 1995-03-27 Approved without change
199212-0915-001 Revision of a currently approved collection 1992-12-21 Approved without change
199207-0915-001 Revision of a currently approved collection 1992-07-16 Approved without change
199102-0915-001 Revision of a currently approved collection 1991-02-28 Approved without change
198912-0915-004 Revision of a currently approved collection 1989-12-28 Approved without change
198906-0915-014 No material or nonsubstantive change to a currently approved collection 1989-06-27 Approved with change
198906-0915-007 No material or nonsubstantive change to a currently approved collection 1989-06-14 Approved with change
198904-0915-011 No material or nonsubstantive change to a currently approved collection 1989-04-10 Approved with change
198811-0915-002 Revision of a currently approved collection 1988-11-03 Withdrawn and continue
198804-0915-002 New collection (Request for a new OMB Control Number) 1988-04-05 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 Appeal.pdf Fillable FileableForm and instruction

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