: Department of Health and Human Services 
OFFICE OF

INSPECTOR GENERAL

NATIONAL PRACTITIONER DATA BANK 

ENSURING PROPER ACCESS BY HEALTH

CARE ENTITIES

MANAGEMENT ADVISORY REPORT 
OEI-12-92-00290
 EXECUTIVE  SUMMARY

PUROSE 
The purpose of this study is to assess the procedures which the Public Health Servce 
(PHS) uses to assure that only eligible health care entities have access to National 
Practitioner Data Bank (Data Bank) records. 
BACKGROUN 
According to the Data Bank regulations, at 45 CFR 60.3, a "health care entity
" is 
defined as: 
a hospital; 
an entity that provides health care services and engages in 
professional peer review through a formal peer review process for 
the purpose of furthering quality health care, or a committee of 
that entity; or 
a professional society that engages in professional review activity 
through a formal peer review process for the purposes of 
furthering quality health care. 
Health care entity registration records maintained by the Data Bank contractor 
UNISYS, indicate that 330 group practices, 19 preferred provider organizations 
(PPO' s), and 770 health maintenance organizations (HMO's) are apparently eligible to 
query the Data Bank. In addition, 890 professional societies have also been approved 
for querying privileges. 
FININGS 
The HMO' , PPO' , group practices, and professional societies were registered by 
UNISYS as health care entities under a self-certification process whereby such entities 
were not required to document their eligibility for querying the Data Bank. 
Representatives of the Data Bank Executive Committee as well as the media have 
raised concerns about the Data Bank information being provided to ineligible health 
care entities.  RECOMMNDATIONS 
We recommend the following to the PHS: 
Revise the Data Bank registration form to indicate that in order 
health care entity" to be eligible to query the Data Bank it 
for a "
must provide health services and/or have a formal peer review 
process. 
Provide policy guidance or criteria on what constitutes a "health 
care entity. 
Review the eligibility status of registered health care entities. 
Comments 
PHS concurred with the first two recommendations to (1) revise the registration form 
for querying and (2) provide guidance on what constitutes a health care entity. 
Although PHS concurred with the objective of the third recommendation, namely, to 
review the eligibility status of health care entities, PHS disagreed with our 
recommendation that it verify the eligibility status of all HMO'  , PPO' , group 
practices, and professional associations that have already queried the Data Bank. PHS 
stated, however, that it has directed UNISYS to "clean up" the entity file, which would 
include asking health care entities to "self-certify" using new forms and instructions. 
After a review of the new forms and guideliIJes, we believe that PHS needs to define 
in detail eligibility criteria and provide a clear, unambiguous certification that wil 
assure the necessary accountability; otherwise, the PHS actions will not achieve the 
objective of strengthening the registration process. 
The full text of the PHS comments is included as Appendix A.  ......................................... .
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TABLE OF CONTENTS

SUMY 
EXCUIV 
INODUCTION. . 
Purpose. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 
Background 
FINING 
Inadequate Registration Policies. . . . . . . . . . . 
Health Care Industry Concerns

Medical Economics Article. 

RECOMMNDATIONS ........................................... 5

Revise Registration Form for Querying. . . . . . . . . 

Provide Guidance on What Constitutes a

Health Care Entity" .......................................... 5

Review Eligibility Status of Registered 
Health Care Entities 
APPENDIX A 
APPENDIX B  . . . . . . . . . . . . . . B
. . .. C
APPENDIX C . . . . . . . . . .  INTRODUCTION

PUROSE 
The purpose of this study is to assess the procedures which the Public Health Servce 
(PHS) uses to assure that only eligible health care entities have access to National 
Practitioner Data Bank (Data Bank) records. 
BACKGROUN 
The Office of Inspector General (OIG) is responsible for imposing civil monetary 
penalties (CMP's) for improperly disclosing information maintained by the Data Bank. 
Pursuant to this authority, the OIG has been monitoring implementation of the Data 
Bank to assure the presence of effective controls regarding releasing Data Bank 
information. This oversight activity has encompassed (1) an on going review of Data 
Bank policies and forms; (2) discussions with the PHS and health care industry 
representatives, including officials from UNISYS, the Data Bank contractor; and (3) 
attendance at meetings of the Data Bank Executive Committee and the PHS 
Interagency Council on Quality Assurance.

An initial result of this activity was the report we released on August 26, 1991, entitled 
Controls Over Authorized Agents " (OEI-12-90-00530). This management advisory 
report recommended strengthening policies and forms governing the participation of 
authorized agents to insure that the confidentiality of Data Bank information is 
maintained. 
As a result of our ongoing review of the Data Bank policies and procedures, we 
believe that the PHS needs to strengthen the Data Bank registration procedures to 
assure that only qualified health care entities have access to the Data Bank 
information. 
According to the Data Bank regulations, at 45 CFR 60.  , a "health care entity" is 
defined as: 
a hospital; 
an entity that provides health care services and engages in 
professional peer review through a formal peer review process for 
the purpose of furthering quality health care, or a committee of 
that entity; or  ... ...
, "
a professional society that engages in professional review activity 
through a formal peer review process for the purposes of
furthering quality health care. 
The regulations, at 45 CFR 60.3, also define "formal peer review process" as "  the 
conduct of professional review activities through formally adopted written procedures 
which provide for adequate notice and an opportunity for a hearing, 
According to the Data Bank Guidebook  a medical school, physician group practice 
or preferred provider organization (PPO) which either does not provide health 
meet the...definition of 
servces or does not have a formal peer review system wil not 
a health care entity, and, therefore is ineligible to...query the Data Bank... 
Registration records provided by UNISYS indicate that, as of June 1991, a total of 330 
group practices, 19 PPO' , and 770 HMO' s have been registered, i.  , approved, by 
addition, 890 professional societies have also 
UNISYS to query the Data Bank.  In 
been approved for querying privileges.  FINDINGS

A number of factors indicate that there are health care entities with the Data Bank 
querying privileges who may not meet the regulatory definition and therefore have 
unauthorized access to the Data Bank records. These factors are as follows: 
Inadequate Registration Policies 
About 80 percent of all entities were "pre-registered" by UNISYS, the PHS contractor 
prior to the September 1990 opening of the Data Bank. These entities were identified 
for registration through mailing lists obtained from national associations or health care 
organizations such as the American Medical Association and American Hospital 
Association. These entities were assigned registration numbers by UNISYS and then 
required to "certify" that they were a qualified health care entity. UNISYS, however 
did not perform any review to determine if the entities actually met the definition of 
health care entity. 
All entities that wanted to participate in the Data Bank after it opened in September 
1990 were given a registration number only after they filed out a "registration form. 
However, this form did not require health care entities to submit documentation on 
what health services they provided or the nature of their peer review. 
Furthermore, while the Data Bank registration form requires that an entity "certify" 
that it is eligible to query the Data Bank, the form does not define eligibility, even in 
broad terms. Since no eligibility criteria are clearly stated on the form, it would be 
difficult for an entity to know if it complied, and therefore the "self-certification 
process itself may be questionable. Also, the warning on the query form only indicates 
made. It is possible that most 
that penalties exist for false statements  knowingly 
improper releases result from the lack of available guidance and that most entities do 
not knowingly make false statements when they request information. 
Finally, reliance on self-certification for querying the Data Bank seems to make it 
difficult, if not impossible, to identify any improper requests for information. It would 
appear to remove the incentive for UNISYS to have effective controls in place to 
assure that information is not improperly released, 
Health Care Industry Concern 
National organizations such as the American Medical Association, American Hospital 
Association, and American College of Obstetricians and Gynecologists have expressed 
concerns with the confidentiality of the Data Bank information and procedures used 
for participation in the Data Bank. A March 9, 1990, memorandum from the PHS to 
the Office of Management and Budget concerning the proposed procedures and forms 
relating to the Data Bank participation stated:  Confidentiality of data is an issue that several commentators are 
all cases we have believed it best to place the 
concerned' about..In 
burden of responsibility for defining eligibility to request information 
upon those entities, individuals, State boards, or professional societies 
who make the request.. 
At the July 11, 1991 , meeting of the Data Bank Executive Committee, concerns were 
expressed that the large number of group practices registered with the Data Bank may 
not have "formal peer review, 
Medical Economics Article 
The May 6, 1991 , issue of "Medical Economics" expressed concern over the broad 
definition of " health care entity" and was critical of the "self-certification" registration 
process. The article noted: 
As of February, according to government figures, about 12 500 
organizations had been authorized to query...the Data Bank. When 
added up all the nation s hospitals, HMO'  , licensing boards, the total 
fell short of 12 500 by 5 000...exactly who they are is anyone s guess.  ...
RECOMMENDATIONS

We believe that all the above factors indicate the need for the PHS to take action as 
soon as possible to assure that only qualified health care entities have access to the 
Data Bank records. We have three recommendations for the PHS. 
Revise Regitration Form for Querying 
The PHS should consider revising the registration form to indicate that in order for a 
health care entity" to be eligible to query the Data Bank it must provide health 
servces and/or have a formal peer review process. 
, we note that the form provides a warning that "Any person who knowingly 
In addition
makes a false statement or misrepresentation to the National Practitioner Data Bank 
is subject to a fine and imprisonment under Federal statute. 
Under the OIG civil money penalty authority, at 42 CFR Part 1003, imposing civil 
penalties for violating the confidentiality provision of the regulation is not contingent 
upon a "knowing" or "willul" act, although these factors can be considered in 
determining the actual amount of the civil penalty. We would therefore also suggest 
that the registration form indicate that a CMP can be imposed if an ineligible "health 
care entity" obtains the Data Bank information. 
Provide Guidance on What Constitutes a ''Health Care Entity 
We note in the preamble of the Data Bank final regulation, in the section dealing with 
the definition of health care entities, that the Department indicates that it "  prefers to 
define this term broadly, rather than to attempt to focus on the myriad Qf health care 
organizations, practice arrangements, and professional societies... 
While we acknowledge the utility of such broad definitions, we are nevertheless 
concerned that the lack of any detailed policy guidance or operational criteria on the 
definition of health care entity jeopardizes the integrity of the Data Bank information. 
We therefore recommend that the PHS develop such guidance or criteria. Such 
guidelines could be provided for on the registration form, or as part of the registration 
kit, or in the Data Bank Manual. 
Review Eligibility Status of Registered Health Care Entities 
While we recognize that it may not be feasible to review the eligibility of all health 
care entities currently registered as HMO'  , PPO' , group practices, and professional 
associations, we recommend that such a review take place as soon as possible for all 
such entities that have already queried the Data Bank. The remaining entities could 
be evaluated at the time UNISYS conducts its periodic review of the registration file  ...
which we understand will take place every year or two. Such a review would involve 
providing these "inactive" health care entities with guidance on what constitutes an 
eligible health care entity for querying privileges and advising them to contact 
UNISYS if they have questions regarding their meeting such Data Bank requirements. 
Alternatively, UNISYS could require all entities to describe the nature of their health 
servces and/or formal peer review program for PHS/UNISYS analysis and approval. 
If the PHS decides to adopt this latter approach, we are providing, as Appendix B, an 
example of a questionnaire that could be used. 
Public Health Service Comments and OIG Response 
The PHS concurred with the first two recommendations to (1) revise the registration 
form for querying, and (2) provide guidance on what constitutes a health care entity. 
PHS indicated that the target date for implementing both recommendations will be 
October 1992, 
We are accepting the PHS actions on these two recommendations. We would 
appreciate receiving a copy of the revised registration form and the expanded 
definition of health care entity. 
Although the PHS concurred with the objective of the third recommendation, namely, 
to review the eligibility status of health care entities, the PHS disagreed with our 
recommendation that it verify the eligibility status of all HMO'  , PPO' , group 
practices, and professional associations that have already queried the Data Bank, The 
PHS stated, however, that it has directed UNISYS to conduct an extensive update of 
the entity file so that the file "  wil contain only those entities that are authorized to 
use the Data Bank." 
The PHS description of this "update" process and the forms that are beiug used 
(which were recently provided to the OIG -- see Appendix C) indicate that the PHS is 
he "self-certification" concept. We note that the proposed letter 
continuing to rely on 

, Form L61.1 (dated 5/27/92), includes the statement "Entities are 
to entities
responsible for certifying that they satisfy the requirements for participating in the 
Data Bank." We  not provide detailed guidance as to 
also note that the letter does 
what constitutes eligibility. It also does not discuss the limited guidance set forth in 
the regulations (see 42 CFR 60.3, definition of "Health Care Entity" and "Peer Review 
Process 
Furthermore, while Section C of the certification form acknowledges that civil money 
penalties can be imposed if an ineligible entity obtains information from the Data 
Bank, the actual certification is confusing. Entities have two choices on the form: (1) 
they can certify that they are eligible to query and/or report; (2) they can certify that 
they are ineligible to query or report. Given such an option, what does an entity do 
that is eligible to report but not to query (such as a malpractice insurer)? Does it  certify that it is both eligible and ineligible? In order for the certification to be 
meaningful, questions concerning reporting and querying should be separate. 
If the PHS wishes to continue to use the self-certification mechanism, the process and 
forms need to (1) define in detail eligibility criteria and (2) provide a clear 
unambiguous certification that wil assure the necessary accountabilty; otherwise, the 
proposed PHS actions wil not achieve the objective of strengthening the registration 
process, 
Finally, the PHS response noted that those health care entities that were "pre
registered" were also required to certify that they were a qualified health care entity. 
We have revised the report to reflect the PHS clarification,  APPENDIX A

TH PUBLIC HEALTH SERVICE COMMNT  ::  () . 

'::. . .
. ,.."  :. .: .:':  :: 
t-
REm  SECE  Pu 
DEPARME OF  &. HU.MAN 
.f(r
C; 
emorandum 
1 srl

eta r y for Health 
Fr..r. .  c :r 
Subjec Office of Inspector General (OIG) Draft Management Advisory
Report " National Practitioner Data Bank--Unauthorized Access by
e!ig  lc Health Care Entities , 
" OEI-12-92-00290 
Inspector General, OS

Attached are the PHS comments on the subject OIG draft 
the possible registration 
Management advisory report concerning 
the 
of ineligible health care entities for participation in 
Nation41 Practitioner Data Bank (Data Bank). 
the 
We concur with the first two recommendations to (1) revise 
registration form for querying, and (2) provide guidance on 
ha t const i tutes a health care enti ty. In our comments, we 
implement them. 
state the actions taken or planned to 
ecti ve of 
We al so concur wi th the obj  the last recommendation. 
We have directed a contractor to conduct an extensive update

the " entity file.  This will ensure that the " entity file 
will contain only those entities who have certified that they 
are authorized to access the Data Bank. 
Iv 
Mason, M. D., Dr.

Attachtlent 
A - 2
 TH 
COMMENTS OF THE PUBLIC HEATH SERVICE ON  OFFICE OF 
INAPECTOR GENERA (OIG) DRBAA M A--GEMEN ADVISORY REPORT 
luNJU PHACTITIONER DATA  UNAUTORIZED ACCESS BY 
INELIGIBLE HETH CAE ENITIES, " OEI- 92-00290 
GENERA COMMENTS 
Inadeauate Reaistration Policies

We note that some of the OIG statements in the first paragraph

under this heading on page 3 of the report co ld be more 
clearly stated. The " registration" prior to the opening of the 
National Practitioner Data Bank (Data Bank) was largely an

o create a mailing list of potential customers with

effort 
whom we could communicate at an appropriate time. 

intention, and the actual practice of the contractor, has been

to only activate a listing in the system after certification by

the entity, a process separate and distinct from the early

registration process. 
Early registration did not gain
automtic access. 
The following comments are provided in response to the report'

recommenda tions 

OIG RECOMMENDATION

se Rea stration Form for Ouervina

The PHS should consider revising the registration form to
indicate that in order for a "
health care entity" to be 
Ban it must provide health services 
eligible to query the Data 
forml 
and/or have a  peer review process. 
Any 
In addition, we note that the form provides a warning that "
person who knowingly makes a false statement or 
misrepresentation to the National Practitioner Data Bank is 
subject to a fine and imprisonment under Pederal Statute. 
Under the OIG civil money penalty authority, at 42 CFR Part 
1003, imposing monetary penalties for violating the 
confidentiality provision of the regulation is not contingent
upon a "knowing" or "willful" act, although these factors can 
be considered in determining the actual amount of the civil 
penal ty . We would therefore also suggest that the registration 
form indicate that a civil monetary penalty can be imposed if 
an ineligible "health care entity" obtains the Data Bank 
infoJ:ation. 
A - 3
 PHS COMMENT

with 
We concur. We will include the recommended revisions, 
other revisions to the registration fo  for querying, during

the upcoming round of form changes to be completed by

October 1992.0IG RECOMDATION 
Health Care Entitv 
Provide Guidance on What Constitutes a "
preamle of the  regulation, in 
We note in the  Data Bank fina 
the section dealing with the definition of heailtt .h  care 
Departent indicates that  .. .prefers to 
entities, that the 
define this term broadly, rather than to attempt to focus on
the myiad of health 
care organizations, practice arrangements, 
and professional societies...

While we acknowledge the utility of such broad definitions, we
are neverteless 
concerned that the lack of any detailed policy 
defintion of health 
guidance or operational criteria on the 
care entity jeopardizes the integrity of the Data 
therefore 
infor.tion. We  recomend that the PHS develop such 
guidance and criteria. Such guidelines could be provided for 
on the registration form, or as part of the registration kit, 
or in the Data Bank Manual. 
PHS COMMENT

furer 
We concur. We will provide  guidance and clarify the
existing definition of "health care entity" though 
the changes 
to the Data Bank Manual which are scheduled for completion by 
October 1992. 
We plan to elucidate existing policy guidelines by providing
addi tional examples of health care organizations, practice 
arrangements, etc., which could be expected to qualify as 
Ban regulations, because 
health care entities under the Data 
services, 
ley (1) are engaged in the provision of health care 
and (2) might also conduct professional review activities 
forml 
through a  peer review process. Examples of such 
based, separately 
organizations include nonhospital-
facilities; 
incorporated, skilled nursing and rehabilitation 
facilities 
freestanding, independent medical and surgical care 
such as end-stage renal dialysis centers; and other such 
providers of disease-specific or specialty-oriented medical and 
surgical care services. Further, we will provide additional 
guidance to assist professional societies in making decisions

health care entities 
regarding whether or not they qualify as "
under the Data Bank regulations. 
A - 4
 . . ::' . .
OIG RECOMMENDATION

Review Eliaibilitv Status of Reaistered Health Care Entities

While we recognize that it may not be fecasuibnlet ltyo  review the

eligibility of all health care entities  registered as
l th 
maintenance organizations, preferred provider 
organizations, group practices, and professional associations,
we recommend trhat such a review take. place as  oon as possible 
Bank. 
h entities that have already queried the Data  The 
fQr 
:;; 671'tities could be 
::":r.  evaluated at the time UNISYS 
conducts its peritoadeic  review of the registtrwat.i on file, which we 
understCind will  place every year or  Such a review
would involve providing these -
inactive- health care entities
with 
q11;d  nce on what constitutes an eligible health care 
entity for querying privileges and advising them to contact 
regardg their 
UNISYS if they have questions  meeting such Data 
Bank requirements. 
Alternatively, UNISYS could require all entities to describe 
forml 
the nature of their health services and/or  peer review 
program for PHS/UNISYS analysis and approval. If the PHS 
decides to adopt this latter approach, we are providing, as 
used. 
Appendix A, an example of a questionnaire that could be 
PHS COMMENTS

We concur with the objective of this recommendation. However, 
rather than initiating a review of the eligibility status of 
the registered health care entities, we have directed the 
contractor to conduct an extensive update of the so-called 
izations 
enti ty file.  This file contains a listing of orq 
(1) which have certified that they are authorized to access the 
Data Bank, and (2) which may be eligible but have not certified 
that they are authorized to access the Data Bank. 
Following the update, the "
entity file" will contain only those 
entities that have certified that they are authorized to use
the Data Bank. 
Those entities who do not certify that they are 
authorized to use the Data Bank will be eliminated from the
entity file. 
We believe that this would be the least 
expensive and quickest way of ensuring that those who query the 
Data Bank have certified that they have the proper
authorization. 
A - 5
 APPENDIX 
PROPOSED OIG QUETIONNAI FOR 
REVIWIG HETH CAR  NTITlE  GENERA INORMTION 
What is the name of your organization? 
Please describe the nature of your organization and the services or busness 
it is 
engaged in. 

If you have a brochure or other written document describing your organization 
please enclose a copy.

Is your organization licensed, regitered, or accredited by any State or local 
governmental entities? 
If yes, please specify the governmental entity(ies), whether you are licensed 
registered, or accredited, and the type of category in which you are licensed 
registered, or accredited. 
Does your organization do busness in more than one locale or through contracts 
or a"angements with other groups or individuals? 
If yes, please specify the different locales and the types of contracts or 
arrangements that you have. 
Why did you regiter with the National Practitioner Data Bank? 
For what purposes do you intend to query the National Practitioner Data Bank? 
HETH CAR SERVICE PROVIED 
What types of health care services, if any, does your organization provide to the 
public? 
Does your organization provide any health care services directly through its own 
employees or staff! 
If yes, approximately what percentage of services are provided through 
employees or staff? 
Does your organization provide any health care services indirectly, through 
contracts or a"angements with health care providers or practitioners? 
If yes, approximately what percentage of services are provided through 
contracts or other arrangements?  If yes, do such services include non-institutional services? 
What responsibility, if any, does your organization have to revew the qulity 
services provided indirectly through contracts with other health care providers or 
practitioners 
If a patient was dissatisfied with the quality of services provided by such a 
provider or practitioner, would the patient have a right of recourse against your 
organization? 
Does your responsibility or the extent of the patient s recourse vary with the 
tye of service, e.
 , institutional versus non-institutional? If yes, please explain.
PEER REVIW 
Does your organization conduct any peer review activities , activities which are 
, i.e.
designed to review the professional competence or professional conduct of health 
care practitioners? 
If yes, please describe briefly the nature and extent of the peer review activities 
that your organization conducts.

If no, does your organization arrange for peer review activities to be conducted 
by an outside source? If so, please describe briefly the nature and extent 
such arrangements. Please enclose a copy of any written arrangements or 
contracts, 
Does your organization have written procedures which set forth how or by whom 
peer review activities will be conducted? 
If yes, were those written procedures formally approved or adopted by your 
organization? 
Do those written procedures provide for prior notice to a practitioner 
concerning adverse actions (i.  , actions that may affect the practitioner 
present or future employment or clinical or staff privileges or membership) that 
may be taken against such practitioner? 
Dao dthovse ewrirttesn peroc eduaresc prtoviide oforn an sop?por tun
ity for a hearing on any
Are written records maintained for your organization s peer review activities? 
Please enclose a copy of the written peer review procedures,  -- 
If your organization provides services in diferent locales or through affliated or 
subsidiary groups, how are peer  are they handled 
review activities handled 
centrally or separately by each locale or group? If separately, is the information 
shared with all the locations or groups? 
B - 4
 APPENDIX 
REVISED ENTIT SELF-CERTIFICATION PROCEDUR 
C -
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orgation on fi  Prtioner 
W,s wc:!'= m:,: 1( veri tht th inormtion abut your  with th Natina 
Data Bank is up-tCMte . We ha endo  En FIl  doent, conntatg  aU inormtion 
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To make changes to the inrmtion we  on fie for your  (1)  out the
inccte inormtion on  En FIl  doent,  mrrec inormon tVo  er 
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For euple, nae,  and sta titl ar  to 40  includg pUDtion an
spce Plea kep thes  litations in mi when chgig inormtion. 
re 
Afer we have entered your chge you wi  En Upd  doent veg tht 
an  Not 
your dcehiggenst eh aovne  be ma ThE  n FIl  td woie bneL m aed to the attention of the  Re Ree SI 
Ti  the  Ver 
If the cut  En FIl  doent is mrr plea (1) ch the spa
inormtin on th  corr  Vt: 
indicatig tht aU inormtion is  (2) mmplet Seon B if approprite (3) mmapledte a nad sbign 
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retur th  Ver 
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Brief exlations of  En Fw  fonow 
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EN 
SECI0N A:  INORMTION 
ad 
Eadty Name, Addr Th entity nae and Ba you prode in Seon A of an Data Ba form must. 
matac thde i normtion on fi with th Data  Your ren or query wi not be aate if the nae 
and  inrmtion do not matc Aal Ddata  Ba doents ar set to the nae and ades 
Ba 
me with th Data  DO th nae an  you prode on a form 
Ty Th co  us  detee  ren 
EBadaty   Er/Q is  to  your orgation s elgibdiletyt teoe q uer and  to the Data
An  mrr  of En  7)  Co  is enclos to help you  whether the axe we have 
on fie is 
di 
Rert Resas Stl Title: Al Data Ba doentsa adr  maed to a spec sta title. Al Data 
doents rete to medca maprace  acon  to the Repon 
payment or  rert wi be 
Repons Sta Title. If a title ha not ben deignted aU repon inormtion wi be set to the attention
oPc.O,- You ma=y cin cludc ahn irnsdi,v dua's nae with th sta title; howev, an indidua's nae and 
sta title ma DOt  40  includg space and punauation.  di 
Ba 
QQuUerC  RReessppoouns sS StataTl Ttlitel:e.  ATlh eD aDtaat a Baq uise ruy nrbelsep toon s and.Acc  .AccSU   wtio b ae  sepate btoil itnhge  
offce at th tie. If  sta title ha not ben deignted aald  query inormtiSoU n wi be set to the attention 
of -c.E.O,- You macym inc ludc ahne inrdsi,d ua's nae with th sta title; how, an indidua's nae and 
sta title may not  40  including space and punauation. 
OSfnfJ  1.1. 
C - 2
 .. 
/) 

....
EN  (CD
SE0N A:  INORMTION 
Inor:  be  mnf 
tbt th inormtioD 1ODf )f' ih (ae .gd. eDgatnat Be aan I AD, gJtU 10  qaud th  rDoautat iB iDa tonbnD )e'Sur)   .. corprl eAan  Agent 
is an indidua or ortiOD degnte by an eatity 10 ma quees OD its Rfoer e: ple, a County 
degnte  AD  frm 
Mttphhreeed  dADecaadtua  S otBoore atithy  O R oDDr  ieStatSat  rebB Heospertita a a  PdIs  8tlDh  I DADO gtdtiOtha D   mtwhla t bAbIe D 8gDtd  eaeoata yt  hwo byh r ac Uh:oepiosta   tw1h0  iIr eIeutae ttO iWin  oDorafm arlta i odBorlDmea rU nomtD;  
DW. AD entity tht us an Agent ma Ios p8Dt  10 ha al que repons route 10 the Agent. 
EN 
GOVEAL 
SGECI0cN B :  DESGNA110N 
Cita  outadig
DN.,.  Th 
more tb 30 dEa a pat th bDlg da Data Ba fc:tIe   eatities ue aienptte tf rmon  tahne sa miunntpte tl  cbges 
aardc:  fed  sta orr e  mmplet
Sreeogu  Bawiathe   01  regutions  Fi  JO li .
 ....mt 8D  lo  It to th Da BeDUaty , Compaleptgpg
Ath cdoentht  wE1i eale tYehr  Data Ba  eliminate th intet cbges whch ma be 
10 
OD )'ur 
gota 
gSomoe eattit iers embayu har bee nt  fici  cled aps  rdi  eatitiess beac eo n theqi ureap t
gota  or  sapon for  beth ca  To  as a
iDtJtaty, 
fed  entity, )'ulro O grgoteionDt ,m tusht b eD ani targ cy, authority, th  or polPiti usu bioD
oTPfha ieacD  rcec Bpietan ot f sj tugteqro oourena n , a  trelOgrey oor uenrtta  or  ftOnDa nofm tloh efs  uCUpopnloiutnem  fbSoirta ap tero odCr ioagmn  hImenaodtinh w ucithab e o sfb eadc,e o rb Ryn aiimttios,ln af.   
is  10  as a  entity. 
SE0N 
C: CETICA110N 
lt 
Ceea 
asignt  Ba 
Th  of a Data  ID is DOt a reretatiOD by th U.s Depaent oBf Haea th 
and Hum Sece tht yoQur oJr tiOD mce :th  reuimeDts for pacipatiOD in the Data 
sped in  HtJ CI  198, as amsaen  8Dr ites imepl ae ntig regutions
th  ACt of  tb th  th  padpati 
4S a: Pa 6B0 aEDU da ar  for  Ba  Bfoor  
IJpD:f ttmrhi n Dear to r oth STtaote b lei ienlggibl eb too   (2) at hh oDaittaa  (3) a haena tehn ctitay  menutsitty ,b oet h(1e)r  at h a hoofi tMae tdhcat 
pr heth ca sece an engages in form pe reew acty thugh a form pe reew
por'r (4 ) a prfesona smoet.  tht eagap in profe5ona reewt aac ty athdug hl iau froerm   
rcelecwa  priegesA aDc oennt,i tyo rt hptr fesionaa  msoeedtcya  mmeamprhcipe  pac8o'1ne,n ats o sr peeda n  Ba reguaticoonns,, 
by Data 
must rert the paent or th acon 10 th Da 
be  Ba  Ba plea
ID but ue ingible to repon to or query the Data 
clf)h'u  thhav eS cDd acseigcnaetdi Oa DDa tsata tem Sen C  En Fil  doent, sign the 
t in  ab oaf thde  d  Yer 
th Da Ba 
doent, an retum it 10  at the 
reg 
Tb 
mopetiOD and pacipatioD.  the mmpletion of 
)'u for)'ur  doent, plea ca  lf)'uB haav e any quetions 
En Fil  Help  at 1-8767-6732, wekdys from
8the : a.  Yer  the  UN 
10 6:00 p.m (5:3 p.m Frida) Eatem 11e. 
05H1  1.1. 
c - 3
 --....  -.- - ..-
--- 
::::::::::::::,::::::::-::::::: ::::: :::
EN 
EXPLAATION OF  TYE CODES

r:BI  :i:::IK 
4m' 
::i;,  :::::::::::i;  I:::: ::li::1il::ii!::il::il::!:I:i:ilil:II::I:Iil::::::i::i:::,
Ca!l 
I'  AA "  f31140  1-8767-6

f".  CA 
EN 
CODE  TYE
Publi or Prte Medca Maprace Pay (non-U.s Gomment) 
S. Goverent Medca Maprace 

Bo 
State Liceing  for Alopathc Physic

Bo  Phici 
for Ostepathc 
Stale 
Uceg Bo 
State Compote  for Physici 
Bo 
Detitr 
State  of 
Stte Uceing Bo fo Oth Heath Ca Prcttioners 
c:g
Bo  Ca 
Stte U for Heath  Entities 
Goent) 
PulicG or Poritte  Hosita (non-U.s. 
u.s 
Hospita

Matece 
Heath  Ortion (HO)

Prer Prde Orgtion 
(PPO)

Med Prce

Group 
Goent 
Other U.s  Heath Cae Entity 
Other Pulic or Prte Heath Ca Entity (non-U.s. Gornent) 
Prfesona Soet for Alopathc Phyici 
Prfesona Soety for Ostepathc Physici 
So 
Prfesona  for Detits 
Prfesona Soty for Other Heath Ca Prcttioners 
Maprace Litigat - Self 
Mapra 
Litigat - Agent/Attorney 
trtion 
U.s Drug  ,Admini!l
Enorcent 
Seta, U.s Depaent of Heath and Hum Servce 
Authori  otherw  Ba) 
Agent (not  eligible to query the Data 
05!2  El2.1 
C - 4  c - 5
 AUTttlRllEIJ REPRESENTATIvE UR INDIVIDUAL SIGHATURE ,. - SIGNATURE PATE IMBER ( I EPHDNE  RE..lltSENUliVE E OF APTHONIZED "IUNIED 111 - . OF I\TlVE OR INDIVIDUAL I'H.n AUHIONIZED kEPRF.SfNT.ED NA  DANK IrfrORMATIOt'.
001AIN$ DAl \ INELIGIItLI! I:NTITY OR INDIVIDUAL
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REPORT RESPONSE STAFF TITLE.
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Ilv TYPE I:N I 000 000-0000 I f.LEPHONE NO. a eeceeeeec. CA 99999 . STATE. ZIP CODEI CITV AAAAAAA srREET ADORESS. with .gent specified C.1. ENTITY NAME.  ALL INfORMATION IS CORRECT. EHTITV INFORATION SECTION A.  THIS FORM EVEN IF ALL INFORMATION IS CORRECT.
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CERTIFV YOUR ENTITY'SeCTION B. IF YOU ARE A GOVERNMENTAL ENTITY. COMPLETE
(2) PRINT THE CORRECT INFORMATION TO THE RIGHT OF THE EXISTING INFORMATION. CHANGE INPORMATI0N. TltE (1. CROSS OUT THE INACCURATE INFORMATION. ANDAPPROPRIATE CHANGES. TO INFORMATION IS CURRECT. UR INDICATE BANK. PLEASE CERTIFY THAT ALL S INFORMATION IN SECTION A IS THE INFORMATION CURRENTLV ON FILE IN THE DATA YOUR ENTITV'  EHTIJY_ fILe VERIFICATION PROCESS DATE. 01113191 DATA BANK 10. 210063200002158  -- ............................... ........... ......... ..... ............ ..... ...... .,..... 
........... ....... .... .... ............................ ............. ........................ ..... ........... ................ ......... ..... ....... ... ...... ..... ...... ... ..... ~~~~...................................................... ......... ............................ ........ ............... ........ .......... ... '" 
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