: 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 

for a "health care entity" to be eligible to query the Data Bank it 

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


EXCUIV SUMY 

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 . . . . . . . . . . . . . . BAPPENDIX C . . . . . . . . . . . . .. 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 

servces or does not have a formal peer review system wil not meet the...definition of 

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 

been approved for querying privileges. 

UNISYS to query the Data Bank. In 
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 

improper releases result from the lack of available guidance and that most entities do 

not knowingly make false statements when they request information. 

that penalties exist for false statements knowingly 

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 

concerned' about..In all cases we have believed it best to place the 

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. 

In addition, we note that the form provides a warning that "Any person who knowingly 

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 

to entities, Form L61.1 (dated 5/27/92), includes the statement "Entities are 

responsible for certifying that they satisfy the requirements for participating in the 

Data Bank." We also note that the letter does not provide detailed guidance as to 

what constitutes eligibility. It also does not discuss the limited guidance set forth in 

continuing to rely on 


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 "preregistered" 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 
,. ..::. :: :: () . . .

DEPARME OF REm &. HU.MAN SECE Pu t-

.f(r C; 

emorandum 

1 srl


Fr..r. . c :r eta r y for Health 

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 

Management advisory report concerning the possible registration 

of ineligible health care entities for participation in the 

Nation41 Practitioner Data Bank (Data Bank). 

We concur with the first two recommendations to (1) revise the 

registration form for querying, and (2) provide guidance on 

ha t const i tutes a health care enti ty. In our comments, we 

state the actions taken or planned to implement them. 

We al so concur wi th the obj ecti ve of 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

COMMENTS OF THE PUBLIC HEATH SERVICE ON TH OFFICE OF 

INAPECTOR GENERA (OIG) DRA MAGEMEN ADVISORY REPORT 

luNJU PHACTITIONER DATA BA -- 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


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


effort 

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 

eligible to query the Data Ban it must provide health services 

and/or have a forml peer review process. 

In addition, we note that the form provides a warning that "Any 

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


We concur. We will include the recommended revisions, with 

other revisions to the registration fo for querying, during


the upcoming round of form changes to be completed by


October 1992. 0IG RECOMDATION 

Provide Guidance on What Constitutes a "Health Care Entitv 

We note in the preamle of the Data Bank fina regulation, in 

the section dealing with the definition of health care 

entities, that the Departent indicates that it . .. .prefers to 

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 

guidance or operational criteria on the defintion of health 

care entity jeopardizes the integrity of the Data 

infor.tion. We therefore 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


We concur. We will provide furer 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 

health care entities under the Data Ban regulations, because 

ley (1) are engaged in the provision of health care services, 

and (2) might also conduct professional review activities 

through a forml peer review process. Examples of such 

organizations include nonhospital-based, separately 

incorporated, skilled nursing and rehabilitation facilities; 

freestanding, independent medical and surgical care facilities 

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


regarding whether or not they qualify as " health care entities 

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 feasible to review the


eligibility of all health care entities cuntly 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 fQr h entities that have already queried the Data Bank. The 

::":r. :;; 671'tities could be evaluated at the time UNISYS 

conducts its periodic review of the registration file, which we 

understCind will tae place every year or tw. 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 

UNISYS if they have questions regardg their meeting such Data 

Bank requirements. 

Alternatively, UNISYS could require all entities to describe 

the nature of their health services and/or forml peer review 

program for PHS/UNISYS analysis and approval. If the PHS 

decides to adopt this latter approach, we are providing, as 

Appendix A, an example of a questionnaire that could be used. 

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 

enti ty file. This file contains a listing of orq izations 

(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 

, institutional versus non-institutional? If yes, please explain. tye of service, e.


PEER REVIW 

Does your organization conduct any peer review activities, i.e., activities which are 

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? 

Do those written procedures provide for an opportunity for a hearing on any adverse actions? 


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 review activities handled are they 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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::::::::i:I:I: !!:!i::: :::!1:; I!!:III: :I:::::II:::::I. 4fWt€lfB::ij:!Il. j.r i:i:::I::::::::

r ,v, )S 
 UU CA 9311-' 1-8767-632

W,s wc:!'= m:,: 1( veri tht th inormtion abut your orgation on fi with th Natina Prtioner 

Data Bank is up-tCMte . We ha endo an En FIl Ver doent, contag aU inormtion 

we cuentl have on fie, wbch we would Uk you to reew, Plea al 8I nt th Bn F* II doent to IaIrR du IIlDorm II co 01 to ma 

To make changes to the inrmtion we ha on fie for your orgatio plea (1) cr out the inccte inormtion on the En FIl Ver doent, (2) prit the mrrec inormon to the right 

of the inccte inormtio (3) coplete and sign Seon C, and (4) reur the En FIl Ver 

docent to the Data Ba 81 the ad ab Goenta entities should al complete Seon 

Some inormtion abut your orgation ma be tnc:te due to cbr litations for ea category. 

For euple, nae, str ad and sta titl ar lite to 40 chrs includg pUDtion an spce Plea kep thes cI litations in mi when chgig inormtion. 

Afer we have entered your chge you wi re an En Upd Not doent veg tht 

your chges have be ma Th t wi be maed to the attention of the Re Ree SI Ti deignte on the En FIl Ver doenL 

If the cut inormtin on th En FIl Vt: doent is mrr plea (1) ch the spa indicatig tht aU inormtion is corr (2) mmplet Seon B if approprite (3) mmplete and sign Seon C, and (4) retur th En FIl Ver doent to the Data Ba at the ad ab 

Brief exlations of ea sen of the En Fw Ver doent fonow 

SECI0N A: EN INORMTION 

Eadty Name, Addr Th entity nae and ad you prode in Seon A of an Data Ba form must. 

matc the inormtion on fi with th Data Ba Your ren or query wi not be aate if the nae 

and ad inrmtion do not matc Al Data Ba doents ar set to the nae and ades 

me with th Data Ba DO th nae an ad you prode on a form 

Eadty Ty Th co is us to detee your orgation s elgibilty to quer and ren to the Data Ba An Er/Q of En is enclos to help you detee whether the axe we have 

on fie is mrr 7) Co 

Rert Resas Stl Title: Al Data Ba doents ar maed to a spec sta title. Al Data 

doents rete to medca maprace payment or ad acon rert wi be di to the Repon 

Repons Sta Title. If a title ha not ben deignted aU repon inormtion wi be set to the attention oPc.O,- You may includ an indivdua's nae with th sta title; howev, an indidua's nae and 

sta title ma DOt =c 40 chrs, includg space and punauation. 

Quer Respous StaTltle: Al Data Ba query respons and.Acc SU wi be di to the 

QUC Respons Sta Title. The Data Ba is unble to ad .Acc SU to a sepate biling 

offce at th tie. If sta title ha not ben deignted al query inormtion wi be set to the attention 

of -c.E.O,- You may includ an indidua's nae with th sta title; how, an indidua's nae and 

sta title may not cm 40 chers, including space and punauation. 

OSfnfJ 1.1. 

C - 2

..... /) 

SE0N A: EN INORMTION (CD Inor: 1f)' ha degnte an Agt 10 qu th Data Ba on )'ur be plea mnf 

tbt th inormtioD OD fi (e.g. Data Ba ID, JU ad routi iDtnDS) .. corr An Agent 

is an indidua or ortiOD degnte by an eatity 10 ma quees OD its be for e:ple, a County 

Medca Soety or State Hospita tiOD ma be degnte by a hopita 10 reuet inormtioD frm 

the Data Ba OD itS be Pl DO th th Agt aa th AD Re ar dlernt; 

the Auori Rereta Is 8D IDda wltb 8D eoty wh c:es th Ieti of laormUoD 

prded to th Da Br ad th Agt Is 8D IDdea orUo wi Ita OW Da Ba m DW. AD entity tht us an Agent ma opt 10 ha al que repons route 10 the Agent. 

SECI0N B: GOVEAL EN DESGNA110N 

intet on an amunt 

more tb 30 da pat th bDlg da Cita eatities ue aept frm thes intet cbges 

Gc Ea DN.,. Th Data Ba c:tI outadig

aardc: with fed regutions fe sta or lo eDUty, pl mmplet JO li .
 Seou Baae 01 th Fi Yer ....mt 8D re It to th Da Ba Completg E1 reg th doent wi eale th Data Ba 10 eliminate th intet cbges whch ma be appg OD )'ur Ac

Some eatities may ha be cled as gota eatities ba on thei rept got reburent or fici sapon for prdi beth ca sece To qua as a gota entity, )'ur OrgtioD must be an agcy, authority, iDtJtaty, or politi subioD of a fed stte or lo goent, th Ditr of Columbia th Commonwth of Pu Rim, a 

Pacc Ba juron, a telOry or OD of the Unite State or an Indi uibe bad, or nation. 

The rept of goen reurt or ftnanml suppon for prodig heath ca sece by itslf 

is iDcient 10 qua as a goenta entity. 

SE0N C: CETICA110N 

Ceea Th asignt of a Data Ba ID is DOt a reretatiOD by th U.s Depaent of Heath 

and Hum Sece tht your ortiOD me th reuimeDts for pacipatiOD in the Data Ba 

HtJ CI QJ lt ACt of 198, as amen 8D its impl entig regutions sped in th 

4S a: Pa 60 EDUda ar for c: tb th sa th reea for padpati 

ID th Dat Ba To be elgible to th Data Ba an entity must be (1) a Bo of Medca 

J:ftminer or oth State liing bo (2) a hoita (3) a heath ca entity, other th a hoita tht pr heth ca sece an engages in form pe reew acty thugh a form pe reew pr or' (4) a prfesona soet tht eagap in profe5ona reew acty thugh a form 

reew pr AD entity tht m. a medca maprce p8'1ent or ta an ad liure acon,

clca prieges acon, or prfesiona soety memhip acon, as speed by Data Ba regutions, 

must rert the paent or th acon 10 th Da 

lf)'u have be asigned a Data Ba ID but ue ingible to repon to or query the Data Ba plea ch th ScDd cecatiOD statemt in Sen C of the En Fil Yer doent, sign the 

doent, an retum it 10 th Da Ba at the ab add 

Tb )'u for)'ur mopetiOD and pacipatioD. lf)'u have any quetions reg the mmpletion of 

En Fil the Yer doent, plea ca the Ba Help UN at 1-8767-6732, wekdys from

8: a. 10 6:00 p.m (5:3 p.m Frida) Eatem 11e. 

05H1 1.1. 

c - 3

.... ::::::::::::::,:::::::::::::: ::::: ...:::

EXPLAATION OF EN TYE CODES


4m' I::::r:BI :i:::IK 

f". I' AA " Ca!l CA f31140 

::i;, :::::::::::i; 

CODE EN TYE

Publi or Prte Medca Maprace Pay (non-U.s Gomment) 

S. Goverent Medca Maprace 


State Liceing Bo for Alopathc Physic


Stale Bo for Ostepathc Phici 

State Compote Uceg Bo for Physici 

State Bo of Detitr 

Stte Uceing Bo fo Oth Heath Ca Prcttioners 

Stte Uc:g Bo for Heath Ca Entities 

Pulic or Prite Hosita (non-U.s. Goent) 

u.s Got Hospita


Heath Matece Ortion (HO)


Prer Prde Orgtion (PPO)


Group Med Prce


Other U.s Goent Heath Cae Entity 

Other Pulic or Prte Heath Ca Entity (non-U.s. Gornent) 

Prfesona Soet for Alopathc Phyici 

Prfesona Soety for Ostepathc Physici 

Prfesona So for Detits 

Prfesona Soty for Other Heath Ca Prcttioners 

Maprace Litigat - Self 

Mapra Litigat - Agent/Attorney 

U.s Drug Enorcent ,Admini!ltrtion 

Seta, U.s Depaent of Heath and Hum Servce 

Authori Agent (not otherw eligible to query the Data Ba) 

i:::, ::li::1il::ii!::il::il::!:I:i:ilil:II:::il::::i: II:::

1-8767-6


05!2 C - 4 El2.1 
................. 

............... ............................ ........ ............... ...................................................... ......... ... 

... ......... ....... .... .... ............ ..... ........... ......... ..... 

..... ... ........ ...... 

...... .,..... 

DATA BANK 10. 210063200002158 EHTIJY_ fILe VERIFICATION PROCESS DATE. 01113191 

YOUR ENTITV' S INFORMATION IN SECTION A IS THE INFORMATION CURRENTLV ON FILE IN THE DATA BANK. PLEASE CERTIFY THAT ALL 

INFORMATION IS CURRECT. UR INDICATE TltE APPROPRIATE CHANGES. TO CHANGE INPORMATI0N. (1. CROSS OUT THE INACCURATE INFORMATION. AND

(2) PRINT THE CORRECT INFORMATION TO THE RIGHT OF THE EXISTING INFORMATION. IF YOU ARE A GOVERNMENTAL ENTITY. COMPLETE


SeCTION B. CERTIFV YOUR ENTITY' S ELIGIBILITY IN SECTION C AND INCLUDe AN ORIGINAL SIGNATURE IN INK.


PLEASE RETURN THIS DOCUMfNT TO THE NATIONAL PRACTITIONER DATA BANK. P. O. BOX 8048. C_MARILLO, CA 83011-8048. If YOU HAVE ANY


QUESTIONS. CALL THE PAtA BANK AT 1-800-767-8732. PLEASE RETURN THIS FORM EVEN IF ALL INFORMATION IS CORRECT.


SECTION A. EHTITV INFORATION ALL INfORMATION IS CORRECT. 

ENTITY NAME. with .gent specified C.1. 

srREET ADORESS. AAAAAAA 

CITV . STATE. ZIP CODEI eeceeeeec. CA 99999 

I f.LEPHONE NO. a 000 000-0000 

I:N I Ilv TYPE 10, NON-FEDERAL MALPRACTICE PAYER


AGENT DA 

QUERv RESPONSE STAFF TITLE.
REPORT RESPONSE STAFF TITLE.


A BANK IDa 21006200000240 I 

AGENT NAME I ZZZZZZZZZZZ 

STREET ADDRESS. ZZZZZZZZZ ( I TV. S 1 A I . ZIP CODE: ZZZZZZZZZ, ccecc 

11:Li;PHONE NO. 000 Ooo-ooon 

ENT START DATE. 07/19/91

AGENT . STOP DATEa 10126/92

AtOtNf ROUTING.. TO AGENT


StCTJON B COVE rLT! CHECK TYPE OF GOVERNMENTAL ENTITY. IF APPLleAoLE. PLEASE CHECK ONLY ONEI 

FEDERAL STATE LOCAL PISTRICT OF COLUMBIA, COMMONWEALTH OF PUERTO RleO. PACIFIC BASIN JURISDICTION; 

-- U. S. TERRITORV OR POSSESSIONI INDIAN TRIBE. BAND. OR NATION 

gmgN CERTIfiCATION CHECK THE APPLICABLE STATEMENT BELOW. 

I CERTIFV THAT THE ENTITY OA INDIVIDUAL IDENTIFIED IN SECTION A OF THIS DOCUMENT IS AUT' AIZED TO REPORT TO ANDIOR QUERV THE OIONAL ')IHCTIYIOHEN DAU ItANK UNpER THE PAOVISIONS Of PUBLIC LAW 99-860. AS AMENDED . AND AS SPECIFIED IN 45 CFA PART 60. I ALSO UH11fV 111A I" I AM UTIIUAIZED TO SUBMIT THIS RESPONSE TO THE DATA BANK. AND THAT lHE INFORMATION f'ROVWED IS TAUE AND COMPLETE. 

THE EtIlTV OR 1NUIVIPUAL IUENTlFIED IN SECTION A Of THIS DOCUMENT IS NOT ELIGIBLE TO REPORT TO OR QUERY THE NATIONAL
 mCT I T IONE.1 DATA t-ANK, 

/ARtHNG: IV PERSON WlIO MAKES A FALSE STATEMENT OR MISREPRESENTATION TO TtIE NATIONAL PRACTITIONER DATA BAtite IS SU8JECT


fiHf. UJ IMPR'SUNMENT ""Df:R HUt-HAl. SIAWIE. CIVil. MONty PENAtrlES CAN BE IMPOSEII IF AN INELIGIItLI! I:NTITY OR INDIVIDUAL
 001AIN$ DAl \ DANK IrfrORMATIOt'.


I'H.n ED NA . OF AUHIONIZED kEPRF.SfNT.I\TlVE OR INDIVIDUAL 

"IUNIED 111 - E OF APTHONIZED RE..lltSENUliVE 

I EPHDNE IMBER ( SIGNATURE PATE 

SIGHATURE ,. - AUTttlRllEIJ REPRESENTATIvE UR INDIVIDUAL 

c - 5