Print these helpful hints for reference. All self-query applications
must be submitted through the on-lineSelf-Query
Service. Complete the required information on the Self-Query
Input screen and then print a copy of the generated self-query.
Sign the formatted copy (in ink) in the presence of a notary public
and mail the notarized form to the NPDB-HIPDB. Some helpful hints
are:
The NPDB-HIPDB employs the latest technology, along with various
implementation measures, to provide a secure environment for transmitting
information to the Data Banks. Security features include firewall
protection from unauthorized access and encryption of transmitted
data to prevent unauthorized use.
Effective July 1, 2004, all self-query requests
are assessed a $8.00 fee for each Data Bank, for a total of $16.00.
The fee must be paid for by credit card (VISA, MasterCard, Discover,
or American Express). Self-queries that are missing
credit card information are rejected.
All self-queriesmust be notarized. Forms that are not
notarized are rejected.
Individual Self-Query Fields
Individual Name: Enter your Last, First, and Middle
Names and any Suffix (e.g., Jr., Sr., III). Do NOT
enter M.D., D.O., D.D.S., R.N., etc.
Other Name Used: Enter Last, First, and Middle Names
and any Suffix of other names used (e.g., Maiden Name).
Gender: Select Male or Female, as appropriate.
Birth Date: Enter your birth date in MMDDYYYY format
(e.g., May 11, 1946 = 05111946).
Work Organization Name: Enter your Organization Name
and select the Organization Type from the pick list. If
you select Organization Type 999, enter a description in the Organization
Description field.
Address: Enter the complete address (home or work) to
which you would like your response sent. Complete the Country
field only if your address is not in the U.S.
Federal Employer Identification Number (FEIN): If available,
enter your nine-digit FEIN (in XXXXXXXXX format), that was assigned
to you by the IRS.
Social Security Number: Enter your nine-digit U.S. Social
Security Number in NNNNNNNNN format.
Individual Taxpayer Identification Number (ITIN): Enter
your nine-digit ITIN in 9NNNNNNNN format.
National Provider Identifier (NPI) Number: If available,
enter your NPI number(s), issued by the Centers for
Medicare & Medicaid Services (CMS).
Drug Enforcement Administration (DEA) Number: If available,
enter each DEA number that you hold.
Unique Physician Identification (UPI) Number: If available,
enter your UPI number, issued by Medicare.
Education Information: Enter the name of each Professional
School Attended and the Year of Graduation in YYYY
format. If you did not graduate, provide the name of the school
and the four digits of the last year of attendance. If you did
not attend a professional school, provide the name of the certificate
program and the year it was completed.
If you did not attend a professional school or complete a certificate
program, enter "None" in the Professional School
Attended and enter the year the State authorize you to provide
health care services in the Year of Graduation.
Licensure Information: Enter each U.S. License Number
that you currently hold, select the State in which the
license is held, and select the three-digit Occupation/Field
of Licensure Code for the license. If you have no U.S. license,
or if you hold a temporary or foreign license, enter "No
License" in the License Number field and select an Occupation/Field
of Licensure Code. Leave the State field blank.
Report Password Preference: In this section, specify
whether you wish to include or omit the Report Password in your
self-query results.
If you are the subject of a report, you will
be assigned a unique, confidential password to access the Report
Response Service. This service allows you to add, modify, or remove
a Subject Statement, initiate or withdraw a dispute or request
for Secretarial Review, or modify your address as maintained by
the Data Banks.
If you plan to share your self-query results with
another person or organization, such as a State licensing board
(i.e., a third party), you may wish to omit password information
from your self-query results.
Credit Card Number: Enter your credit card number and
the expiration date in MMYYYY format (e.g., December 2002 = 122002).
Cardholder Name and Cardholder Billing Address: Enter
the cardholder name as listed on the card and the cardholder billing
address. If it is identical to the address information submitted
in the self-query, you may click the box provided
to copy address information from above.
Certification and Notarization: Sign and date the form
in the presence of a Notary Public. The Notary must: (1) fill
in the date on which the individual appeared, (2) print his/her
name, (3) sign the form, (4) provide the date his/her commission
expires, (5) affix his/her seal. If the Notary Public does not
have a stamp or seal, the Notary must provide other proof of his
or her office (e.g., a copy of his or her Notary certificate).
Organization Self-Query Fields
Organization Name: Enter your organization's name.
Other Organization Names Used: Enter any other names
used by your organization.
Organization Address: Enter your organization's complete
street address. Complete the Country field only if your
organization's address is not in the U.S
Organization Type and Organization Description:
Select the Organization Type from the pick list. If you select
Organization Type 999, enter a description in the Organization
Description field.
Federal Employer Identification Number (FEIN): Enter
the nine-digit FEIN that was assigned to your organization by
the IRS.
Social Security Number (SSN): Enter your nine-digit U.S. Social
Security Number in NNNNNNNNN format.
Individual Taxpayer Identification Number (ITIN): Enter
your nine-digit ITIN in 9NNNNNNNN format.
Licensure Information: Enter each current U.S. License
Number and select the State in which the license is
held. If you have no U.S. license, or if you hold a temporary
or foreign license, enter "No License" in the License
Number field and leave the State field blank.
Drug Enforcement Administration (DEA) Number: If available,
enter each DEA number that you hold.
Clinical Laboratory Improvement Act (CLIA) Number: If
available, enter the CLIA number assigned to your organization
by the CMS.
Food and Drug Administration (FDA) Number: If available,
enter your organization's FDA number.
National Provider Identifier (NPI) Number: If available,
enter the NPI number(s) issued to your organization by the Center
for Medicare and Medicaid Services (CMS).
Medicare Provider/Supplier Number: If available, enter
the Medicare Provider/Supplier Number assigned to your organization
by the Medicare Program.
Report Password Preference: In this section, specify
whether you wish to include or omit the Report Password in your
self-query results.
If you are the subject of a report, you will
be assigned a unique, confidential password to access the Report
Response Service. This service allows you to add, modify, or remove
a Subject Statement, initiate or withdraw a dispute or request
for Secretarial Review, or modify your address as maintained by
the Data Banks.
If you plan to share your self-query results with
another person or organization, such as a State licensing board
(i.e., a third party), you may wish to omit password information
from your self-query results.
Credit Card Number: Select the type of credit card you
are using (VISA, MasterCard, Discover, or American Express), and
enter your credit card number and the expiration date in MMYYYY
format (e.g., December 2002 = 122002).
Cardholder Name and Cardholder Billing Address: Enter
the cardholder name as listed on the card and the cardholder billing
address. If it is identical to the address information submitted
in the self-query, you may click the box provided to copy address
information from above.
Certification and Notarization: Complete the Authorized
Submitter's Name, Title, and Phone. Sign and date the form
in the presence of a Notary Public. The Notary must: (1) fill
in the date on which the authorized submitter appeared, (2) print
his/her name, (3) sign the form, (4) provide his/her complete
phone number, (5) provide the date his/her commission expires,
and (6) affix his/her seal. If the Notary Public does not have
a stamp or seal, the Notary must provide other proof of his or
her office (e.g., a copy of his or her Notary certificate).
To ensure that all features of this site work properly,
use one of the following supported browser versions:
Netscape Communicator 7.2, 8.0 or 8.1
or Internet Explorer 6.0 SP1, 6.0 SP2 or 7.0.
