Form hipdb
Health Integrity and Protection Data Bank for Final Adverse Information on Health Care Providers, Suppliers and Practitioners
0239 Forms 2007
Health Integrity and Protection Data Bank for Final Adverse Information on Health Care Providers, Suppliers and Practitioners
OMB: 0915-0239
Entity Registration
Agent Registration
Entity Registration Update
Agent Registration Update
Entity Registration Renewal
Agent Registration Renewal
Initial AAR
Correction AAR
Correction Legacy AAR
Revision to Action AAR
Explicit Query
Subject Database (individual)
Subject Database (organization)
Self Query (individual)
Self Query Organization
Subject Dispute
Secretarial Review
Authorized Agent Designation
Authorized Agent Designation (update)
Electronic Fund Transfer Authorization
Account Discrepancy Form
Initial Accreditation
Accreditation Correction
Accreditation Revision
QIO Initial
QIO Correction
QIO Revision to Action
| File Type | application/msword |
| File Title | Entity Registration |
| Author | HRSA |
| Last Modified By | HRSA |
| File Modified | 2007-07-19 |
| File Created | 2007-07-19 |
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