NPDB Query and Reporting Log

Log for documenting National Practitioner Data Bank (NPDB) queries completed during initial credentialing and renewal for each provider, including query timing, results, follow-up actions, and audit trail details.

Submission Notice

• Submission purpose
• I confirm this entry is submitted for credentialing compliance and audit trail purposes.
• I understand this form should not collect SSNs, full DOBs, or other unnecessary PII.

Provider and Query Details

• Provider identifier
  Enter the internal provider ID or credentialing file number. Avoid collecting sensitive identifiers unless required.
• Provider name
• Provider role
• Query type
• Date of NPDB query
• Query completed by
  Enter the staff member or department responsible for completing the query.

NPDB Query Results

• Query result
• Reportable match details
  Describe the reportable match at a high level. Do not include unnecessary PII or sensitive clinical details.
• Follow-up required?
• Follow-up owner
  Identify the person or team responsible for next steps.
• Follow-up due date

Audit Trail and Sign-Off

• Record location
  Enter the system, folder, or credentialing file location where the NPDB query record is stored.
• Retention reference
  Optional internal retention or policy reference for this record.
• Reviewed by
  Optional reviewer or supervisor name for internal audit trail.
• Review date
• Notes
  Add only compliance-related notes needed for the record. Avoid unnecessary PII.