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Refund Request (Account Discrepancy Form)

Requests for credits should be made within 60 days of the query submission. If you suspect that your bill is incorrect, or you need more information about a transaction, you should complete this form. Requests are usually responded to within 5-7 business days of receipt.

Note: Fields with an asterisk (*) are required in order to ensure an accurate response; the information will not be used for any other purpose.


OMB Number: 0915-0126 Expiration Date: 04/30/2024

Public Burden Statement: The NPDB is a web-based repository of reports containing information on medical malpractice payments and certain adverse actions related to health care practitioners, providers, and suppliers. Established by Congress in 1986, it is a workforce tool that prevents practitioners from moving state-to-state without disclosure or discovery of previous damaging performance. The statutes and regulations that govern and maintain NPDB operations include: Title IV of Public Law 99-660, Health Care Quality Improvement Act (HCQIA) of 1986, Section 1921 of the Social Security Act, Section 1128E of the Social Security Act, and Section 6403 of the Patient Protection and Affordable Care Act of 2010. The NPDB regulations implementing these laws are codified at 45 CFR Part 60. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this information collection is 0915-0126 and it is valid until 04/30/2024. This information collection is voluntary. 45 CFR Section 60.20 provides information on the confidentiality of the NPDB. Information reported to the NPDB is considered confidential and shall not be disclosed outside of HHS, except as specified in Sections 60.17, 60.18, and 60.21. Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or paperwork@hrsa.gov.