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Licensee Reporting Obligations

The recent letter concerning surgical practices was sent out mistating the contact email address; the accurate address is

Colleague reporting

Practitioners (physicians and podiatrists) must report to the Board if they have information that reasonably indicates that another practitioner has demonstrated impairment, gross incompetence or unprofessional conduct that would present imminent danger to a patient or to the public. N.J.S.A.45:1-37.

The Patient Safety Act encourages health care professionals employed by health care facilities - including physicians - to report preventable and adverse events to the health care facility, in the form to be determined by the Commissioner of Health.
N.J.S.A. 26:2H-12.25

Surgical and Anesthesia Complications

Physicians performing surgery or special procedures in the physician’s office must report any incident related to surgery, special procedures or the administration of anesthesia within the office which results in a patient death, transport of the patient to the hospital for observation or treatment for a period in excess of 24 hours, or a complication or other untoward event. The report is to be made to the Executive Director of the Board. The Report should be made by telephone within 24 hours as well as mailed within seven days, using the form provided at Such a report will be investigated by the Board and will be deemed confidential pursuant to N.J.S.A.45:9-19.3.

Change of Address

Practitioners are required to report to the Board , in writing, any change in address. The failure to provide timely notice of any change of address from the address that appears on the licensee’s most recent license renewal or application may be deemed a failure to cooperate and, therefore, professional misconduct and grounds for suspension or revocation of license. A change of address form is available for physicans, podiatrists and the lab directors.

Change of Status

A licensee is required to provide notice to the Board in writing, and within 21 days,
of any changes, additions or deletions pertaining to the following information as it was last provided by the licensee on the biennial license renewal form:

  1. The name and address of all practice locations.
  2. The name of all practitioners directly associated with the practice, or the practice name if five or more practitioners are offering professional services through the same practice entity.
  3. The name and address of each licensed health care facility and health maintenance organization with which the licensee has an affiliation, except that with respect to health maintenance organization affiliations, the licensee shall be relieved of this reporting obligation if the entities with which the licensees has an affiliation have agreed to provide the Board with a list of participating providers on a quarterly basis.
  4. The name and address of the licensee’s medical malpractice insurer, if any.
  5. The name and address of any health care service entity in which the licensee or any member of his or her immediate family has acquired a financial interest, the date on which that interest was acquired and whether the licensee refers patients to that service.

National Practitioner Data Bank - Adverse Clinical Privileges Actions

As defined in the National Practitioner Data Bank Guidebook, an adverse clinical privileges action is one that is "based on a physician’s or dentist’s professional competence or professional conduct that adversely affects, or could adversely affect, the health or welfare of a patient."

To be reportable, a privileges action must be related to the physician’s professional competence or conduct in a way that adversely affects or could adversely affect the patient’s health or welfare. The adverse clinical privileges action must be reported to the National Practitioner Data Bank if the privileges action lasts more than 30 days. An example would be the denial of a physician’s application for privileges based on professional competence or professional conduct.

Note that not all actions affecting a physician’s privileges are reportable to the National Practitioner Data Bank. Two examples of actions mentioned in the NPDB Guidebook that are NOT reportable include:

  • A physician's or dentist's clinical privileges are suspended for administrative reasons not related to professional competence or professional conduct."
  • A physician or dentist is denied medical staff appointment or clinical privileges because the health care entity has too many specialists in the practitioner's discipline."

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