SHEPS CENTER DATA REQUEST FORM
NC Health Professions Data
Physician and Physician Assistant
Fill out this form, print, and fax it to:
NC Medical Board
1203 Front Street
Raleigh, NC 27609
Mr. R. David Henderson, Executive Director
Phone: (919) 326-1100
Fax: (919) 326-1130

Please also fax a copy to the Health Professions Data System at (919) 966-5764.

Attach a separate page describing the intended use for the labels/listing. Once approval has been received by the Sheps Center, you will be contacted with an estimated price and delivery date of the output. Contact the Sheps Center Data Coordinator at nchp@unc.edu or (919)966-7112 if you have questions or need additional information.

Requester's Name:
Business Name:
Address:
City, State & ZIP:
Telephone Number:
Fax Number:
Email Address:
Type of Organization: For-Profit (FP)     Non-Profit (NP)

Electronic Output Request Type: Check one or more
Name, address, specialty, county ($4.50/100 names: $100.00(NP)/$200(FP) minimum)
All data available ($7.00/100 names: $200.00(NP)/$300(FP) minimum)

Output format:
 Tab-delimited Comma-delimited Fixed Field
Other (please specify):

SELECTION CRITERIA (check all that apply):

Profession:
Medical Doctors   Doctors of Osteopathy   Physician Assistants

Activity Status: Active   Inactive

Area Selection: In-state   Out-of-state
Specific counties:
Other (please specify)

Residency-in-Training Status (for physician requests only):
Non-Residents (physicians who have completed residency training)
Residents-in-training

Federal Provider Indicator (for physician requests only):
Non-Federal
Federal (physicians in the armed services, US Public Health Service, Indian Health Service, or the Department of Veterans Affairs)

Primary Specialty (for physician requests only):
List specialties:

Other Statistical Criteria:
List any other criteria (e.g., gender, race, primary practice location facility type, etc.):

Description of Request: List other details of your request in the box below.


What order do you want the output sorted in?

NOTICE: Data are provided by the NC Medical Board as of October each year and compiled by the Sheps Center. Address changes are made only at the time of the annual update. Contact the Sheps Center Data Coordinator at nchp@unc.edu or (919)966-7112 for more detailed information regarding the Sheps Center files.

For NC Medical Board Use Only:
Approved by:______________________________________________  Date:________

Note to Board: Please send this form with approval to the Sheps Center Data Coordinator:
Fax (919) 966-5764.

Updated 5/1/05