FCRA

Background Check Report – Dispute Form

The Fair Credit Reporting Act (FCRA) is a federal law that protects consumers’ credit report information and ensures the accuracy of that information. The FCRA also gives victims of identity theft specific rights.

The credentials verification and credentialing application services offered through Pharmacy Profiles may be considered background checking services under federal and state law. Although Pharmacy Profiles does not conduct typical background screenings, such as credit and criminal checks, we comply with the federal Fair Credit Reporting Act (FCRA) and similar state laws. Read more about the FCRA and the Dispute Process.

You may complete this form online or print the PDF form.

Dispute Form

To dispute the accuracy, currency, or completeness of your report, you must complete the required fields marked with an asterisk (*). Mark N/A if a field is not applicable. When completing this form, please:

Clearly identify each item in your report that you believe is inaccurate, incomplete, or outdated.
Include supporting documentation such as: board order(s), board decision(s), screenshot(s) of board licensure web pages, or other documentation that you believe supports your dispute.
Clearly tell us why the item is inaccurate, incomplete, or outdated.
Sign this form.
If you choose to print the form, send the completed dispute form and supporting documents as follows:
- Send by email to: dispute@pharmacyprofiles.com
- Send by mail to:
  Pharmacy Profiles
  Attn: Dispute Form
  2215 Constitution Avenue, NW
  Washington, DC 20037

Telephone: 833-483-0837

See Pharmacy Profiles Investigative Consumer Reporting Privacy Policy.

"*" indicates required fields

This field is for validation purposes and should be left unchanged.

Name*

Previous name(s) used

Address*

Street Address Address Line 2 City State Zip Code

Best phone number to reach you*

Email Address*

Enter Email Confirm Email

Date of birth (MM/DD/YYYY*

NABP eProfile ID*

License Type*

License Number*

License State*

If applicable, name of board taking action or discipline and date of action or discipline

Use the space below to provide a clear and brief statement of the information you are disputing. Please attach any supporting documentation.

File

Drop files here or

Accepted file types: jpg, png, pdf, doc, docx, Max. file size: 8 MB.

My signature below (1) authorizes you to disclose information to me about the report that Pharmacy Profiles prepared about me and (2) requests that each item of information I am disputing that is found to be in error be removed, corrected, or modified.

Sign by typing your name*

Date*

IMPORTANT: Do you authorize Pharmacy Profiles to communicate with you via email regarding your dispute?*

Yes

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Background Check Report – Dispute Form

Dispute Form

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