Get Dhcs 7107

The Dhcs 7107 form is essential for reporting provider-preventable conditions associated with Medi-Cal payments. This guide will help you understand each section of the form and provide step-by-step instructions for completing it online.

Follow the steps to successfully fill out the Dhcs 7107 form online.

1. Click the ‘Get Form’ button to access the Dhcs 7107 form and open it in the online editor.
2. Enter the name of the facility where the provider-preventable condition (PPC) occurred in the designated field.
3. Input the facility's National Provider Identifier (NPI) to ensure accurate identification.
4. Select the type of facility by checking either the 'Inpatient' or 'Outpatient' box.
5. Provide the complete address of the facility, including the city, state, and zip code.
6. If reporting an Other Provider-Preventable Condition (OPPC), input the date the condition occurred.
7. Check the appropriate box if there was an occurrence of wrong surgery/invasive procedure.
8. Indicate if the surgery was performed on the wrong body part by checking the corresponding box.
9. Mark the box if the surgical procedure was performed on the wrong patient.
10. For Health Care-Acquired Conditions (HCAC), enter the date the condition was detected.
11. Check the appropriate boxes for any HCACs experienced by the patient, such as air embolism or blood incompatibility.
12. Complete the patient information section by confirming if the patient is under 21 years old and entering their personal details.
13. Provide the Client Index Number (CIN) for the patient as stated on their identification.
14. Determine if the patient has Managed Care Medi-Cal and indicate the plan code if applicable.
15. Fill in the contact information for the person completing the report, including name, title, phone number, email, and fax.
16. Before submission, ensure to mark the document as 'Protected Health Information: Confidential'.
17. Submit the completed report within five working days via secure fax, U.S. mail, or courier services.
18. Finally, save the changes made to the form and download or print it for your records.

Get started by filling out the Dhcs 7107 form online today!