Get Form Hcfd-2 (pdf) - Mass.gov - Mass

Filling out the Form HCFD-2 is a crucial step for reporting the status of disciplinary actions in the healthcare sector. This guide provides a clear, step-by-step explanation to assist users in completing this form accurately and efficiently.

Follow the steps to fill out Form HCFD-2 correctly.

1. Press the ‘Get Form’ button to access the form and open it in your preferred PDF editor.
2. Begin with the Physician Information section. Enter the physician's name and license number clearly, ensuring all information is accurate.
3. Next, provide details about the Reporting Health Care Facility. Fill in the organization name and the corresponding telephone number.
4. Indicate the date of the initial disciplinary action and the date of the initial report to the Board. Use the format MM/DD/YYYY for these dates.
5. Identify who completed the report. Fill in the name, title, and ensure that the professional's signature is included along with the report date.
6. Complete Part A if a disciplinary action was reversed on appeal. Enter the reversal date, indicate the type of appeal (internal, external, or both), and describe the basis for this reversal.
7. If there has been a modification, complete Part B. Specify the date of modification and describe what the modification entails and its basis.
8. If the disciplinary action is complete, fill out Part C by providing the date the action was completed and the physician’s status with the health care facility.
9. For ongoing actions, complete Part D. Every 60 days, provide a report detailing whether the physician is in compliance and any unmet terms or conditions.
10. If applicable, the Supervisor or Monitor must fill in their information, including two questions about the physician's compliance and conduct.
11. After filling in all sections of the form, review all information for accuracy. Save any changes made to the document.
12. Download, print, or share the filled form as required, ensuring it is mailed or submitted according to the provided instructions.

Act now to complete your Form HCFD-2 online and ensure timely reporting of disciplinary actions.