Get Choices Critical Incident Report Form - Providers Amerigroup

Filling out the CHOICES Critical Incident Report Form is an essential step in reporting incidents related to the CHOICES program. This guide will provide you with clear, step-by-step instructions to ensure you complete the form accurately and efficiently online.

Follow the steps to complete the CHOICES Critical Incident Report Form.

1. Click ‘Get Form’ button to access the CHOICES Critical Incident Report Form and open it for editing.
2. Begin by filling in the CHOICES member information, including their last name, first name, social security number, date of birth, and Amerigroup ID number.
3. Record the date and time the incident occurred in the designated space. This is crucial for accurate reporting.
4. Provide your own information as the person submitting the incident report. Include your last name, first name, title or role, date and time you were notified of the incident, and your contact phone number.
5. Enter the date and time when you are submitting the report to Amerigroup.
6. Fill in the provider information, including the provider name and Amerigroup provider ID number.
7. In the incident information section, select the type of incident from the list provided, such as unexpected death, medication error, severe injury, theft, or any other incidents. If you select 'Other,' provide a description of the incident.
8. Document the date and time that you reported the incident to Adult Protective Services (APS), Child Protective Services (CPS), or TennCare, if applicable.
9. Enter the name of the APS, CPS, or TennCare worker who you contacted regarding the incident.
10. Provide the location of the incident, including the address and setting (e.g., room, indoor/outdoor).
11. List any other individuals or witnesses involved in the incident, along with their contact numbers.
12. In the incident description section, provide a detailed account of the events leading up to, during, and after the incident. Include as much information as possible, and use additional pages if necessary.
13. Indicate if the CHOICES member is subject to further harm or has additional emergency needs at this time by selecting 'Yes' or 'No'. If 'Yes', explain the circumstances.
14. Once all fields are filled out, save your changes, and choose to download, print, or share the completed report as needed.

Ensure timely and accurate reporting by completing documents online today.