Get Provider Adverse Incident Reporting Form - Magellan Provider's ...

Filling out the Provider Adverse Incident Reporting Form is an essential process for reporting incidents involving members in a structured and efficient manner. This guide will provide you with clear, step-by-step instructions to ensure the form is completed accurately and submitted properly.

Follow the steps to complete and submit the form online.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred document viewer.
2. Begin by entering the date you received the form at Magellan in the designated field.
3. Fill in the member's county of residence by selecting from the options provided, which include Bucks County, Delaware County, Lehigh County, Montgomery County, and Northampton County.
4. Complete the Facility/Provider Name section with the relevant details of your organization.
5. Document the date of the report in the appropriate field.
6. Enter the reporting person's name and position to identify the individual filling out the form.
7. Input the reporting person's phone number for follow-up or clarification.
8. Provide the member's name, Social Security Number (SSN), ID number, and date of birth to ensure proper identification.
9. Describe the location of the incident where it took place.
10. Indicate the date of the incident, ensuring that it matches the occurrence.
11. Check any relevant categories involved in the incident from the list provided, such as member death, fire/police involvement, or attempted suicide.
12. Offer a brief description of the event to provide context and details surrounding the incident.
13. Detail the actions taken immediately following the event to ensure the safety of all involved, including any debriefing efforts.
14. Indicate whether the parent or guardian was notified and provide the date and person who was informed.
15. Specify if the member was seen by a psychiatrist or physician after the incident, and include any treatments provided.
16. Sign the form where indicated, along with dating it to affirm the information is accurate.
17. Once completed, save your changes, optionally download or print the form, and ensure it is faxed to the correct Magellan Behavioral Health number within 24 hours.

Take the next step in documenting incident reports by filling out the Provider Adverse Incident Reporting Form online.