Get Provider Adverse Incident Report Form - Massachusetts Behavioral

Filling out the Provider Adverse Incident Report Form is essential for documenting incidents effectively. This guide provides a clear and supportive step-by-step process to assist users in completing the form accurately online.

Follow the steps to successfully complete the form

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. Indicate the state agency involved in the incident by selecting the appropriate option, such as MBHP or DCF. This helps ensure the report is directed to the correct agency.
3. Fill in the member name and include their new MMIS number. This information is crucial for identifying the individual associated with the incident.
4. Provide the social security number of the member. This detail is sensitive, so ensure it is entered accurately.
5. Select the gender of the member using the designated checkboxes. This data is used for demographic purposes.
6. Enter the date of birth (DOB) in the specified format. This helps verify the member’s identity.
7. Input the member’s age and the facility name where the incident occurred, including the city and provider number for record-keeping.
8. Select whether the facility is a 24-hour or non-24-hour facility based on its operation hours.
9. Specify the level of care provided and enter the diagnosis relevant to the member.
10. Record the date and time of the incident and the date and time of its discovery using the required mm/dd/yyyy@hh:mm format.
11. Clearly describe the type of incident and provide thorough details regarding the incident itself. If applicable, include search, notification, and commitment status for AWA cases.
12. Document the immediate response to the incident, detailing any actions taken by the staff or facilities.
13. Indicate if restraints were used and, if so, check the appropriate type (none, mechanical, chemical, or physical). Include the time spent in restraints.
14. Check any recommended follow-up actions such as internal investigations or staff training. This helps ensure proper resolution following the incident.
15. Indicate if any additional information is attached to the report as this may provide further context for the incident.
16. Include the name and title of the person reporting the incident, along with their contact telephone number.
17. Sign and date the form, ensuring that it is completed accurately before submission.
18. Once the form is filled out, save any changes, and you may have options to download, print, or share as needed.

Complete and submit your Provider Adverse Incident Report Form online to ensure proper documentation and follow-up.