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TENNCARE BEHAVIORAL HEALTH ADVERSE OCCURRENCE REPORT Provider Name: Name of Reporting Person: Name/Title of Person Submitting Report:Consumer Name: (Last, First ) Address: SSN:Contact Number: Date.

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Adverse Incident Reporting Guide The term “adverse incident” means an event over which health care personnel could exercise control and which is associated in. whole or in part with medical intervention, rather than the condition for which such intervention occurred, and which results.

An adverse incident is an event or circumstance that might give rise to a claim, complaint or allegation against you. With claims-made protection, you are required to report an adverse incident to Medical Protection as soon as reasonably practicable after it occurs (or when you become aware that it has occurred).

Any event that reaches a patient, regardless of whether or not it resulted in harm, is considered an incident. If that event does result in harm, it is considered an adverse event.

Examples include allergic brochospasm (a serious problem with breathing) requiring treatment in an emergency room, serious blood dyscrasias (blood disorders) or seizures/convulsions that do not result in hospitalization.

A Serious Adverse Incident (SAI) is defined as any event or circumstance that led or could have led to unintended or unexpected harm, loss or damage.

When an adverse incident occurs, the provider must complete the Adverse Incident Form and submit it to MassHealth Office of Behavioral Health via secure email. The form must be submitted within 24-hours of discovery of the incident, or if it's a holiday or weekend, the next business day.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232