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Get Ny Doh-hh-ic001 2019-2026
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How to fill out the NY DOH-HH-IC001 online
The NY DOH-HH-IC001 form is essential for reporting incidents within health home services in New York State. This guide provides clear, step-by-step instructions to help users complete the form accurately and efficiently online.
Follow the steps to complete the NY DOH-HH-IC001 online.
- Press the ‘Get Form’ button to access the form and open it in the designated online environment.
- Enter the DOH ID in the appropriate field to ensure your report is correctly linked to your organization.
- Fill in the report submission date. This should be the date when the incident report is being submitted.
- Provide Health Home and reporter information. Select the Health Home from the dropdown list and enter the Care Management Agency, specifying the population served.
- Complete the sections for the HH reporter's first and last name, email, and phone number to allow for follow-up communication.
- In the member information section, fill in the first and last name of the affected member, their date of birth, enrollment date, and CIN.
- Document the last contact date with the member and provide a brief description of the last interaction.
- Specify the member’s current location and list any pertinent diagnoses that are relevant to the incident.
- In the incident information section, select the appropriate incident category from the provided options.
- Record the occurrence date and time of the incident as well as the discovery date and time.
- If applicable, note any media coverage of the incident and provide the source or link.
- Provide a detailed incident description, outlining what occurred in the situation.
- Describe the immediate actions taken in response to the incident, including steps to protect the member, report to investigative agencies, or connect to further services.
- Once all fields are completed, review your entries for accuracy. You can then save changes, download, print, or share the completed form as needed.
Complete your NY DOH-HH-IC001 form online today to ensure proper reporting!
Related links form
Medicaid members eligible to be enroll in a Health Home must have: Two or more chronic conditions OR. One single qualifying chronic condition: HIV/AIDS or. Serious Mental Illness (SMI) (Adults) or. Sickle Cell Disease (both Adults and Children) or. Serious Emotional Disturbance (SED) or Complex Trauma (Children)