Follow the steps to successfully complete the form.

1. Press the ‘Get Form’ button to acquire the form and open it in your preferred editing tool.
2. Fill out the 'Health Home Information' section, selecting the appropriate health home and care management agency. Ensure to include the reporter's name and email, alongside the date reported.
3. In the 'Member Information' section, enter the member's CIN, name, enrollment date, date of birth, pertinent diagnoses, last contact date prior to the incident, description of the last contact, and the member's current location.
4. Complete the 'Incident Information' section by selecting the incident type, and providing the date and time of occurrence and discovery. Offer a detailed description of the incident.
5. Indicate whether there has been media coverage of the incident by selecting 'Yes' or 'No.' If yes, specify the source of the media coverage.
6. Document the immediate actions taken in response to the incident, including any protective measures or linkage to services.
7. Review all the information entered for completeness and accuracy. Once verified, you can save your changes, download the completed form, print it, or share it as needed.

Begin completing your NY DOH-HH-IC001 form online today for a seamless reporting process.