Follow the steps to successfully complete the form online.

1. Press the ‘Get Form’ button to retrieve the form and open it for editing.
2. Begin filling out the form by entering the patient's name in the designated fields, including last name, first name, and middle name.
3. Provide the patient's address, including street number, city, state, and ZIP code, ensuring all information is accurate.
4. Enter the patient's date of birth and their medical record number in the appropriate fields.
5. In the next section, provide the name of the physician who performed the surgery, including their first, last, and middle names.
6. Complete fields regarding the physician’s practice specialty and their license number. This information is essential for proper identification.
7. Indicate the date when the surgery took place and add the patient identifier, such as Social Security Number or Patient ID Number.
8. Supply the name and address of the outpatient setting where the surgery was performed, including the specific street address, city, state, and ZIP code.
9. Describe the circumstances of the patient’s death. You may use additional sheets if necessary to provide detailed information.
10. List the name and location of the hospital or emergency center to which the patient was transferred. Note that a separate Patient Transfer Form is also necessary.
11. Date the report and include your name as the physician completing the form.
12. Confirm that the outpatient setting is licensed, certified, and/or accredited, and specify the types of outpatient procedures that are performed.
13. Once you have filled out all necessary sections, review the form for accuracy. You can then save your changes, download, print, or share the completed form as needed.

Complete your forms online to ensure timely and accurate submissions.