Get Hcsis Incident Management Contingency Form 2018-2025

Filling out the HCSIS Incident Management Contingency Form online is a critical process when HCSIS is not accessible. This guide provides clear instructions to ensure that you can complete the form accurately and efficiently.

Follow the steps to complete the form with ease.

1. Click ‘Get Form’ button to obtain the form and open it in the designated editing tool.
2. Enter the date of your report in the format of month (MM), day (DD), and year (YYYY) in the provided fields.
3. Fill in the time of the report, indicating AM or PM as required.
4. Provide the name of the individual involved by entering their last name, first name, and middle initial.
5. Input the provider name and fill in the address, including the city, state, and zip code.
6. Complete the second address section with city, county of registration, state, and zip code, followed by the phone number.
7. Enter the base service unit number associated with the incident.
8. Provide the date of birth of the individual using the format month (MM), day (DD), and year (YYYY).
9. Mark the appropriate box for the sex of the individual, indicating male or female.
10. Classify the incident according to the guidelines provided, ensuring accuracy.
11. Record the date of the incident's occurrence or its recognition using the format month (MM), day (DD), and year (YYYY).
12. Document the time when the incident occurred or was discovered and specify AM or PM.
13. If applicable, enter the date and time of death, ensuring to follow the required format.
14. Include the provider license number if applicable.
15. Thoroughly describe the type of incident, actions taken regarding the individual’s health and safety, response to the incident, any necessary medical referrals, and any contributing circumstances. You may attach additional sheets if needed.
16. Fill in the name of the relative or guardian, their relationship to the individual, and indicate if they have been notified.
17. Enter the name of the point person responsible, their title, and provide their phone number.
18. Once all fields are completed, review the information for accuracy, then save changes, download, print, or share the form as needed.

Begin completing the HCSIS Incident Management Contingency Form online today to ensure prompt and accurate documentation.