Follow the steps to complete the IA 470-4698 form online.

1. Click the ‘Get Form’ button to access the form and open it in the editor.
2. Fill in the report status by selecting either 'Initial' or 'Completed', depending on the stage of the investigation.
3. Provide the Medicaid member's information, including their National Provider Identifier, name, address, phone number, and email. Ensure the details are accurate.
4. Record the Medicaid number, date of birth, and gender of the member. Select the appropriate HCBS Waiver options as needed.
5. Document the date and time of the incident, noting whether the incident was discovered or witnessed.
6. Select the location of the incident from the provided options and list any individuals present at the time.
7. Detail the type of services being provided during the incident or indicate if none were being provided.
8. Describe the incident comprehensively, addressing the who, what, when, where, and how components.
9. Fill in the immediate resolution details, including the actions taken to secure the member’s safety after the incident.
10. If applicable, complete the Circumstances section and Physical Injury Type before addressing Injury due to specifics.
11. Outline any necessary reviews and resolutions, including staff, member, equipment, supply, and environmental assessments.
12. Upon finishing all sections, save your changes, and choose to download, print, or share the completed form as needed.

Start filling out the IA 470-4698 online today to ensure timely and accurate reporting of critical incidents.