Get Az Pm Form 7.4.1 2012-2025

Filling out the AZ PM Form 7.4.1 is a critical process for reporting incidents, accidents, or deaths in licensed behavioral health facilities. This guide provides clear, step-by-step instructions to help users complete the form online efficiently.

Follow the steps to successfully complete the AZ PM Form 7.4.1 online.

1. Press 'Get Form' button to acquire the form and open it in the designated online editor.
2. Complete all sections of the form. Ensure that information is either typed or printed clearly.
3. Fill in the T/RBHA Name, which is Magellan Health Services, along with the GSA, Provider Name, and the Behavioral Health License number. Include the Tracking ID and Facility Address & Phone Number.
4. Select the Type of Report by checking all applicable boxes, including Death, Suicide, Homicide, Accident, and other relevant categories.
5. Provide details about the Assigned Member or Non-Enrolled Behavioral Health Recipient involved in the incident, including their name, age, AHCCCS ID, gender, and any applicable identifiers.
6. Record the Incident Details including the date and time of the incident, address & location, and provider information.
7. List Individuals Who Observed the Incident, including their name, relationship to the recipient, address, and phone number.
8. In the Description of Incident section, describe the events leading up to and following the incident along with the person's health conditions before and after.
9. Document any actions taken and recommendations for preventing similar incidents in the future.
10. Fill out the section for incidents requiring medical services, detailing who provided immediate attention, medical services, and relevant timings.
11. Complete the Clinical Director's or Designee's review section, including their name, credentials, and signature to finalize the review of the incident.
12. Indicate Notification Made by checking all applicable boxes and entering the relevant dates/times for each notification made.
13. Once all fields are completed accurately, you may save changes, download, print, or share the form as needed.

Complete your documents online efficiently and ensure timely reporting today.