Incident, Accident, Death Report Form
INSTRUCTIONS
1.
Complete ALL sections of this form. Information provided must be either typed or printed.
2.
Incidents, accidents and deaths, must be reported in writing to the Mercy Maricopa within two business days of the incident.
3.
Please email completed reports to MMIC@aetna.com
MEMBER INFORMATION
Member Name
Date of Birth
Age
Gender
CIS ID
AHCCCS ID
Eligibility Status
Category
On COT at the
DDD
CMDP
time of the
Incident
Diagnoses
Code
Name
Code
Name
Code
Name
Code
Name
Code
Name
Code
Name
Code
Name
Code
Name
Code
Name
Code
Name
T/RBHA INFORMATION
T/RBHA
Mercy Maricopa Integrated Care
Assigned GSA
6
Incident, Accident, Death Report Form
INSTRUCTIONS
1.
Complete ALL sections of this form. Information provided must be either typed or printed.
2.
Incidents, accidents and deaths, must be reported in writing to the Mercy Maricopa within two business days of the incident.
3.
Please email completed reports to MMIC@aetna.com
MEMBER INFORMATION
Member Name
Date of Birth
Age
Gender
CIS ID
AHCCCS ID
Eligibility Status
Category
On COT at the
DDD
CMDP
time of the
Incident
Diagnoses
Code
Name
Code
Name
Code
Name
Code
Name
Code
Name
Code
Name
Code
Name
Code
Name
Code
Name
Code
Name
T/RBHA INFORMATION
T/RBHA
Mercy Maricopa Integrated Care
Assigned GSA
6
PROVIDER INFORMATION
Provider Name
License #
Phone Number
Provider
Street
Address
City
State
Zip Code
Date of Last
Date of Last Visit
Visit With
With the BHMP or
Clinical Team
PCP
INCIDENT INFORMATION
Date of Incident
Time of Incident
Date reported to the
(i.e. 3:00 pm)
provider
Location of the
Incident
Description of
the Incident
Type of Incident
Suicide
Homicide (victim)
(select ALL
that apply)
Accidental Death
Natural death
Death from unknown causes
Suicide attempt
Injury (includes self-injury) requiring emergency treatment
Injury as the result of personal, chemical, or mechanical restraint
Medication error/adverse reaction to medication requiring medical attention
Unauthorized Absence from a licensed facility, group home, or HCTC home of children or recipients under court
order for treatment
Suspected or alleged criminal activity
Physical abuse
Neglect
Emotional abuse
Verbal abuse
Sexual Abuse
Discrimination
Exploitation
Coercion
Manipulation
Retaliation for submitting a complaint to authorities
Threat of discharge/transfer for punishment
Treatment involving denial of food
Treatment involving denial of opportunity to sleep
Treatment involving denial of opportunity to use the toilet
Use of restraint or seclusion as retaliation
Discovery that a client, staff member, or employee has a communicable disease
Health Care Acquired Condition (HCAC) (during inpatient hospitalization)
Other Provider Preventable Condition (OPPC) (during inpatient hosptialization)
Other
Members
Condition
Before & After
the Incident
Individuals who
Witnessed the
Incident
Description of
any Medical
Services
Received
Actions Taken
and/0r
Recommended
NOTIFICATIONS
Agency
T/RBHA
Arizona Center for Disability Law (ACDL)
Police
Adult Protective Services (APS)
Child Protective Services (CPS)
Case Management/Assigned CSP/Provider
DES Case Worker
Parent / Guardian/ TSS Case Worker
Probation
AHCCCS
Other
PREPARER'S SIGNATURE
Name &
Credentials
Date
Signature
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