Magellan incident report: Fill out & sign online

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Click ‘Get Form’ to open it in the editor.
Begin by entering the Member’s County of Residence. Select from the provided options such as Bucks County or Delaware County.
Fill in the Facility/Provider Name, Date of Report, and your details as the Reporter including Name, Position, and Phone Number.
Complete the Member’s information: Name, SSN, Date of Birth, and Level of Care/Service.
Document the Location of Incident along with the Date and Time of Incident.
Check any relevant categories involved in the incident such as Death or Abuse/Childline report.
Provide a detailed Description of Event and outline Actions taken to ensure safety.
Indicate if Parent/Guardian was notified and provide their details along with any follow-up treatment received by the member.
Finally, sign and date the form before submitting it via fax to the appropriate department within 24 hours.

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