470 4698-2026

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  1. Click ‘Get Form’ to open the 470 4698 in the editor.
  2. Begin by entering the 'Date Received' and 'Incident ID' at the top of the form. This information is crucial for tracking the incident.
  3. Fill in the 'Staff Reviewer' and 'Case Manager' sections, ensuring you provide accurate details about who is handling the report.
  4. Complete the 'Medicaid Member' section with all relevant personal information, including name, address, and Medicaid State Number.
  5. In the 'Incident' section, accurately document the date and time of the incident, along with a clear description of what occurred.
  6. Provide detailed information regarding witnesses and any services being provided at the time of the incident in their respective fields.
  7. Finally, review all entries for accuracy before submitting your completed form electronically through our platform for efficient processing.

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2021 4.8 Satisfied (167 Votes)
2020 4.3 Satisfied (78 Votes)
2019 4.2 Satisfied (75 Votes)
2018 4.2 Satisfied (86 Votes)
2016 4.6 Satisfied (50 Votes)
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