Health facility reporting 2025

1. Click ‘Get Form’ to open the Health Facility Reporting Form in the editor.
2. Begin by selecting the appropriate reporting entity. Check one of the options: Ambulatory Surgical Center, Health Care Facility or Clinic, or Other Entity. If you select 'Other', provide a brief description.
3. Fill in the contact details of the person preparing the report, including their name, phone number, and email address.
4. Enter information for the Chief Executive Officer, Medical Director, or Administrator, including their contact details.
5. Provide the facility's name and address along with city, state, and zip code.
6. Select the licentiate type from options such as Physician, Podiatrist, or Licensed Midwife and enter their name and license number.
7. In the Patient & Incident Information section, input the patient's name, gender, phone number, address, and email. Record the date when allegations were reported in writing.
8. Detail the incident in the provided space. If necessary, attach additional pages for more information.
9. Ensure to attach a copy of the patient-reported allegation before signing and dating your report.

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