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Health facility reporting 2026
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- Click ‘Get Form’ to open the Health Facility Reporting Form in the editor.
- 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.
- Fill in the contact details of the person preparing the report, including their name, phone number, and email address.
- Enter information for the Chief Executive Officer, Medical Director, or Administrator, including their contact details.
- Provide the facility's name and address along with city, state, and zip code.
- Select the licentiate type from options such as Physician, Podiatrist, or Licensed Midwife and enter their name and license number.
- 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.
- Detail the incident in the provided space. If necessary, attach additional pages for more information.
- Ensure to attach a copy of the patient-reported allegation before signing and dating your report.
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