Department affairs 2025

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The document is a supplemental claim and incident information form that requires detailed reporting of claims or incidents related to patient care. It includes sections for patient information, incident details, status of the claim, court outcomes, attorney information, and preventive actions taken. Each section must be completed thoroughly, with options for multiple claims or incidents.

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Click ‘Get Form’ to open the Supplemental Claim / Incident Information form in the editor.
Begin by entering the patient's name and age in the designated fields. Ensure accuracy as this information is crucial for processing.
Fill in the sex of the patient and provide details about the incident, including the date reported to the insurance company and the name of that company.
Document the date of the incident along with a brief description of your treatment. Use additional sheets if necessary for clarity.
In the allegations/circumstances section, provide a detailed account of what occurred. This is essential for understanding the context of your claim.
Indicate any additional defendants involved and describe the current condition of the patient in detail.
Complete the status of claim section by selecting appropriate options regarding legal actions taken or outcomes achieved.
Finally, sign and print your name at the bottom of the form, ensuring all required fields are filled out before submission.

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