Performcare incident report: Fill out & sign online

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Click ‘Get Form’ to open the performcare incident report in the editor.
Begin by entering the 'Date of Report' at the top of the form. This is essential for tracking and reference purposes.
Fill in the 'Name of Member' along with their 'MA Identifier Number' and 'Date of Birth'. Accurate member information is crucial for proper documentation.
Complete the 'Provider Name', 'Provider Address', and contact details. Ensure that all fields are filled out correctly to facilitate communication.
Specify the 'Date of Incident' and 'Time of Incident'. This helps in establishing a timeline for the event.
Select the type of incident from the provided options. Make sure to refer to PerformCare Policy QI_-CIR-001 for guidance on categorization.
In the section labeled 'Describe what happened', provide a detailed account of the incident, including any contributing factors. Use additional sheets if necessary.
Finally, complete sections regarding outcomes, actions taken, and mandatory notifications. Ensure all required signatures are included before submission.

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