HEAlth CARE PROFESSiONAl RESPONSibility ANd REPORtiNG - njconsumeraffairs 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the 'Health Care Entity Information' section. Indicate whether this is an initial report or a follow-up, and select the type of health care entity from the provided options.
3. Complete the contact information for the person submitting the report, including their name, title, telephone number, and email address.
4. In the 'Health Care Professional Information' section, provide details about the health care professional involved, including their last name, first name, license type, and relationship to the health care entity.
5. Address 'Additional Information' by selecting relevant actions or events related to the health care professional's conduct. Be thorough in providing details where required.
6. Finally, ensure that you sign and date the report before submission. Confirm if copies have been provided to relevant parties as indicated.

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