Critical Incident Report - Providers - Keystone First Community HealthChoices Critical Incident Repo 2025

1. Click ‘Get Form’ to open the Critical Incident Report in the editor.
2. Begin by filling out the Provider/Facility Information section. Enter your National Provider Identifier (NPI), phone number, agency name, and address details accurately.
3. In the Reporting Party section, provide the reporter’s first and last name, title, email, and phone number. If there is a different point of contact for discussing the incident, include their information as well.
4. Complete the Keystone First CHC Participant details by entering their Medicaid number, address, date of birth, age, and gender.
5. Document the incident specifics including date and time of occurrence. Indicate if it was witnessed and provide details on who learned about it.
6. Fill in the Location of Incident section by selecting the appropriate location type and providing its address.
7. List any witnesses present during the incident along with their relationship to the participant.
8. Describe the incident thoroughly in the Incident Description section, noting all relevant circumstances.
9. Finally, review all sections for accuracy before submitting your report through our platform.

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