HTML Preview Physician Office Incident Report page number 1.
DH-MQA1030-12/06
Page 1 of 3
STATE OF FLORIDA
Rick Scott, Governor
PHYSICIAN OFFICE
ADVERSE INCIDENT REPORT
SUBMIT FORM TO:
Department of Health, Consumer Services Unit
4052 Bald Cypress Way, Bin C75
Tallahassee, Florida 32399-3275
I. OFFICE INFORMATION
_____________________________________ ___________________________________
Name of office Street Address
_______________________ ___________ ______________ ________________________________________________
City Zip Code County Telephone
__________________________________________________ ________________________________________________
Name of Physician or Licensee Reporting License Number & office registration number, if applicable
__________________________________________________
Patient's address for Physician or Licensee Reporting
II. PATIENT INFORMATION
_________________________________________________ ______________ _____________
Patient Name Age Gender Medicaid Medicare
_________________________________________________ ________________________________________________
Patient's Address Date of Office Visit
_________________________________________________ ________________________________________________
Patient Identification Number Purpose of Office Visit
_________________________________________________ ________________________________________________
Diagnosis ICD-9 Code for description of incident
________________________________________________
Level of Surgery (II) or (III)
III. INCIDENT INFORMATION
_________________________________________________ Location of Incident:
Incident Date and Time Operating Room Recovery Room
Other_________________
Note: If the incident involved a death, was the medical examiner notified? Yes No
Was an autopsy performed?
Yes No
A) Describe circumstances of the incident (narrative)
(use additional sheets as necessary for complete response)
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________