Use this form to report adverse incidents that include member injuries that occur during the delivery of managed care plan covered services and incidents of suspected abuse, neglect and exploitation.
If you have questions regarding this form or need to update a previously submitted form, please contact Risk Management at firstname.lastname@example.org.
Please note: This tool does not have the ability to save entered data and retrieve it at a later date.
You may also download and submit the form via fax or email. (Instructions are on the form):