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CRITICAL INCIDENT REFERRAL TEMPLATE (Medicaid Members Only) Please securely submit completed template to MedicaidCriticalIncident@MolinaHealthcare.com. * Denotes when a response is required *Template
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How to fill out critical incident referral template
How to fill out critical incident referral template
01
Begin by opening the critical incident referral template
02
Fill in the date and time of the incident
03
Provide a detailed description of the incident including what happened, who was involved, and any relevant facts
04
Include any supporting documentation or evidence related to the incident
05
List any witnesses to the incident and their contact information
06
Be sure to include any actions that were taken in response to the incident
07
Review the completed template for accuracy and completeness before submitting
Who needs critical incident referral template?
01
Anyone involved in or witnessing a critical incident that requires documentation and reporting
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What is critical incident referral template?
The critical incident referral template is a standardized form used to report and document critical incidents within an organization.
Who is required to file critical incident referral template?
All employees who witness or are involved in a critical incident are required to file the critical incident referral template.
How to fill out critical incident referral template?
To fill out the critical incident referral template, employees must provide detailed information about the incident, including date, time, location, individuals involved, and a description of what happened.
What is the purpose of critical incident referral template?
The purpose of the critical incident referral template is to ensure that all critical incidents are properly documented and investigated in a timely manner.
What information must be reported on critical incident referral template?
Information such as date, time, location, individuals involved, description of the incident, and any actions taken following the incident must be reported on the critical incident referral template.
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