Hospital And Ambulatory Surgical Center Fax Report Form
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11HOSPITAL AND AMBULATORY SURGICAL CENTER
FAX REPORTING OF INCIDENTS AND ABUSE
GENERAL INSTRUCTIONS:
1. These instructions apply to reporting all hospital and ASC incidents, and suspected abuse,
neglect, mistreatment and misappropriation of patient property under the Patient Abuse Law.
2. Complete a separate blank form for each occurrence following the instructions below.
3. Use the attached tables to enter a description for those items that are marked “see table.”
4. Submit your completed report by fax to the Department immediately for (1) fires; (2) suicide; (3)
serious criminal acts; (4) pending or actual strike; (5) serious physical injury or harm to a patient
resulting from accident or unknown cause; and, (6) suspected abuse, neglect, mistreatment or
misappropriation involving nursing home, rest home, home health, homemaker and hospice
patients. Notify the Department immediately by phone at 617-753-8150 of any deaths
resulting from incidents, medication errors, abuse or neglect; and full or partial evacuation
of the facility for any reason. Submit other completed reports within seven days of the date of
the occurrence of an incident seriously affecting the health and safety of patients.
5. Fax your completed report to the Department at 617-753-8165.
LINE BY LINE INSTRUCTIONS
FROM: Please provide the name and address of the facility making the report.
DATE OF REPORT: Enter the date that you are submitting your report to the Department.
FOR ABUSE, NEGLECT, MISTREATMENT or MISAPPROPRIATION OCCURING IN
NURSING HOME, REST HOME, HOME HEALTH, HOMEMAKER OR HOSPICE SETTING,
NOT AT THE REPORTING HOSPITAL/ASC:
FACILITY/AGENCY NAME: Indicate the name of the provider at which the suspected
abuse, neglect, mistreatment or misappropriation occurred.
ADDRESS: Indicate the address (city or town, if street address is not known) of the
provider at which the suspected abuse, neglect or misappropriation occurred.
Please indicate the date and time of the occurrence. If you are not able to determine when the event
occurred, state “unknown”.
PATIENT INFORMATION:
Please provide information here regarding the patient
involved. The information reported here should reflect the patient’s condition prior to the
occurrence. If more than one patient was injured, or if one patient has injured another
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