Hospital And Ambulatory Surgical Center Fax Report Form Page 11
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SRE REPORT UPDATE: If this is an SRE, the following update to this report is required within 30 days of the
initial reporting
REPORTING FACILITY: ____________________________ DATE OF OCCURRENCE: ____________
PATIENT NAME _________________
_________
DATE OF REPORT:
_______________
Please check the boxes below to confirm the following statements:
□
This updated report is being made within 30 days of the initial reporting of the event.
□
The patient or patient’s representative has been provided with a copy of this updated report.
□
Any responsible third party payer has been provided with a copy of this updated report.
PATIENT INSURER:
INSURANCE IDENTIFICATION NUMBER:
PREVENTABILITY DETERMINATION NARRATIVE: [Attach additional pages as needed.]
DECISION TO SEEK PAYMENT:
□
The facility is seeking payment for services provided as a result of this SRE.
□
The facility is not seeking payment for services provided as a result of this SRE.
□
The patient is a Medicare and/or MassHealth patient. Medicare and/or MassHealth rules apply.
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