Physician Office Adverse Incident Report - Florida Department Of Health
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3STATE 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:
Operating Room
Recovery Room
Incident Date and Time
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)
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
DH-MQA1030-12/06
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