jQuery UI Datepicker - Default functionality






All information provided in these appended materials is compiled at the direction of the CountyCare Quality Department and is privileged and confidential to be used solely in the course of internal quality control and for the purpose of reducing morbidity and mortality and assessing or improving the quality of care provided to our members. This information is protected under the Illinois Medical Studies Act.

Date:*

Organization/Department:*

Name & Title:*

Telephone number/extension:(000) 000-0000 *

Email:*

Supervisor Name & Title (if referent is not a supervisor):

Supervisor telephone number/extension:

Email:


Member Name:*

Members DOB:*

Medicaid RIN:*

Medical Home/PCP:

CME:

Provider/Facility/Practitioner:*

Location of Incident:*

Date of Incident:*


Adverse Medical Event Adverse surgical event Allergic/Adverse Drug Reaction Unexpected Death (includes fetal death >24 wks. gestation)
Readmission within 30 days Infection Suicide
Improper Treatment