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Get and Sign Critical Incident Report Providers AmeriHealth Caritas Pennsylvania Community HealthChoices Critical Incident Report Form
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AmeriHealth Caritas PA CHC Participant
Medicaid number:
First name:
Last name:
Address:
City:
Date of birth:
State:
ZIP code:
Participant’s gender: ☐ Male ☐ Female
Age:
Service Coordinator (SC)
First name:
Last name:
Address:
City:
State:
Email:
ZIP code:
Phone number:
SC contacted Participant within 24 hours of discovering incident? ☐ Yes ☐ No
Date SC contacted Participant:
Time SC contacted Participant:
Incident
Date...
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