Healthcare Not Open During Duty Form

Healthcare Not Open During Duty Form

Use this form to document an instance in which the healthcare facility, unit, or clinic was not open or available during scheduled duty hours. The information provided will become an official incident record for administrative review, potential corrective action, and, where applicable, billing or continuity-of-care adjustments. Knowingly providing false information on this form may subject the signatory to disciplinary or legal consequences.

Patient Information

Date of Birth:    Gender: Male Female Other/Prefer not to say

Insurance Information

Medical History (Brief)

Attempted Visit / Incident Details

Facility / Unit Name:    Location:

Date of Attempted Visit:    Time of Arrival:

Scheduled Appointment: Yes No    If yes, Appointment Date:    Appointment Time:

Scheduled Duty Shift (as expected):    Staff on Duty (as known):

Facility Status Observed

Closed - No staff present
Limited services (triage only)
Open but not accepting patients
Signage present indicating closure or reduced services
Power outage affecting operations
Staffing shortage / clinical staff unavailable
Other (describe below)

Notification and Witness Information

Was facility management or on-call personnel notified at the time? Yes No

Impact on Care / Costs

Did this incident require you to seek care elsewhere? Yes No

Acknowledgment and Certification

By signing below I certify that the information I have provided on this form is true and accurate to the best of my knowledge. I understand this report will be retained in the facility's incident records and may be used for administrative review, corrective action, and for communication with my insurer if I authorize such release. I acknowledge that filing this report does not constitute a waiver of any legal rights I may have, nor does it create an admission of liability by the facility.

I acknowledge receipt of the facility's privacy practices and understand that information in this report will be handled in accordance with applicable privacy laws and facility policy.
I acknowledge the privacy practices described above.

I authorize the facility to release this incident report and supporting documentation to my insurer for claims or continuity-of-care purposes. Policy number listed above will be used for release verification.

I understand I may request a copy of this report and that I retain the right to submit a formal complaint or request review through facility administrative channels.

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