Significant Event Notification Form

Your MTM Email*

example@example.com

Reporting Department*

Additional Email Recipients

example@example.com

State Incident Occurred in*

Are you filling out a New Significant Event Notification Form or a Follow Up?*

Trip NumberComplaint NumberSignificant Event Number

Enter Number*

Follow up request information*

If this section is blank, go to the next page

Select the appropriate category for the reported incident.*

Select appropriate member condition related to incident*

QA Analyst Name*

CCR Name*

Contact ID#*

Call Date*

Date

Call Time*

Hour Minutes

AM/PM Option

Sent for Coaching*

Provider Trip #

Incident Date

Date

Alcohol testing can only be completed when reported within 24 hours of the trip.

Marijuana testing can only be completed when reported within 30 days of the incident.

Due to HIPAA do not provide the caller any information regarding the

member, transportation provider, or trip.

Date of alleged Incident*

Date

To (T) LegReturn (R)LegOther

Trip NumberComplaint Number

Enter Trip Number*

Enter Complaint Number*

Member Name*

First NameLast Name

Member Name*

First NameLast Name

Member ID*

Member Date of Birth*

Date

Member ID (if available)

Member DOB (needed to decipher commonality in names)

Date

Transportation Company*

Caller Type*

Caller Name*

First NameLast Name

Call Back Number*

Please enter a valid phone number.Format: (000) 000-0000.

Date of alleged Incident*

Date

To (T) LegReturn (R) LegOther

Rows	Yes	No	Unknown
Did the driver assist or ask if you were ok?
Did the driver stay on scene of the incident?
Were the Police or EMS called?
Was member taken to the hospital?
Sought medical attention on their own after incident

Type*

MemberDriverAdditional Passenger

Rows	Yes	No	Unknown
Were the Police called?
Did the Police show up on scene?
Was anyone arrested?

Rows	Yes	No	Unknown
Were the Police called?
Did the Police show up on scene?
Was anyone arrested?
Was member taken to the hospital?
Sought medical attention on their own after incident

Please inform the caller they will need to email any of the following documentation to A2CSE@mtm-inc.net    &#13;&#10;&#13;&#10;•	Letter of Representation (LOR) &#13;&#10;•	Release of Information form (ROI) &#13;&#10;•	Subpoena&#13;&#10;&#13;&#10;If the caller states they do not have any of the documentation listed above inform them we are unable to assist them due to HIPAA and PHI.  Once the documentation listed above is received we will reach out to them.  No information will be provided until we are in receipt of the required documentation.

See Policy 221; When the caller states they are suicidal, homicidal, or want to cause injury to others, the Associate will follow a process to work with emergency services and their supervisor in support of the caller.&#13;&#10;&#13;&#10;  •When receiving the call, the associate will immediately inform their supervisor of the situation.&#13;&#10;&#13;&#10;  •Associate will start a trip and get the callers current location and phone number.&#13;&#10;&#13;&#10;  •Supervisor or Associate is to immediately contact 911.&#13;&#10;&#13;&#10;  •If caller describes suicide or homicide method(s), notate for emergency services.&#13;&#10;&#13;&#10;  •Attempt to keep the caller on the line until emergency services is at the location.

Trip or Complaint Number*

Copy and Paste Complaint

Please add additional information obtained regarding the incident or requests from caller.

CompletedNot completed

Yes – Health Plan allows complaint submission; protocols were reviewed and followed. A complaint was submitted.No – Health Plan does not allow complaint submission; protocols were reviewed and followed. A complaint was not submitted.

Provide description of the incident and/or injuries*

Upload Any Supporting Documents

The form cannot be submitted until you enter a Trip Remark in the related trip stating “A potential SE has been submitted”.

Please enter this Remark now and change the answer above to Completed

Significant Event Notification Form

Follow Up Request

New Significant Event Notification