but ‘natural’, the provider shall report the death, in addition to all parties listed below, to the medical examiner. Please check notifications performed. ● Immediate Notification Required: Law Enforcement Official in the jurisdiction in the death occurred; and The Secretary of the Department of Health and Mental Hygiene. ● Notification required by close of business of the next working day: The Director of the Behavioral Health Administration; The Health Officer in the jurisdiction the death occurred; and The designated State protection and advocacy system. Please fax a copy of this form to Maryland Disability Law Center at 410.727.6389. notification: ● ‘natural’) The Medical Examiner (if the of death is believed to be other than J. Contact Information. Printed name & of person submitting form: Telephone number: Signature of individual submitting form: CONFIDENTIALITY NOTICE This document contains confidential information. Disclosure of this document could be a violation of the Maryland Confidentiality of Medical Records law. REDISCLOSURE IS STRICTLY PROHIBITED, unless made pursuant to HG §4-302(d) of the Annotated Code of Maryland. IF YOU RECEIVE THIS DOCUMENT IN ERROR, PLEASE IMMEDIATELY NOTIFY THE SENDER TO ARRANGE THE RETURN OF THE ORIGINAL DOCUMENT(S).
but ‘natural’, the provider shall report the death, in addition to all parties listed below, to the medical examiner. Please check notifications performed. ● Immediate Notification Required: Law Enforcement Official in the jurisdiction in the death occurred; and The Secretary of the Department of Health and Mental Hygiene. ● Notification required by close of business of the next working day: The Director of the Behavioral Health Administration; The Health Officer in the jurisdiction the death occurred; and The designated State protection and advocacy system. Please fax a copy of this form to Maryland Disability Law Center at 410.727.6389. ● notification: The Medical Examiner (if the of death is believed to be other than ‘natural’) J. Contact Information. Printed name & of person submitting form: Telephone number: Signature of individual submitting form: CONFIDENTIALITY NOTICE This document contains confidential information. Disclosure of this document could be a violation of the Maryland Confidentiality of Medical Records law. REDISCLOSURE IS STRICTLY PROHIBITED, unless made pursuant to HG §4-302(d) of the Annotated Code of Maryland. IF YOU RECEIVE THIS DOCUMENT IN ERROR, PLEASE IMMEDIATELY NOTIFY THE SENDER TO ARRANGE THE RETURN OF THE ORIGINAL DOCUMENT(S).
DHMH%204364%20Report%20of%20Death%20-%20April%207,%202016.docx