Date Submitted: Year: Quarter: Contractor Name: Date of Incident Hospital or Setting Was there a Date of Birth Last Name First Name AHCCCS ID or Service (Use Proper Name of HCAC OPPC quality of care Severity Level MM/DD/YYYY MM/DD/YYYY Provider) concern?
Date Submitted: Year: Quarter: Contractor Name: Last Name First Name AHCCCS ID Date of Birth MM/DD/YYYY Date of Incident or Service MM/DD/YYYY Hospital or Setting (Use Proper Name of Provider) HCAC OPPC Was there a quality of care concern? Severity Level
960-Attachment-B-Health-Care-Acquired-Conditions-Other-Provider-Preventable-Conditions-Reporting-Tool.docx