Notification



Notification Issue Date:



Policy Attachment


Attachment to Policy # 00.01.44h


Attachment:D

Policy #:00.01.44h

Description:Never Event or Preventable Adverse Event Reporting Form

Title:Never Events and Preventable Adverse Events



Never Events and Preventable Adverse Events Reporting Form

Procedure for reporting Never Events and Preventable Adverse Events to the Company.

1.The participating facility will either send a letter on letterhead or use the attached form to report the event. If using letterhead, please include all the information on the form.

2.

Mail or fax the letter to CFID.




Report of a Never Event or Preventable Adverse Event

MEMBER NAME __________________________________

Member # __________________

Date of Birth ____________________ Age_____________

Gender: (circle) Female Male

Occurrence Date _________________________________

Date Reported _________________________

Reported by ____________________________________

Contact Phone # ________________________

Attending Physician(s)______________________________

Facility Name(s) (location of incident/concern)_____________________________________________

Facility Type (Hospital, Surgery Center, etc) _______________________________________________

SUMMARY OF EVENT
___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________


Please send report under confidential cover to:
CFID
1901 Market Street
15th Floor
Philadelphia, PA 19103
or (fax) 215-567-6901

Version Effective Date: 10/01/2018
Version Issued Date: 10/01/2018
Version Reissued Date: N/A

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Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.