Medicaid E-FORM

General Information
County Reported to DLC Resident on Resident
Date of Incident (MM/DD/YYYY) Photos Requested
Incident Narrative
Complainant's Information
Complainant First Name Complainant Last Name Complainant Middle Name Suffix
Address One Address Two City
State Zip Code Address Type
Home Phone
- -
Extn.
Work Phone
- -
Extn.
Email to get confirmation Email Confirm
Title Employer Name
Facility Information
Facility Name
Address One Address Two
City State Zip Code
Victim's Information
Victim First Name Victim Last Name Victim Middle Name Suffix
Date of Birth (MM/DD/YYYY) Address One Address Two
City State Zip Code
Restraints/Special Observations/Assist Orders Victim Cognizance Level
Family Member/Responsible Party Information
Relationship
FM/RP First Name FM/RP Last Name FM/RP Middle Name Suffix
Address One Address Two City
State Zip Code Address Type
Home Phone
- -
Extn.
Work Phone
- -
Extn.
Suspect's Information
Suspect First Name Suspect Last Name Suspect Middle Name Suffix
Address One Address Two City
State Zip Code Address Type
Date of Birth (MM/DD/YYYY) SSN Employee of Facility
Cognizance Level