Provider Information

The Provider Information screen within the incident first section displays information about the provider and the provider service location pertaining to the incident.


Notes:

  • The first time a user accesses this screen they will see a Provider Search which allows the user to search for a provider and provider service locations/sites that they have access to based on their organizational scope and that have a relationship to the individual that the incident is being filed for (individual incidents only). Providers and State Centers (ODP-ID/A only) will only need to choose a service location, as other parameters will be defaulted
    • Once a provider or a site/location has been selected, its information will appear in read-only mode on the Provider Information screen.
    • If the user would like to select a different provider or provider service location/site, they may do so by clicking the Select Provider/Location link.
  • In any instance where the incident is being filed by an SCO, the MPI number and service location chosen on this screen should represent the SCO's legal entity. If no service locations are returned after performing a search for the SCO within an individual incident, create a consumer/provider relationship in HCSIS between the individual and the SCO's legal entity.


Field Name

Field Description

MPI

 This read-only field displays the provider's Master Provider Index (MPI) number.

Name

 This read-only field displays the name of the provider associated to the MPI.

Service Location Provider Type

 This read-only field displays the MPI provider type associated with the service location.

Service Location Specialty

This read-only field displays the Service Location Specialty associated with the service location.

 

Note: This field only displays if the Service Location Specialty is one of the following specialties:

  • 456. CRR-Adult

  • 520. Child Residential Services - 3600

  • 521. Adult Residential - 6400

  • 522. Family Living Homes - 6500

  • 524. Unlicensed

  • 584. Medically Complex Conditions

Service Location ID

 This read-only field displays the provider's four-digit Service Location ID that corresponds to the site address where the service is offered.

Service Location Name

 This read-only field displays the service location name for the selected provider.

Phone

 This read-only field displays the provider's phone number.

Email

 This read-only field displays the provider's e-mail address.

Address Line 1

 This read-only field lists the address of the provider service location.

Address Line 2

 This read-only field lists the additional address information of the provider service location.

Address Line 3

 This read-only field lists the additional address information of the provider service location.

City

This read-only field displays the city corresponding to the above address.

County

 This read-only field displays the county corresponding to the above address.

State

 This read-only field displays the state corresponding to the above address.

Zip Code

 This read-only field displays the zip code corresponding to the above address.
Initial Reporter First Name Enter the first name of the initial reporter.
Initial Reporter Last Name Enter the last name of the initial reporter.

Relationship to the individual

 Select from the drop-down the reporter's relationship to the individual.
If other, please specify If 'Other' was specified for the relationship to the individual above, specify the relationship.
Immediate Contact (First Name) Enter the first name of the person who is knowledgeable about the incident and can be contacted immediately.
Immediate Contact (Last Name) Enter the last name of the person who is knowledgeable about the incident and can be contacted immediately.
Phone Enter the phone number of the person who is knowledgeable about the incident and can be contacted immediately.
Email

Enter the email address of the person who is knowledgeable about the incident and can be contacted immediately.