Mandatory Report from a Licensed Facility/Organization Reporting a Licensed Health Professional

Licensed Health Facilities Reporting Licensed Health Professionals for adverse action to the Division of Public Health – Investigations Unit.

State of Nebraska
Department of Health and Human Services, Division of Public Health
Office of Professional & Occupational Investigations
P.O. Box 94722, Lincoln, Nebraska 68509
PHONE: 402-471-0175
FAX: 402-742-8335
EMAIL: DHHS.InvestigationsPOL@nebraska.gov

We are a*:

Health Care Facility

Peer Review Organization

Professional Association

Identifying Information For Professional I am Reporting

Prefix

First Name

Last Name

Middle Initial

Suffix

Primary Phone

Alt Phone

Fax

Email Address

Physical Address

Address Line 1

Address Line 2

City

State

Zip Code

Is Mailing Address the same as Physical Address?

Yes

Mailing Address

Address Line 1

Address Line 2

PO Box

City

State

Zip Code

List the profession and license number for each Nebraska license, certificate, or registration held.

Profession

License Number

Reporting Party Information

Business Name

Contact/Owner Prefix

Contact/Owner First Name

Contact/Owner Last Name

Contact/Owner Middle Initial

Contact/Owner Suffix

Primary Phone

Alt Phone

Fax

Email Address

Physical Address

Address Line 1

Address Line 2

City

State

Zip Code

Is Mailing Address the same as Physical Address?

Yes

Mailing Address

Address Line 1

Address Line 2

PO Box

City

State

Zip Code

Relationship to Health Care Professional

Preferred method of contact:

Do you wish to remain anonymous?

Yes

Health Care Facility Only:

Made a payment due to adverse judgement, settlement, or award of a professional liability claim against the health care facility or health care professional.

Took action adversely affecting the privileges, membership, or employment of a health care professional due to alleged:

Incompetence

Professional negligence

Unprofessional conduct

Physical, mental, or chemical impairment

Peer Review Organization or Professional Association Only:

Took action adversely affecting the privileges, membership, or employment of a health care professional due to alleged:

Incompetence

Professional negligence

Unprofessional conduct

Physical, mental, or chemical impairment

Reporting an adverse action

Date action was taken:

Effective Date:

Duration of the effect of the action:

Type of adverse action:

Patient or client giving rise to the action taken

Name:

Date of Birth:

Address:

Date of act, omission, or conduct:

Where did it occur?

Malpractice payment

Name of patient or client:

Address:

Name of court:

Address:

Date of judgment, settlement, or award:

Date of payment:

Amount of payment:

List all persons present at time of incident that would have first-hand knowledge of the incident.

Name:

Title:

Address:

Phone:

Name:

Title:

Address:

Phone:

Name:

Title:

Address:

Phone:

Reason for Complaint

Please describe the complaint and include as much detail as possible. Include where and when the complaint occurred and whom the complaint is against.

Attach any additional documentation.

Allowed file extensions: .tiff, .tif, .pdf, .doc, .docx, .jpg, .jpeg, .png and .gif
Max file size allowed: 20 MB.

The statements I have made are true and correct to the best of my knowledge. By signing this form, I am agreeing to the submission of this complaint by electronic means. I understand that an electronic signature has the same legal effect and enforceability as a written signature on a complaint.

Please sign by typing your name below.

Date

4/19/2024

Mandatory Report from a Licensed Facility/Organization Reporting a Licensed Health Professional

Licensed Health Facilities Reporting Licensed Health Professionals for adverse action to the Division of Public Health – Investigations Unit.

State of Nebraska Department of Health and Human Services, Division of Public Health Office of Professional & Occupational Investigations P.O. Box 94722, Lincoln, Nebraska 68509 PHONE: 402-471-0175 FAX: 402-742-8335 EMAIL: DHHS.InvestigationsPOL@nebraska.gov

We are a*:

Identifying Information For Professional I am Reporting

Physical Address

Mailing Address

List the profession and license number for each Nebraska license, certificate, or registration held.

Profession

License Number

Reporting Party Information

Physical Address

Mailing Address

Date action was taken:

Effective Date:

Duration of the effect of the action:

Type of adverse action:

Name:

Date of Birth:

Address:

Date of act, omission, or conduct:

Where did it occur?

Name of patient or client:

Address:

Name of court:

Address:

Date of judgment, settlement, or award:

Date of payment:

Amount of payment:

Name:

Title:

Address:

Phone:

Name:

Title:

Address:

Phone:

Name:

Title:

Address:

Phone:

Reason for Complaint

Please describe the complaint and include as much detail as possible. Include where and when the complaint occurred and whom the complaint is against.

State of Nebraska
Department of Health and Human Services, Division of Public Health
Office of Professional & Occupational Investigations
P.O. Box 94722, Lincoln, Nebraska 68509
PHONE: 402-471-0175
FAX: 402-742-8335
EMAIL: DHHS.InvestigationsPOL@nebraska.gov