Report Claim

Submission Form

Please send the papers you received along with patient records to info@ccrrg.com

For questions call 860-408-2181

Contact Us

I. Member Information

I. Member Information

Member/Facility:

Fax Number:

Phone Number:

Address:

Member Contact:

Title:

Email:

II. Facility Contact Information (if different from above)

II. Facility Contact Information (if different from above)

Name of Administrator / Risk Manager:

Title:

Phone Number:

Fax Number:

Email:

Name and Title of Person Completing this Form:

Name and Title of Person Completing this Form:

Name/Title:

Date:

III. Notification of Claim

III. Notification of Claim

Indicate how facility was notified of claim (attach applicable supporting documents including complaints, notice letters and all Incident Reports relating to this Resident/Visitor):

LETTER / COMPLAINT FROM FAMILY MEMBER

RECORD REQUEST received from an ATTORNEY in anticipation of litigation

RECORD REQUEST received from FAMILY MEMBER or GUARDIAN with cause for concern

LETTER OF REPRESENTATION FROM ATTORNEY representing resident/family member(s)

NOTICE OF CLAIM/INTENT TO INITIATE LITIGATION

SUMMONS AND COMPLAINT; LAWSUIT SERVED

VISITOR INJURY

OTHER; SUCH AS SERIOUS INCIDENT, unexpected outcome/death, unusual occurrence/regulatory action or investigation, elopement, amputation or paralysis, allegation of sexual abuse, allegation of breaches of resident rights.

IV. Claimant Information

IV. Claimant Information

Claimant (Resident/Visitor Involved) Name:

Date of Incident:

Location:

Date of Admission:

Admission Diagnosis:

Date of Discharge:

Reason for Discharge:

Discharge Destination:

Primary Physician:

Brief Description of Incident: (Attach additional sheet as necessary)