Free 53266.FH11 - Indiana

REQUEST FOR INFORMATION MORTALITY REVIEW
State Form 53266 (R / 3-08) / QA 2000

Family and Social Services Administration Division of Aging Mortality Review Process This document contains confidential medical information and is not subject to disclosure as a public record.

(Type or print all information. When attaching additional sheets, clearly indicate which answer is being continued.)

To: Mortality Review Process

Division of Aging 402 West Washington Street IGCS, Room W454, MS-21 P.O. Box 7083 Indianapolis, IN 46207-7083 Fax: Brenda Hogan (317) 232-7867 Telephone: Brenda Hogan (317) 232-7132

From:

Agency Address (number and street) City, state, ZIP code Name of contact person (name and title) Telephone number

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PARTICIPANT INFORMATION
Name of deceased Gender County where death occurred Date of death (month, day, year) Race Date of birth (month, day, year)

Male

Female

Address of deceased (number and street, city, state, and ZIP code)

PROGRAM INFORMATION
Service type (check the appropriate service type):

A&D Waiver Yes
If Yes, name of facility

Traumatic Brain Injury Waiver

CHOICE

Other: ____________________________________________

Was the deceased a resident of a nursing facility in the previous ninety (90) days prior to death?

No
Date of discharge (month, day, year)

Address of facility (number and street, city, state, and ZIP code) County of facility Name of contact person Telephone number

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REPORTING CONTACT VERIFICATION
Date of this report (month, day, year)

CONTACT APS (required for age 18 and over) DCS (required for under age 18)

DATE

TIME

NAME OF PERSON CONTACTED

HOW NOTIFIED

NOTIFIED BY WHOM

Contact information for individual(s).
Name of legal guardian (if applicable) Address (number and street, city, state, and ZIP code) Name of case manager Case managers agency Telephone number Relationship Telephone number

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Address of case manager (number and street, city, state, and ZIP code) Name of APS / DCS contacted Address of APS / DCS (number and street, city, state, and ZIP code) APS / DCS county Telephone number

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INFORMATION REGARDING DEATH
1) Date of death (month, day, year) 2) Day of death 3) Time of death

AM PM

4) Address where death occurred (number and street, city, state, and ZIP code) 5) Type of setting where death occurred 6) Name of setting where death occurred (if applicable) 7) Primary cause of death 8) Secondary cause of death 9) Was death result of suspected or alleged abuse or neglect? 10) Was a terminal illness diagnosed? Was death result of suspected or alleged suicide or homicide? Was death result of trauma or accident?

Yes Yes

No No

Yes

No

Yes No

No

If Yes, were hospice services provided?

Unknown

Yes

11) Identify terminal illness 12) Name of physician attending at time of death (if applicable) 14) Address of attending physician (number and street, city, state, and ZIP code) 15) Advance Directive / DNR status 16) Postmortem reports: Was an autopsy completed? 13) Telephone number of attending physician

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Yes

No

Unknown

Yes

No

17) If yes, provide contact information for autopsy report. 18) Name of primary physician 20) Address of primary physician (number and street, city, state, and ZIP code) 21) Date of clients last medical appointment with primary physician (month, day, year) 22) Have there been any incident reports, per DA reporting requirements, of abuse, neglect or injuries sustained by deceased (for 12 months prior to death)? 19) Telephone number of primary physician

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Yes

No TYPE OF REPORT DATE REPORTED (month, day, year)

23) If Yes, indicate the type of report and the date of report and attach any copies of relevant information relating to incidents that occurred prior to the individuals death.

HOSPITALIZATION INFORMATION
24) Was the client hospitalized in the six (6) months preceding time of death?

Yes
Name of hospital

No

If Yes, list name of hospital date(s) of admission(s) / date(s) discharged / reason(s) for hospitalization.
Date of admission (month, day, year) Date of discharge (month, day, year)

Address of hospital (number and street, city, state, and ZIP code) Reason for hospitalization Physicians orders upon discharge

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HOSPITALIZATION INFORMATION (continued)
Name of hospital Address of hospital (number and street, city, state, and ZIP code) Reason for hospitalization Physicians orders upon discharge Date of admission (month, day, year) Date of discharge (month, day, year)

Name of hospital Address of hospital (number and street, city, state, and ZIP code) Reason for hospitalization Physicians orders upon discharge

Date of admission (month, day, year)

Date of discharge (month, day, year)

Name of hospital Address of hospital (number and street, city, state, and ZIP code) Reason for hospitalization Physicians orders upon discharge

Date of admission (month, day, year)

Date of discharge (month, day, year)

ADDITIONAL INFORMATION 25) Provide copies of the following data for the 30-day period prior to the death from any HCBS provider serving this individual. (Submit in chronological order from date of death. If hospitalized prior to death, proved information for the last 30 days of services provided) Staff notes Nurses notes Staffing schedules up to and including the date of the participants death ADDITIONAL INFORMATION (continued)
26) Give any additional information that you feel is pertinent to this report. (use additional sheets, if necessary)

VERIFICATION OF INFORMATION INCLUDED IN THE REPORT 27) Signature I hereby verify that the information contained in this report is accurate.
Signature Printed Name and Title Date verified (month, day, year) Telephone number

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This form is HIPAA compliant per the requirements of 45 CFR § 164.508(c).

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