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Adverse Outcome Reporting

Providers for all levels of care have the responsibility to notify Magellan of member adverse outcomes. Please utilize the electronic form below, or submit the information via fax at 1-888-656-5396.

Member’s Name *

Member’s Medicaid Number *

Facility / Provider Name *

National Provider Identification (NPI) *

Date of the incident *

Incident Type *

Provider contact name *

Provider contact number *

Detailed description of the incident (including the location, status of the member, steps taken to ensure continued member safety, and entities or other people notified) *

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Adverse Outcome Reporting

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