Other Report Forms
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Fire Incident Report Form
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167.6 kB
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Memorandum regarding AHCA Form 3130-8006, Organ & Tissue Donation Request Summary Data Form
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31.1 kB
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Disposition of Fetal Remains Form (AHCA Form 3100-0006 January 2005)
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54.6 kB
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- Quarterly Patient Immigration Status Form
Reporting Death in Restraint/Seclusion to the CMS Atlanta Regional Office
Hospitals must report patient deaths associated with restraints and/or seclusion using Form CMS 10455 following the instruction sheet provided.
Hospital Restraint Death Reporting Instructions
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49.4 kB
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Form CMS 10455
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46.8 kB
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The completed form must be submitted to the CMS Regional Office in Atlanta no later than close of business on the next business day following knowledge of the patient's death. Reporting methods include:
Facsimile: (443) 380-5912 Available 24/7
Electronically: [email protected] Available 24/7
Mandatory Monthly Report of Induced Terminations of Pregnancy (ITOP)
Chapter 390.0112, Florida Statutes, requires each director of any medical facility to submit a monthly report of induced terminations of pregnancy to the Agency. The report must be submitted within 30 days following the preceding month and a $200 fine may be imposed if reports are not submitted timely. The statute requires that data reported shall be kept confidential. The reports are not permitted to be released to anyone except upon court order in a civil or criminal proceeding.
Effective July 13, 2008, the monthly report must be submitted electronically to the Agency.
ITOP Monthly Reporting System via the AHCA Portal login
