## Draft Medical Malpractice Payment Report

+-----------------------------------------------------------------------+
| ##                                                                    |
|                                                                       |
| #                                                                     |
| # This form is for your convenience in drafting Medical Malpractice P |
| ayment Reports for ultimate submission to the NPDB. Do not mail this  |
| form to the Data Banks. Medical Malpractice Payment Reports must be s |
| ubmitted to the National Practitioner Data Bank (NPDB) using the Inte |
| grated Querying and Reporting Service (IQRS), the Querying and Report |
| ing XML Service (QRXS), or the Interface Control Document (ICD) Trans |
| fer Program (ITP), which are available at *www.npdb‑hipdb.hrsa.gov*.  |
+-----------------------------------------------------------------------+
| ##                                                                    |
+-----------------------------------------------------------------------+
| ## Please provide                                                     |
| as much of the following information as possible.  Failure to provide |
|  sufficient information to permit identification of a single subject  |
| will result in the report being rejected, necessitating resubmission. |
|  If spaces are provided for multiple responses to an item, you only n |
| eed to complete as many of the responses as you have information for. |
|  There is no need to repeat responses or enter "Not Applicable," etc. |
+-----------------------------------------------------------------------+
| ##                                                                    |
+-----------------------------------------------------------------------+
| ## OMB \# 0915-0126 expiration date 07/31/10                          |
|                                                                       |
| ##  [Publi                                                            |
| c Burden Statement:]{.underline} An agency may not conduct or sponsor |
| , and a person is not required to respond to, a collection of informa |
| tion unless it displays a currently valid OMB control number. The OMB |
|  control number for this project is 0915-0126 (NPDB). Public reportin |
| g burden for this collection of information is estimated to average 4 |
| 5 minutes to complete the forms, including the time for reviewing ins |
| tructions, searching existing data sources, and completing and review |
| ing the collection of information. Send comments regarding this burde |
| n estimate or any other aspect of this collection of information, inc |
| luding suggestions for reducing this burden, to HRSA Reports Clearanc |
| e Officer, 5600 Fishers Lane, Room 14-22, Rockville, Maryland, 20857. |
+-----------------------------------------------------------------------+

## 

+---+---------------------+----------------+---------------+----------+
| # |                     |                |               |          |
| # |                     |                |               |          |
|   |                     |                |               |          |
| S |                     |                |               |          |
| u |                     |                |               |          |
| b |                     |                |               |          |
| j |                     |                |               |          |
| e |                     |                |               |          |
| c |                     |                |               |          |
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|   |                     |                |               |          |
| N |                     |                |               |          |
| a |                     |                |               |          |
| m |                     |                |               |          |
| e |                     |                |               |          |
+---+---------------------+----------------+---------------+----------+
| # | ## Last Name        | ## First Name  | #             | #        |
| # |                     |                | # Middle Name | # Suffix |
|   | #                   | ## *(1         |               |          |
|   | # *(25 characters)* | 5 characters)* | ## *(15       | ##       |
|   |                     |                |  characters)* | *(4 char |
|   |                     |                |               | acters)* |
+---+---------------------+----------------+---------------+----------+
| # | ##                  | ##             | ##            | ##       |
| # |                     |                |               |          |
|   |                     |                |               |          |
+---+---------------------+----------------+---------------+----------+
| # |                     |                |               |          |
| # |                     |                |               |          |
|   |                     |                |               |          |
+---+---------------------+----------------+---------------+----------+
| # |                     |                |               |          |
| # |                     |                |               |          |
|   |                     |                |               |          |
| O |                     |                |               |          |
| t |                     |                |               |          |
| h |                     |                |               |          |
| e |                     |                |               |          |
| r |                     |                |               |          |
|   |                     |                |               |          |
| N |                     |                |               |          |
| a |                     |                |               |          |
| m |                     |                |               |          |
| e |                     |                |               |          |
| s |                     |                |               |          |
|   |                     |                |               |          |
| U |                     |                |               |          |
| s |                     |                |               |          |
| e |                     |                |               |          |
| d |                     |                |               |          |
+---+---------------------+----------------+---------------+----------+
| # | ## Last Name        | ## First Name  | #             | #        |
| # |                     |                | # Middle Name | # Suffix |
|   | #                   | ## *(1         |               |          |
|   | # *(25 characters)* | 5 characters)* | ## *(15       | ##       |
|   |                     |                |  characters)* | *(4 char |
|   |                     |                |               | acters)* |
+---+---------------------+----------------+---------------+----------+
| # | ##                  | ##             | ##            | ##       |
| # |                     |                |               |          |
|   |                     |                |               |          |
| 1 |                     |                |               |          |
| . |                     |                |               |          |
+---+---------------------+----------------+---------------+----------+
| # | ##                  | ##             | ##            | ##       |
| # |                     |                |               |          |
|   |                     |                |               |          |
| 2 |                     |                |               |          |
| . |                     |                |               |          |
+---+---------------------+----------------+---------------+----------+
| # | ##                  | ##             | ##            | ##       |
| # |                     |                |               |          |
|   |                     |                |               |          |
| 3 |                     |                |               |          |
| . |                     |                |               |          |
+---+---------------------+----------------+---------------+----------+
| # | ##                  | ##             | ##            | ##       |
| # |                     |                |               |          |
|   |                     |                |               |          |
| 4 |                     |                |               |          |
| . |                     |                |               |          |
+---+---------------------+----------------+---------------+----------+
| # | ##                  | ##             | ##            | ##       |
| # |                     |                |               |          |
|   |                     |                |               |          |
| 5 |                     |                |               |          |
| . |                     |                |               |          |
+---+---------------------+----------------+---------------+----------+

## 

+--------+---------+----------+---------------------------------------+
| ## G   | #       | ##       | ##  Unknown                           |
| ender: | #  Male |   Female |                                       |
+--------+---------+----------+---------------------------------------+

## 

+---------------------+----------+-------------------------------------+
| ## Bir              | ##       |                                     |
| th Date (MMDDYYYY): |          |                                     |
+---------------------+----------+-------------------------------------+
| ##                  | ##       |                                     |
+---------------------+----------+-------------------------------------+
| ## Wor              |          | ##                                  |
| k Organization Name |          |                                     |
|  *(50 characters)*: |          |                                     |
+---------------------+----------+-------------------------------------+

## 

+---+---------------------------------+---------------------------------+
| # |                                 |                                 |
| # |                                 |                                 |
|   |                                 |                                 |
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| s |                                 |                                 |
|   |                                 |                                 |
| # |                                 |                                 |
| # |                                 |                                 |
|   |                                 |                                 |
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| ) |                                 |                                 |
+---+---------------------------------+---------------------------------+
| # | Street Address (40 characters): |                                 |
| # |                                 |                                 |
|   |                                 |                                 |
+---+---------------------------------+---------------------------------+
| # | Address Line 2 (40 characters): |                                 |
| # |                                 |                                 |
|   |                                 |                                 |
+---+---------------------------------+---------------------------------+
| # | City (28 characters):           |                                 |
| # |                                 |                                 |
|   |                                 |                                 |
+---+---------------------------------+---------------------------------+
| # | State (Choose State code from   |                                 |
| # | List A-1):                      |                                 |
|   |                                 |                                 |
+---+---------------------------------+---------------------------------+
| # | ZIP Code:                       |      -                          |
| # |                                 |                                 |
|   |                                 |                                 |
+---+---------------------------------+---------------------------------+
| # | Country (If U.S., leave blank;  |                                 |
| # | 20 characters):                 |                                 |
|   |                                 |                                 |
+---+---------------------------------+---------------------------------+

## 

+---+--------------------------------+---------------------------------+
| # |                                |                                 |
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| ) |                                |                                 |
+---+--------------------------------+---------------------------------+
| # | Street Address (40             |                                 |
| # | characters):                   |                                 |
|   |                                |                                 |
+---+--------------------------------+---------------------------------+
| # | Address Line 2 (40             |                                 |
| # | characters):                   |                                 |
|   |                                |                                 |
+---+--------------------------------+---------------------------------+
| # | City (28 characters):          |                                 |
| # |                                |                                 |
|   |                                |                                 |
+---+--------------------------------+---------------------------------+
| # | State (Choose State code from  |                                 |
| # | List A-1):                     |                                 |
|   |                                |                                 |
+---+--------------------------------+---------------------------------+
| # | ZIP Code:                      |      -                          |
| # |                                |                                 |
|   |                                |                                 |
+---+--------------------------------+---------------------------------+
| # | Country (If U.S., leave blank; |                                 |
| # | 20 characters):                |                                 |
|   |                                |                                 |
+---+--------------------------------+---------------------------------+

## 

## 

+------------------+---------------------------------------------------+
| ## Is S          | ##  No                                            |
| ubject Deceased? |                                                   |
+------------------+---------------------------------------------------+
| ##               | ##  Unknown                                       |
+------------------+---------------------------------------------------+
| ##               | ##  Yes -- Deceased Date (MMDDYYYY):              |
+------------------+---------------------------------------------------+

## 

+---+----------------------+---+-------------------------------------+
| # |                      |   |                                     |
| # |                      |   |                                     |
|   |                      |   |                                     |
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| N |                      |   |                                     |
| N |                      |   |                                     |
| ) |                      |   |                                     |
+---+----------------------+---+-------------------------------------+
| # | ##                   | # | ##                                  |
| # |                      | # |                                     |
|   |                      |   |                                     |
| 1 |                      | 2 |                                     |
| . |                      | . |                                     |
|   |                      |   |                                     |
+---+----------------------+---+-------------------------------------+
| # | ##                   | # | ##                                  |
| # |                      | # |                                     |
|   |                      |   |                                     |
| 3 |                      | 4 |                                     |
| . |                      | . |                                     |
|   |                      |   |                                     |
+---+----------------------+---+-------------------------------------+
| # |                      |   |                                     |
| # |                      |   |                                     |
|   |                      |   |                                     |
+---+----------------------+---+-------------------------------------+
| # |                      |   |                                     |
| # |                      |   |                                     |
|   |                      |   |                                     |
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| ) |                      |   |                                     |
| * |                      |   |                                     |
+---+----------------------+---+-------------------------------------+
| # | ##                   | # | ##                                  |
| # |                      | # |                                     |
|   |                      |   |                                     |
| 1 |                      | 2 |                                     |
| . |                      | . |                                     |
|   |                      |   |                                     |
+---+----------------------+---+-------------------------------------+
| # | ##                   | # | ##                                  |
| # |                      | # |                                     |
|   |                      |   |                                     |
| 3 |                      | 4 |                                     |
| . |                      | . |                                     |
|   |                      |   |                                     |
+---+----------------------+---+-------------------------------------+

## 

+---+-----------------------------------+------------------------------+
| * |                                   | **Year of Graduation**       |
| * |                                   | (Format YYYY)                |
| P |                                   |                              |
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+---+-----------------------------------+------------------------------+
| * |                                   |                              |
| * |                                   |                              |
| 1 |                                   |                              |
| . |                                   |                              |
| * |                                   |                              |
| * |                                   |                              |
+---+-----------------------------------+------------------------------+
| * |                                   |                              |
| * |                                   |                              |
| 2 |                                   |                              |
| . |                                   |                              |
| * |                                   |                              |
| * |                                   |                              |
+---+-----------------------------------+------------------------------+
| * |                                   |                              |
| * |                                   |                              |
| 3 |                                   |                              |
| . |                                   |                              |
| * |                                   |                              |
| * |                                   |                              |
+---+-----------------------------------+------------------------------+
| * |                                   |                              |
| * |                                   |                              |
| 4 |                                   |                              |
| . |                                   |                              |
| * |                                   |                              |
| * |                                   |                              |
+---+-----------------------------------+------------------------------+
| * |                                   |                              |
| * |                                   |                              |
| 5 |                                   |                              |
| . |                                   |                              |
| * |                                   |                              |
| * |                                   |                              |
+---+-----------------------------------+------------------------------+

## 

## Occupation and State Licensure Information

## (Provide at least one license. Check 'No License' if the subject does not have a State License Number. Up to 60 licenses may be provided.)

+---+------------------------------+----------+------+---+---+----------+
|   |                              |          |      |   |   |          |
+---+------------------------------+----------+------+---+---+----------+
| * | **State License Number** (16 |          |      | * |   |          |
| * | characters)**:**             |          |      | * | N |          |
| 1 |                              |          |      | O | o |          |
| . |                              |          |      | R | L |          |
| * |                              |          |      | * | i |          |
| * |                              |          |      | * | c |          |
|   |                              |          |      |   | e |          |
|   |                              |          |      |   | n |          |
|   |                              |          |      |   | s |          |
|   |                              |          |      |   | e |          |
+---+------------------------------+----------+------+---+---+----------+
|   | **State of Licensure**       |          |      |   |   |          |
|   | (Choose State code from List |          |      |   |   |          |
|   | A-1):                        |          |      |   |   |          |
+---+------------------------------+----------+------+---+---+----------+
|   | **Occupation/Field of        |          |      |   |   |          |
|   | Licensure** (Choose one      |          |      |   |   |          |
|   | three-digit code from List   |          |      |   |   |          |
|   | B):                          |          |      |   |   |          |
+---+------------------------------+----------+------+---+---+----------+
|   | **Description** (Only        |          |      |   |   |          |
|   | complete for                 |          |      |   |   |          |
|   | Occupation/Field of          |          |      |   |   |          |
|   | Licensure Code 699; 60       |          |      |   |   |          |
|   | characters)**:**             |          |      |   |   |          |
|   |                              |          |      |   |   |          |
|   |                              |          |      |   |   |          |
+---+------------------------------+----------+------+---+---+----------+
|   |                              |          |      |   |   |          |
+---+------------------------------+----------+------+---+---+----------+
|   |                              |          |      |   |   |          |
+---+------------------------------+----------+------+---+---+----------+
| * | **State License Number** (16 |          |      | * |   |          |
| * | characters)**:**             |          |      | * | N |          |
| 2 |                              |          |      | O | o |          |
| . |                              |          |      | R | L |          |
| * |                              |          |      | * | i |          |
| * |                              |          |      | * | c |          |
|   |                              |          |      |   | e |          |
|   |                              |          |      |   | n |          |
|   |                              |          |      |   | s |          |
|   |                              |          |      |   | e |          |
+---+------------------------------+----------+------+---+---+----------+
|   | **State of Licensure**       |          |      |   |   |          |
|   | (Choose State code from List |          |      |   |   |          |
|   | A-1):                        |          |      |   |   |          |
+---+------------------------------+----------+------+---+---+----------+
|   | **Occupation/Field of        |          |      |   |   |          |
|   | Licensure** (Choose one      |          |      |   |   |          |
|   | three-digit code from List   |          |      |   |   |          |
|   | B):                          |          |      |   |   |          |
+---+------------------------------+----------+------+---+---+----------+
|   | **Description** (Only        |          |      |   |   |          |
|   | complete for                 |          |      |   |   |          |
|   | Occupation/Field of          |          |      |   |   |          |
|   | Licensure Code 699; 60       |          |      |   |   |          |
|   | characters)**:**             |          |      |   |   |          |
|   |                              |          |      |   |   |          |
|   |                              |          |      |   |   |          |
+---+------------------------------+----------+------+---+---+----------+
|   |                              |          |      |   |   |          |
+---+------------------------------+----------+------+---+---+----------+
|   |                              |          |      |   |   |          |
+---+------------------------------+----------+------+---+---+----------+
| * | **State License Number** (16 |          |      | * |   |          |
| * | characters)**:**             |          |      | * | N |          |
| 3 |                              |          |      | O | o |          |
| . |                              |          |      | R | L |          |
| * |                              |          |      | * | i |          |
| * |                              |          |      | * | c |          |
|   |                              |          |      |   | e |          |
|   |                              |          |      |   | n |          |
|   |                              |          |      |   | s |          |
|   |                              |          |      |   | e |          |
+---+------------------------------+----------+------+---+---+----------+
|   | **State of Licensure**       |          |      |   |   |          |
|   | (Choose State code from List |          |      |   |   |          |
|   | A-1):                        |          |      |   |   |          |
+---+------------------------------+----------+------+---+---+----------+
|   | **Occupation/Field of        |          |      |   |   |          |
|   | Licensure** (Choose one      |          |      |   |   |          |
|   | three-digit code from List   |          |      |   |   |          |
|   | B):                          |          |      |   |   |          |
+---+------------------------------+----------+------+---+---+----------+
|   | **Description** (Only        |          |      |   |   |          |
|   | complete for                 |          |      |   |   |          |
|   | Occupation/Field of          |          |      |   |   |          |
|   | Licensure Code 699; 60       |          |      |   |   |          |
|   | characters)**:**             |          |      |   |   |          |
|   |                              |          |      |   |   |          |
|   |                              |          |      |   |   |          |
+---+------------------------------+----------+------+---+---+----------+
|   |                              |          |      |   |   |          |
+---+------------------------------+----------+------+---+---+----------+
|   |                              |          |      |   |   |          |
+---+------------------------------+----------+------+---+---+----------+
| * | **State License Number** (16 |          |      | * |   |          |
| * | characters)**:**             |          |      | * | N |          |
| 4 |                              |          |      | O | o |          |
| . |                              |          |      | R | L |          |
| * |                              |          |      | * | i |          |
| * |                              |          |      | * | c |          |
|   |                              |          |      |   | e |          |
|   |                              |          |      |   | n |          |
|   |                              |          |      |   | s |          |
|   |                              |          |      |   | e |          |
+---+------------------------------+----------+------+---+---+----------+
|   | **State of Licensure**       |          |      |   |   |          |
|   | (Choose State code from List |          |      |   |   |          |
|   | A-1):                        |          |      |   |   |          |
+---+------------------------------+----------+------+---+---+----------+
|   | **Occupation/Field of        |          |      |   |   |          |
|   | Licensure** (Choose one      |          |      |   |   |          |
|   | three-digit code from List   |          |      |   |   |          |
|   | B):                          |          |      |   |   |          |
+---+------------------------------+----------+------+---+---+----------+
|   | **Description** (Only        |          |      |   |   |          |
|   | complete for                 |          |      |   |   |          |
|   | Occupation/Field of          |          |      |   |   |          |
|   | Licensure Code 699; 60       |          |      |   |   |          |
|   | characters)**:**             |          |      |   |   |          |
|   |                              |          |      |   |   |          |
|   |                              |          |      |   |   |          |
+---+------------------------------+----------+------+---+---+----------+
|   |                              |          |      |   |   |          |
+---+------------------------------+----------+------+---+---+----------+
|   |                              |          |      |   |   |          |
+---+------------------------------+----------+------+---+---+----------+
| * | **State License Number** (16 |          |      | * |   |          |
| * | characters)**:**             |          |      | * | N |          |
| 5 |                              |          |      | O | o |          |
| . |                              |          |      | R | L |          |
| * |                              |          |      | * | i |          |
| * |                              |          |      | * | c |          |
|   |                              |          |      |   | e |          |
|   |                              |          |      |   | n |          |
|   |                              |          |      |   | s |          |
|   |                              |          |      |   | e |          |
+---+------------------------------+----------+------+---+---+----------+
|   | **State of Licensure**       |          |      |   |   |          |
|   | (Choose State code from List |          |      |   |   |          |
|   | A-1):                        |          |      |   |   |          |
+---+------------------------------+----------+------+---+---+----------+
|   | **Occupation/Field of        |          |      |   |   |          |
|   | Licensure** (Choose one      |          |      |   |   |          |
|   | three-digit code from List   |          |      |   |   |          |
|   | B):                          |          |      |   |   |          |
+---+------------------------------+----------+------+---+---+----------+
|   | **Description** (Only        |          |      |   |   |          |
|   | complete for                 |          |      |   |   |          |
|   | Occupation/Field of          |          |      |   |   |          |
|   | Licensure Code 699; 60       |          |      |   |   |          |
|   | characters)**:**             |          |      |   |   |          |
|   |                              |          |      |   |   |          |
|   |                              |          |      |   |   |          |
+---+------------------------------+----------+------+---+---+----------+
|   |                              |          |      |   |   |          |
+---+------------------------------+----------+------+---+---+----------+
|   |                              |          |      |   |   |          |
+---+------------------------------+----------+------+---+---+----------+
| * | **State License Number** (16 |          |      | * |   |          |
| * | characters)**:**             |          |      | * | N |          |
| 6 |                              |          |      | O | o |          |
| . |                              |          |      | R | L |          |
| * |                              |          |      | * | i |          |
| * |                              |          |      | * | c |          |
|   |                              |          |      |   | e |          |
|   |                              |          |      |   | n |          |
|   |                              |          |      |   | s |          |
|   |                              |          |      |   | e |          |
+---+------------------------------+----------+------+---+---+----------+
|   | **State of Licensure**       |          |      |   |   |          |
|   | (Choose State code from List |          |      |   |   |          |
|   | A-1):                        |          |      |   |   |          |
+---+------------------------------+----------+------+---+---+----------+
|   | **Occupation/Field of        |          |      |   |   |          |
|   | Licensure** (Choose one      |          |      |   |   |          |
|   | three-digit code from List   |          |      |   |   |          |
|   | B):                          |          |      |   |   |          |
+---+------------------------------+----------+------+---+---+----------+
|   | **Description** (Only        |          |      |   |   |          |
|   | complete for                 |          |      |   |   |          |
|   | Occupation/Field of          |          |      |   |   |          |
|   | Licensure Code 699; 60       |          |      |   |   |          |
|   | characters)**:**             |          |      |   |   |          |
|   |                              |          |      |   |   |          |
|   |                              |          |      |   |   |          |
+---+------------------------------+----------+------+---+---+----------+
|   |                              |          |      |   |   |          |
+---+------------------------------+----------+------+---+---+----------+
|   |                              |          |      |   |   |          |
+---+------------------------------+----------+------+---+---+----------+
| * | **State License Number** (16 |          |      | * |   |          |
| * | characters)**:**             |          |      | * | N |          |
| 7 |                              |          |      | O | o |          |
| . |                              |          |      | R | L |          |
| * |                              |          |      | * | i |          |
| * |                              |          |      | * | c |          |
|   |                              |          |      |   | e |          |
|   |                              |          |      |   | n |          |
|   |                              |          |      |   | s |          |
|   |                              |          |      |   | e |          |
+---+------------------------------+----------+------+---+---+----------+
|   | **State of Licensure**       |          |      |   |   |          |
|   | (Choose State code from List |          |      |   |   |          |
|   | A-1):                        |          |      |   |   |          |
+---+------------------------------+----------+------+---+---+----------+
|   | **Occupation/Field of        |          |      |   |   |          |
|   | Licensure** (Choose one      |          |      |   |   |          |
|   | three-digit code from List   |          |      |   |   |          |
|   | B):                          |          |      |   |   |          |
+---+------------------------------+----------+------+---+---+----------+
|   | **Description** (Only        |          |      |   |   |          |
|   | complete for                 |          |      |   |   |          |
|   | Occupation/Field of          |          |      |   |   |          |
|   | Licensure Code 699; 60       |          |      |   |   |          |
|   | characters)**:**             |          |      |   |   |          |
|   |                              |          |      |   |   |          |
|   |                              |          |      |   |   |          |
+---+------------------------------+----------+------+---+---+----------+
|   |                              |          |      |   |   |          |
+---+------------------------------+----------+------+---+---+----------+
|   |                              |          |      |   |   |          |
+---+------------------------------+----------+------+---+---+----------+
| * | **State License Number** (16 |          |      | * |   |          |
| * | characters)**:**             |          |      | * | N |          |
| 8 |                              |          |      | O | o |          |
| . |                              |          |      | R | L |          |
| * |                              |          |      | * | i |          |
| * |                              |          |      | * | c |          |
|   |                              |          |      |   | e |          |
|   |                              |          |      |   | n |          |
|   |                              |          |      |   | s |          |
|   |                              |          |      |   | e |          |
+---+------------------------------+----------+------+---+---+----------+
|   | **State of Licensure**       |          |      |   |   |          |
|   | (Choose State code from List |          |      |   |   |          |
|   | A-1):                        |          |      |   |   |          |
+---+------------------------------+----------+------+---+---+----------+
|   | **Occupation/Field of        |          |      |   |   |          |
|   | Licensure** (Choose one      |          |      |   |   |          |
|   | three-digit code from List   |          |      |   |   |          |
|   | B):                          |          |      |   |   |          |
+---+------------------------------+----------+------+---+---+----------+
|   | **Description** (Only        |          |      |   |   |          |
|   | complete for                 |          |      |   |   |          |
|   | Occupation/Field of          |          |      |   |   |          |
|   | Licensure Code 699; 60       |          |      |   |   |          |
|   | characters)**:**             |          |      |   |   |          |
|   |                              |          |      |   |   |          |
|   |                              |          |      |   |   |          |
+---+------------------------------+----------+------+---+---+----------+
|   |                              |          |      |   |   |          |
+---+------------------------------+----------+------+---+---+----------+
|   |                              |          |      |   |   |          |
+---+------------------------------+----------+------+---+---+----------+
| * | **State License Number** (16 |          |      | * |   |          |
| * | characters)**:**             |          |      | * | N |          |
| 9 |                              |          |      | O | o |          |
| . |                              |          |      | R | L |          |
| * |                              |          |      | * | i |          |
| * |                              |          |      | * | c |          |
|   |                              |          |      |   | e |          |
|   |                              |          |      |   | n |          |
|   |                              |          |      |   | s |          |
|   |                              |          |      |   | e |          |
+---+------------------------------+----------+------+---+---+----------+
|   | **State of Licensure**       |          |      |   |   |          |
|   | (Choose State code from List |          |      |   |   |          |
|   | A-1):                        |          |      |   |   |          |
+---+------------------------------+----------+------+---+---+----------+
|   | **Occupation/Field of        |          |      |   |   |          |
|   | Licensure** (Choose one      |          |      |   |   |          |
|   | three-digit code from List   |          |      |   |   |          |
|   | B):                          |          |      |   |   |          |
+---+------------------------------+----------+------+---+---+----------+
|   | **Description** (Only        |          |      |   |   |          |
|   | complete for                 |          |      |   |   |          |
|   | Occupation/Field of          |          |      |   |   |          |
|   | Licensure Code 699; 60       |          |      |   |   |          |
|   | characters)**:**             |          |      |   |   |          |
|   |                              |          |      |   |   |          |
|   |                              |          |      |   |   |          |
+---+------------------------------+----------+------+---+---+----------+
|   |                              |          |      |   |   |          |
+---+------------------------------+----------+------+---+---+----------+
|   |                              |          |      |   |   |          |
+---+------------------------------+----------+------+---+---+----------+
| * | **State License Number** (16 |          |      | * |   |          |
| * | characters)**:**             |          |      | * | N |          |
| 1 |                              |          |      | O | o |          |
| 0 |                              |          |      | R | L |          |
| . |                              |          |      | * | i |          |
| * |                              |          |      | * | c |          |
| * |                              |          |      |   | e |          |
|   |                              |          |      |   | n |          |
|   |                              |          |      |   | s |          |
|   |                              |          |      |   | e |          |
+---+------------------------------+----------+------+---+---+----------+
|   | **State of Licensure**       |          |      |   |   |          |
|   | (Choose State code from List |          |      |   |   |          |
|   | A-1):                        |          |      |   |   |          |
+---+------------------------------+----------+------+---+---+----------+
|   | **Occupation/Field of        |          |      |   |   |          |
|   | Licensure** (Choose one      |          |      |   |   |          |
|   | three-digit code from List   |          |      |   |   |          |
|   | B):                          |          |      |   |   |          |
+---+------------------------------+----------+------+---+---+----------+
|   | **Description** (Only        |          |      |   |   |          |
|   | complete for                 |          |      |   |   |          |
|   | Occupation/Field of          |          |      |   |   |          |
|   | Licensure Code 699; 60       |          |      |   |   |          |
|   | characters)**:**             |          |      |   |   |          |
|   |                              |          |      |   |   |          |
|   |                              |          |      |   |   |          |
+---+------------------------------+----------+------+---+---+----------+
|   |                              |          |      |   |   |          |
+---+------------------------------+----------+------+---+---+----------+

## 

  ------------------ --------------------------- -------------------- -------------------
  **Hospital                                     **City** (28         **State** (Choose
  Affiliation(s)**                               characters)          State code from
  (40 characters)                                                     List A-1)

  **1.**                                                                

  **2.**                                                                

  **3.**                                                                

  **4.**                                                                

  **5.**                                                                
  ------------------ --------------------------- -------------------- -------------------

##  

+---------------------------------+------------------------------------+
| **Payment Information**         |                                    |
+---------------------------------+------------------------------------+
| Relationship of Entity to This  |                                    |
| Practitioner (Choose one from   |                                    |
| list):                          |                                    |
|                                 |                                    |
| **Note:** A health insurance    |                                    |
| company, managed care           |                                    |
| organization, or health care    |                                    |
| entity (such as a hospital,     |                                    |
| health plan, group practice,    |                                    |
| government agency and           |                                    |
| department that provides health |                                    |
| care services) that makes a     |                                    |
| payment for a practitioner on   |                                    |
| its own staff because the       |                                    |
| company pays its own            |                                    |
| malpractice claims rather than  |                                    |
| having coverage for malpractice |                                    |
| claims under an insurance       |                                    |
| policy issued by another        |                                    |
| company should report as a      |                                    |
| Self-Insured Organization. A    |                                    |
| State fund should select the    |                                    |
| code \"State Medical            |                                    |
| Malpractice Payment Fund as the |                                    |
| Primary Payer for the           |                                    |
| Practitioner\" if the fund is   |                                    |
| the payer of first resort for a |                                    |
| claim and select the code       |                                    |
| \"State Medical Malpractice     |                                    |
| Payment Fund as a Secondary     |                                    |
| Payer for the Practitioner\" if |                                    |
| the fund is the payer for any   |                                    |
| amount in excess of the primary |                                    |
| amount.                         |                                    |
+---------------------------------+------------------------------------+
| Insurance Company -- Primary    |                                    |
| Insurer                         |                                    |
|                                 |                                    |
| Insurance Company -- Excess     |                                    |
| Insurer                         |                                    |
|                                 |                                    |
| Self-Insured Organization       |                                    |
|                                 |                                    |
| Insurance Guaranty Fund         |                                    |
|                                 |                                    |
| State Medical Malpractice       |                                    |
| Payment Fund as the Primary     |                                    |
| Payer for This Practitioner     |                                    |
|                                 |                                    |
| State Medical Malpractice       |                                    |
| Payment Fund as a Secondary     |                                    |
| Payer for This Practitioner     |                                    |
+---------------------------------+------------------------------------+

## 

+---------------------+---------------------+----+--------------------+
| **Payments by This  |                     |    |                    |
| Payer for This      |                     |    |                    |
| Practitioner**      |                     |    |                    |
|                     |                     |    |                    |
| If you made a       |                     |    |                    |
| single payment for  |                     |    |                    |
| multiple            |                     |    |                    |
| practitioners and   |                     |    |                    |
| if the settlement   |                     |    |                    |
| agreement or        |                     |    |                    |
| judgment does not   |                     |    |                    |
| specify an amount   |                     |    |                    |
| for each            |                     |    |                    |
| practitioner, you   |                     |    |                    |
| must allocate the   |                     |    |                    |
| total payment       |                     |    |                    |
| between the         |                     |    |                    |
| practitioners and   |                     |    |                    |
| specify an amount   |                     |    |                    |
| greater than zero   |                     |    |                    |
| for this            |                     |    |                    |
| practitioner. If a  |                     |    |                    |
| settlement          |                     |    |                    |
| agreement           |                     |    |                    |
| specifically states |                     |    |                    |
| that no payment was |                     |    |                    |
| made for this       |                     |    |                    |
| practitioner, do    |                     |    |                    |
| not file this       |                     |    |                    |
| report. The total   |                     |    |                    |
| amount paid or to   |                     |    |                    |
| be paid by you for  |                     |    |                    |
| all practitioners   |                     |    |                    |
| must be specified   |                     |    |                    |
| in the appropriate  |                     |    |                    |
| field. You must     |                     |    |                    |
| file a separate     |                     |    |                    |
| report for each     |                     |    |                    |
| practitioner named  |                     |    |                    |
| in the claim and    |                     |    |                    |
| judgment or         |                     |    |                    |
| settlement unless   |                     |    |                    |
| the judgment or     |                     |    |                    |
| settlement          |                     |    |                    |
| specifically states |                     |    |                    |
| that no payment was |                     |    |                    |
| made for that       |                     |    |                    |
| practitioner.       |                     |    |                    |
+---------------------+---------------------+----+--------------------+
| Amount of This      |                     |    | \$                 |
| Payment for This    |                     |    |                    |
| Practitioner        |                     |    |                    |
|                     |                     |    |                    |
| (Format             |                     |    |                    |
| NNNNNNNNN.NN):      |                     |    |                    |
+---------------------+---------------------+----+--------------------+
| Date of This        |                     |    |                    |
| Payment (MMDDYYYY): |                     |    |                    |
+---------------------+---------------------+----+--------------------+
| Select the payment  |                     |    |                    |
| type (i.e., Single  |                     |    |                    |
| or Multiple) to     |                     |    |                    |
| indicate whether    |                     |    |                    |
| the payment         |                     |    |                    |
| specified in the    |                     |    |                    |
| Amount of This      |                     |    |                    |
| Payment field is a  |                     |    |                    |
| single final        |                     |    |                    |
| payment or is one   |                     |    |                    |
| of multiple         |                     |    |                    |
| payments to be paid |                     |    |                    |
| in series. Only the |                     |    |                    |
| first payment of a  |                     |    |                    |
| series of payments  |                     |    |                    |
| must be reported,   |                     |    |                    |
| except when a       |                     |    |                    |
| preliminary payment |                     |    |                    |
| is made before a    |                     |    |                    |
| final settlement is |                     |    |                    |
| reached.            |                     |    |                    |
|                     |                     |    |                    |
| If this payment     |                     |    |                    |
| represents a        |                     |    |                    |
| preliminary payment |                     |    |                    |
| prior to            |                     |    |                    |
| settlement:         |                     |    |                    |
|                     |                     |    |                    |
| 1.  Select One of   |                     |    |                    |
|     Multiple        |                     |    |                    |
|     Payments in     |                     |    |                    |
|     this field;     |                     |    |                    |
|     enter the       |                     |    |                    |
|     preliminary     |                     |    |                    |
|     payment amount  |                     |    |                    |
|     in both the     |                     |    |                    |
|     Amount of This  |                     |    |                    |
|     Payment for     |                     |    |                    |
|     This            |                     |    |                    |
|     Practitioner    |                     |    |                    |
|     and the Total   |                     |    |                    |
|     Amount Paid or  |                     |    |                    |
|     to be Paid by   |                     |    |                    |
|     This Payer for  |                     |    |                    |
|     This            |                     |    |                    |
|     Practitioner    |                     |    |                    |
|     fields; and     |                     |    |                    |
|                     |                     |    |                    |
| 2.  Explain the     |                     |    |                    |
|     circumstances   |                     |    |                    |
|     of the          |                     |    |                    |
|     preliminary     |                     |    |                    |
|     payment in the  |                     |    |                    |
|     Description of  |                     |    |                    |
|     the Judgment or |                     |    |                    |
|     Settlement      |                     |    |                    |
|     field.          |                     |    |                    |
|                     |                     |    |                    |
| 3.  Once the        |                     |    |                    |
|     settlement is   |                     |    |                    |
|     reached, file a |                     |    |                    |
|     Correction      |                     |    |                    |
|     Report and      |                     |    |                    |
|     provide the     |                     |    |                    |
|     revised total   |                     |    |                    |
|     amount of all   |                     |    |                    |
|     payments in the |                     |    |                    |
|     Total Amount    |                     |    |                    |
|     Paid or to be   |                     |    |                    |
|     Paid by This    |                     |    |                    |
|     Payer for This  |                     |    |                    |
|     Practitioner    |                     |    |                    |
|     field.          |                     |    |                    |
|                     |                     |    |                    |
| If this payment     |                     |    |                    |
| represents a        |                     |    |                    |
| payment made after  |                     |    |                    |
| a final settlement, |                     |    |                    |
| only the first      |                     |    |                    |
| payment of a series |                     |    |                    |
| of payments must be |                     |    |                    |
| reported. In these  |                     |    |                    |
| cases:              |                     |    |                    |
|                     |                     |    |                    |
| 1.  Report the      |                     |    |                    |
|     amount of the   |                     |    |                    |
|     first payment   |                     |    |                    |
|     in the Amount   |                     |    |                    |
|     of This Payment |                     |    |                    |
|     for This        |                     |    |                    |
|     Practitioner    |                     |    |                    |
|     field.          |                     |    |                    |
|                     |                     |    |                    |
| 2.  Complete the    |                     |    |                    |
|     Total Amount    |                     |    |                    |
|     Paid or to be   |                     |    |                    |
|     Paid by This    |                     |    |                    |
|     Payer for This  |                     |    |                    |
|     Practitioner    |                     |    |                    |
|     field,          |                     |    |                    |
|     consistent with |                     |    |                    |
|     the             |                     |    |                    |
|     instructions    |                     |    |                    |
|     below.          |                     |    |                    |
+---------------------+---------------------+----+--------------------+
| This Payment        | A Single Final      |    |                    |
| Represents:         | Payment             | O  |                    |
|                     |                     | ne |                    |
|                     |                     | of |                    |
|                     |                     | Mu |                    |
|                     |                     | lt |                    |
|                     |                     | ip |                    |
|                     |                     | le |                    |
|                     |                     | Pa |                    |
|                     |                     | ym |                    |
|                     |                     | en |                    |
|                     |                     | ts |                    |
+---------------------+---------------------+----+--------------------+

+---------------+------------+------------+------+--------------------+
| If this       |            |            |      |                    |
| report        |            |            |      |                    |
| concerns a    |            |            |      |                    |
| preliminary   |            |            |      |                    |
| payment       |            |            |      |                    |
| before a      |            |            |      |                    |
| final         |            |            |      |                    |
| settlement is |            |            |      |                    |
| reached and   |            |            |      |                    |
| the total     |            |            |      |                    |
| amount        |            |            |      |                    |
| ultimately to |            |            |      |                    |
| be paid is    |            |            |      |                    |
| unknown:      |            |            |      |                    |
|               |            |            |      |                    |
| 1.  Enter     |            |            |      |                    |
|     only the  |            |            |      |                    |
|     amount of |            |            |      |                    |
|     this      |            |            |      |                    |
|     payment;  |            |            |      |                    |
|     and       |            |            |      |                    |
|               |            |            |      |                    |
| 2.  Explain   |            |            |      |                    |
|     in the    |            |            |      |                    |
|               |            |            |      |                    |
|   Description |            |            |      |                    |
|     of the    |            |            |      |                    |
|     Judgment  |            |            |      |                    |
|     or        |            |            |      |                    |
|               |            |            |      |                    |
|    Settlement |            |            |      |                    |
|     field;    |            |            |      |                    |
|               |            |            |      |                    |
| 3.  Then,     |            |            |      |                    |
|     file a    |            |            |      |                    |
|               |            |            |      |                    |
|    Correction |            |            |      |                    |
|     Report    |            |            |      |                    |
|     once the  |            |            |      |                    |
|               |            |            |      |                    |
|    settlement |            |            |      |                    |
|     is        |            |            |      |                    |
|     reached   |            |            |      |                    |
|     and the   |            |            |      |                    |
|     total     |            |            |      |                    |
|     amount is |            |            |      |                    |
|     known.    |            |            |      |                    |
|               |            |            |      |                    |
| If this       |            |            |      |                    |
| payment       |            |            |      |                    |
| represents a  |            |            |      |                    |
| payment made  |            |            |      |                    |
| after a final |            |            |      |                    |
| settlement,   |            |            |      |                    |
| only the      |            |            |      |                    |
| first payment |            |            |      |                    |
| of a series   |            |            |      |                    |
| of payments   |            |            |      |                    |
| must be       |            |            |      |                    |
| reported. If  |            |            |      |                    |
| this payment  |            |            |      |                    |
| is part of a  |            |            |      |                    |
| structured    |            |            |      |                    |
| settlement,   |            |            |      |                    |
| report the    |            |            |      |                    |
| cost of       |            |            |      |                    |
| purchasing    |            |            |      |                    |
| the           |            |            |      |                    |
| structured    |            |            |      |                    |
| settlement    |            |            |      |                    |
| arrangement   |            |            |      |                    |
| or the        |            |            |      |                    |
| present value |            |            |      |                    |
| of the total  |            |            |      |                    |
| payments to   |            |            |      |                    |
| be made over  |            |            |      |                    |
| the lifetime  |            |            |      |                    |
| of the        |            |            |      |                    |
| obligation if |            |            |      |                    |
| a structured  |            |            |      |                    |
| settlement    |            |            |      |                    |
| arrangement   |            |            |      |                    |
| is not        |            |            |      |                    |
| purchased.    |            |            |      |                    |
+---------------+------------+------------+------+--------------------+
| Total Amount  |            |            |      | \$                 |
| Paid or to Be |            |            |      |                    |
| Paid by This  |            |            |      |                    |
| Payer for     |            |            |      |                    |
| This          |            |            |      |                    |
| Practitioner  |            |            |      |                    |
|               |            |            |      |                    |
| (Format       |            |            |      |                    |
| N             |            |            |      |                    |
| NNNNNNNN.NN): |            |            |      |                    |
+---------------+------------+------------+------+--------------------+
| Payment       | Judgment   |            |      |                    |
| Result of:    |            | Settlement | Pay  |                    |
|               |            |            | ment |                    |
|               |            |            | P    |                    |
|               |            |            | rior |                    |
|               |            |            | to   |                    |
|               |            |            | Se   |                    |
|               |            |            | ttle |                    |
|               |            |            | ment |                    |
+---------------+------------+------------+------+--------------------+
| Date of       |            |            |      |                    |
| Judgment or   |            |            |      |                    |
| Settlement,   |            |            |      |                    |
| if Any        |            |            |      |                    |
| (MMDDYYYY):   |            |            |      |                    |
+---------------+------------+------------+------+--------------------+
| Adjudicative  |            |            |      |                    |
| Body Case     |            |            |      |                    |
| Number (if    |            |            |      |                    |
| Applicable;   |            |            |      |                    |
| 20            |            |            |      |                    |
| characters):  |            |            |      |                    |
+---------------+------------+------------+------+--------------------+
| Adjudicative  |            |            |      |                    |
| Body Name (if |            |            |      |                    |
| Applicable;   |            |            |      |                    |
| 60            |            |            |      |                    |
| characters):  |            |            |      |                    |
+---------------+------------+------------+------+--------------------+
| Court File    |            |            |      |                    |
| Number (if    |            |            |      |                    |
| Applicable;   |            |            |      |                    |
| 10            |            |            |      |                    |
| characters):  |            |            |      |                    |
+---------------+------------+------------+------+--------------------+

+-----------------------------------------------------------------------+
| **Description of Judgment or Settlement and Any Conditions, Including |
| Terms of Payment** (Limit 4,000 characters including spaces and       |
| punctuation)                                                          |
|                                                                       |
| ***Note:*** Do not reference any personal identification information  |
| (e.g. names) of anyone other than the subject of this report.         |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+

## 

+-------------------------------------------------+--------------------+
| ## Payments by                                  |                    |
| This Payer for Other Practitioners in This Case |                    |
+-------------------------------------------------+--------------------+
| Total Amount Paid or to Be Paid by This Payer   | \$                 |
| for All Practitioners in This Case (Including   |                    |
| the Amount Specified Above for This             |                    |
| Practitioner; Format NNNNNNNNN.NN):             |                    |
+-------------------------------------------------+--------------------+
| Number of Practitioners for Whom This Payer Has |                    |
| Paid or Will Pay in This Case:                  |                    |
+-------------------------------------------------+--------------------+

## 

+-------------------------------------------------+--------------------+
| ## Payments by Others for This Practitioner     |                    |
+-------------------------------------------------+--------------------+
| Complete if your entity is an Insurance Company |                    |
| or a Self-Insured Organization.                 |                    |
+-------------------------------------------------+--------------------+
| Has a State Guaranty Fund or State Excess       | Yes                |
| Judgment Fund Made a Payment for This           |                    |
| Practitioner in This Case, or Is Such a Payment | No                 |
| Expected to Be Made?                            |                    |
|                                                 | Unknown            |
+-------------------------------------------------+--------------------+
| Amount Paid or Expected to Be Paid by the State | \$                 |
| Fund (Format NNNNNNNNN.NN):                     |                    |
+-------------------------------------------------+--------------------+

## 

+-------------------------------------------------+--------------------+
| Complete if your entity is an Insurance         |                    |
| Company, an Insurance Guaranty Fund or a State  |                    |
| Medical Malpractice Payment Fund.               |                    |
+-------------------------------------------------+--------------------+
| Has a Self-Insured Organization and/or Other    | Yes                |
| Insurance Company/Companies Made Payment(s) for |                    |
| This Practitioner in This Case, or Is/Are Such  | No                 |
| Payment(s) Expected to Be Made?                 |                    |
|                                                 | Unknown            |
+-------------------------------------------------+--------------------+
| Amount Paid or Expected to Be Paid by           | \$                 |
| Self-Insured Organization(s) and/or Other       |                    |
| Insurance Company/Companies (Format             |                    |
| NNNNNNNNN.NN):                                  |                    |
+-------------------------------------------------+--------------------+

## 

  ------------------ ------------ ------------- ---------- ---------- ---------- ----------------
  **Classification                                                               
  of Act(s) or                                                                   
  Omissions**                                                                    

  Patient's Age at                              Days (if                           
  Time of Initial                               less than                        
  Event (enter 0                                1 month)                         
  days if the                                                                    
  patient is a                                                                   
  fetus):                                                                        

                                                Months (if                         
                                                less than                        
                                                1 year)                          

                                                Years                               

                                                Unknown                          

  Patient's Gender:  Male         Female                   Unknown               

  Patient Type:      Inpatient    Outpatient               Both       Unknown    
  ------------------ ------------ ------------- ---------- ---------- ---------- ----------------

## 

## 

+-----------------------------------------------------------------------+
| **Description of the Medical Condition With Which the Patient         |
| Presented for Treatment (Prior to the Event That Led to the           |
| Malpractice Allegation)**                                             |
|                                                                       |
| Enter a narrative description of the actual diagnosis with which the  |
| patient presented for treatment. Do not report a misdiagnosis. If the |
| patient had more than one condition, enter the condition most         |
| applicable to the alleged acts or omissions. (Limit 4,000 characters  |
| including spaces and punctuation)                                     |
|                                                                       |
| ***Note:*** Do not reference any personal identification information  |
| (e.g. names) of anyone other than the subject of this report.         |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| **Description of the Procedure Performed**                            |
|                                                                       |
| Enter a narrative description of the treatment rendered by the        |
| insured to the patient for the initial medical condition specified in |
| this report. If more than one procedure was performed by the insured, |
| report the one that is most significant to the claims generation.     |
| (Limit 4,000 characters including spaces and punctuation)             |
|                                                                       |
| ***Note:*** Do not reference any personal identification information  |
| (e.g. names) of anyone other than the subject of this report.         |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
| **Nature of Allegation** (choose one from list)**:**                  |
+-----------------------------------------------------------------------+
| Anesthesia Related                                                    |
|                                                                       |
| Behavioral Health Related                                             |
|                                                                       |
| Diagnosis Related                                                     |
|                                                                       |
| Equipment/Product Related                                             |
|                                                                       |
| IV & Blood Products Related                                           |
|                                                                       |
| Medication Related                                                    |
|                                                                       |
| Monitoring Related                                                    |
|                                                                       |
| Obstetrics Related                                                    |
|                                                                       |
| Surgery Related                                                       |
|                                                                       |
| Treatment Related                                                     |
|                                                                       |
| Other Miscellaneous                                                   |
+-----------------------------------------------------------------------+

## 

+---+-----------------------------------------------+-----+------------+
| # |                                               |     |            |
| # |                                               |     |            |
|   |                                               |     |            |
| S |                                               |     |            |
| p |                                               |     |            |
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| o |                                               |     |            |
| n |                                               |     |            |
| c |                                               |     |            |
| e |                                               |     |            |
| a |                                               |     |            |
| n |                                               |     |            |
| d |                                               |     |            |
| o |                                               |     |            |
| n |                                               |     |            |
| d |                                               |     |            |
| i |                                               |     |            |
| f |                                               |     |            |
| f |                                               |     |            |
| e |                                               |     |            |
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| n |                                               |     |            |
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| d |                                               |     |            |
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| t |                                               |     |            |
| e |                                               |     |            |
| s |                                               |     |            |
| . |                                               |     |            |
+---+-----------------------------------------------+-----+------------+
| * | **Specific Allegation** (Choose one           |     |            |
| * | three-digit code from List C):                |     |            |
| 1 |                                               |     |            |
| . |                                               |     |            |
| * |                                               |     |            |
| * |                                               |     |            |
+---+-----------------------------------------------+-----+------------+
|   | **Description** (Only complete for Specific   |     |            |
|   | Allegation Code 999; 60 characters):          |     |            |
|   |                                               |     |            |
|   |                                               |     |            |
+---+-----------------------------------------------+-----+------------+
|   | **Date of Event Associated With Allegation or |     |            |
|   | Incident** (MMDDYYYY):                        |     |            |
+---+-----------------------------------------------+-----+------------+
|   |                                               |     |            |
+---+-----------------------------------------------+-----+------------+
| * | **Specific Allegation** (Choose one           |     |            |
| * | three-digit code from List C):                |     |            |
| 2 |                                               |     |            |
| . |                                               |     |            |
| * |                                               |     |            |
| * |                                               |     |            |
+---+-----------------------------------------------+-----+------------+
|   | **Description** (Only complete for Specific   |     |            |
|   | Allegation Code 999; 60 characters):          |     |            |
|   |                                               |     |            |
|   |                                               |     |            |
+---+-----------------------------------------------+-----+------------+
|   | **Date of Event Associated With Allegation or |     |            |
|   | Incident** (MMDDYYYY):                        |     |            |
+---+-----------------------------------------------+-----+------------+
|   |                                               |     |            |
+---+-----------------------------------------------+-----+------------+
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+---+-----------------------------------------------+-----+------------+
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+---+-----------------------------------------------+-----+------------+

## 

+-----------------------------------------------------------------------+
| **Description of the Allegations and Injuries or Illnesses Upon Which |
| the Action or Claim Was Based**                                       |
|                                                                       |
| Reporting entities must use this field to summarize the allegations   |
| of the plaintiff or claimant in demanding payment even if the         |
| reporting entity believes these allegations to be without merit.      |
| Reporters may also use this section to summarize important issues in  |
| the case and to provide, as needed, additional information not        |
| reported in the Classification of Acts or Omissions section of this   |
| report. (Limit 4,000 characters including spaces and punctuation)     |
|                                                                       |
| ***Note:*** Do not reference any personal identification information  |
| (e.g. names) of anyone other than the subject of this report.         |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+

+-------------------------------------------------------+--------------+
| **Entity Internal Report Reference**                  |              |
|                                                       |              |
| This optional field allows your entity to include an  |              |
| internal file number or other reference information   |              |
| to help you identify this report in your files. This  |              |
| information is not used by the Data Banks, but it     |              |
| will be provided on copies of the report sent to      |              |
| queriers.                                             |              |
+-------------------------------------------------------+--------------+
| Entity Internal Report Reference (e.g., claim number; |              |
| 20 characters):                                       |              |
+-------------------------------------------------------+--------------+

**List A-1**

**State Abbreviations and U.S. Territories**

+-----+----------------+-----+----------------+-----+----------------+
| AL  | Alabama        | KY  | Kentucky       | ND  | North Dakota   |
|     |                |     |                |     |                |
| AK  | Alaska         | LA  | Louisiana      | OH  | Ohio           |
|     |                |     |                |     |                |
| AZ  | Arizona        | ME  | Maine          | OK  | Oklahoma       |
|     |                |     |                |     |                |
| AR  | Arkansas       | MD  | Maryland       | OR  | Oregon         |
|     |                |     |                |     |                |
| CA  | California     | MA  | Massachusetts  | PA  | Pennsylvania   |
|     |                |     |                |     |                |
| CO  | Colorado       | MI  | Michigan       | RI  | Rhode Island   |
|     |                |     |                |     |                |
| CT  | Connecticut    | MN  | Minnesota      | SC  | South Carolina |
|     |                |     |                |     |                |
| DE  | Delaware       | MS  | Mississippi    | SD  | South Dakota   |
|     |                |     |                |     |                |
| DC  | District of    | MO  | Missouri       | TN  | Tennessee      |
|     | Columbia       |     |                |     |                |
| FL  |                | MT  | Montana        | TX  | Texas          |
|     | Florida        |     |                |     |                |
| GA  |                | NE  | Nebraska       | UT  | Utah           |
|     | Georgia        |     |                |     |                |
| HI  |                | NV  | Nevada         | VT  | Vermont        |
|     | Hawaii         |     |                |     |                |
| ID  |                | NH  | New Hampshire  | VA  | Virginia       |
|     | Idaho          |     |                |     |                |
| IL  |                | NJ  | New Jersey     | WA  | Washington     |
|     | Illinois       |     |                |     |                |
| IN  |                | NM  | New Mexico     | WV  | West Virginia  |
|     | Indiana        |     |                |     |                |
| IA  |                | NY  | New York       | WI  | Wisconsin      |
|     | Iowa           |     |                |     |                |
| KS  |                | NC  | North Carolina | WY  | Wyoming        |
|     | Kansas         |     |                |     |                |
+-----+----------------+-----+----------------+-----+----------------+
| AS  | American Samoa | GU  | Guam           | PR  | Puerto Rico    |
|     |                |     |                |     |                |
| FM  | Federated      | MP  | Northern       | VI  | Virgin Islands |
|     | States of      |     | Marianas       |     |                |
|     | Micronesia     | PW  |                |     |                |
|     |                |     | Palau          |     |                |
+-----+----------------+-----+----------------+-----+----------------+
| AA  | Central and    | AE  | Europe (Armed  | AP  | Pacific (Armed |
|     | South America  |     | Forces)        |     | Forces)        |
|     | (Armed Forces) |     |                |     |                |
+-----+----------------+-----+----------------+-----+----------------+
| Ple |                |     |                |     |                |
| ase |                |     |                |     |                |
| adh |                |     |                |     |                |
| ere |                |     |                |     |                |
| to  |                |     |                |     |                |
| the |                |     |                |     |                |
| fol |                |     |                |     |                |
| low |                |     |                |     |                |
| ing |                |     |                |     |                |
| g   |                |     |                |     |                |
| uid |                |     |                |     |                |
| eli |                |     |                |     |                |
| nes |                |     |                |     |                |
| w   |                |     |                |     |                |
| hen |                |     |                |     |                |
| en  |                |     |                |     |                |
| ter |                |     |                |     |                |
| ing |                |     |                |     |                |
| f   |                |     |                |     |                |
| ore |                |     |                |     |                |
| ign |                |     |                |     |                |
| or  |                |     |                |     |                |
| mi  |                |     |                |     |                |
| lit |                |     |                |     |                |
| ary |                |     |                |     |                |
| ad  |                |     |                |     |                |
| dre |                |     |                |     |                |
| sse |                |     |                |     |                |
| s:\ |                |     |                |     |                |
| \   |                |     |                |     |                |
| **  |                |     |                |     |                |
| Add |                |     |                |     |                |
| res |                |     |                |     |                |
| ses |                |     |                |     |                |
| for |                |     |                |     |                |
| Uni |                |     |                |     |                |
| ted |                |     |                |     |                |
| Sta |                |     |                |     |                |
| tes |                |     |                |     |                |
| Te  |                |     |                |     |                |
| rri |                |     |                |     |                |
| tor |                |     |                |     |                |
| ies |                |     |                |     |                |
| :** |                |     |                |     |                |
|     |                |     |                |     |                |
| -   |                |     |                |     |                |
|  En |                |     |                |     |                |
| ter |                |     |                |     |                |
|     |                |     |                |     |                |
|     |                |     |                |     |                |
| Ter |                |     |                |     |                |
| rit |                |     |                |     |                |
| ory |                |     |                |     |                |
|     |                |     |                |     |                |
|     |                |     |                |     |                |
| abb |                |     |                |     |                |
| rev |                |     |                |     |                |
| iat |                |     |                |     |                |
| ion |                |     |                |     |                |
|     |                |     |                |     |                |
|  in |                |     |                |     |                |
|     |                |     |                |     |                |
|     |                |     |                |     |                |
| \"S |                |     |                |     |                |
| tat |                |     |                |     |                |
| e\" |                |     |                |     |                |
|     |                |     |                |     |                |
|     |                |     |                |     |                |
| fie |                |     |                |     |                |
| ld. |                |     |                |     |                |
|     |                |     |                |     |                |
| **  |                |     |                |     |                |
| Add |                |     |                |     |                |
| res |                |     |                |     |                |
| ses |                |     |                |     |                |
| o   |                |     |                |     |                |
| uts |                |     |                |     |                |
| ide |                |     |                |     |                |
| the |                |     |                |     |                |
| Uni |                |     |                |     |                |
| ted |                |     |                |     |                |
| Sta |                |     |                |     |                |
| tes |                |     |                |     |                |
| or  |                |     |                |     |                |
| its |                |     |                |     |                |
| te  |                |     |                |     |                |
| rri |                |     |                |     |                |
| tor |                |     |                |     |                |
| ies |                |     |                |     |                |
| :** |                |     |                |     |                |
|     |                |     |                |     |                |
| -   |                |     |                |     |                |
|  Le |                |     |                |     |                |
| ave |                |     |                |     |                |
|     |                |     |                |     |                |
|     |                |     |                |     |                |
| the |                |     |                |     |                |
|     |                |     |                |     |                |
|     |                |     |                |     |                |
| \"S |                |     |                |     |                |
| tat |                |     |                |     |                |
| e\" |                |     |                |     |                |
|     |                |     |                |     |                |
|  fi |                |     |                |     |                |
| eld |                |     |                |     |                |
|     |                |     |                |     |                |
|     |                |     |                |     |                |
| bla |                |     |                |     |                |
| nk. |                |     |                |     |                |
|     |                |     |                |     |                |
| -   |                |     |                |     |                |
|  En |                |     |                |     |                |
| ter |                |     |                |     |                |
|     |                |     |                |     |                |
|     |                |     |                |     |                |
| the |                |     |                |     |                |
|     |                |     |                |     |                |
|   c |                |     |                |     |                |
| ity |                |     |                |     |                |
|     |                |     |                |     |                |
|     |                |     |                |     |                |
| and |                |     |                |     |                |
| /or |                |     |                |     |                |
|     |                |     |                |     |                |
|  pr |                |     |                |     |                |
| ovi |                |     |                |     |                |
| nce |                |     |                |     |                |
|     |                |     |                |     |                |
|  in |                |     |                |     |                |
|     |                |     |                |     |                |
|     |                |     |                |     |                |
| the |                |     |                |     |                |
|     |                |     |                |     |                |
|  \" |                |     |                |     |                |
| Cit |                |     |                |     |                |
| y\" |                |     |                |     |                |
|     |                |     |                |     |                |
|     |                |     |                |     |                |
| fie |                |     |                |     |                |
| ld. |                |     |                |     |                |
|     |                |     |                |     |                |
| -   |                |     |                |     |                |
|  En |                |     |                |     |                |
| ter |                |     |                |     |                |
|     |                |     |                |     |                |
|     |                |     |                |     |                |
| the |                |     |                |     |                |
|     |                |     |                |     |                |
|   C |                |     |                |     |                |
| oun |                |     |                |     |                |
| try |                |     |                |     |                |
|     |                |     |                |     |                |
|   C |                |     |                |     |                |
| ode |                |     |                |     |                |
|     |                |     |                |     |                |
|  in |                |     |                |     |                |
|     |                |     |                |     |                |
|     |                |     |                |     |                |
| the |                |     |                |     |                |
|     |                |     |                |     |                |
|   \ |                |     |                |     |                |
| "ZI |                |     |                |     |                |
| P\" |                |     |                |     |                |
|     |                |     |                |     |                |
|  fi |                |     |                |     |                |
| eld |                |     |                |     |                |
| s - |                |     |                |     |                |
|     |                |     |                |     |                |
|   m |                |     |                |     |                |
| axi |                |     |                |     |                |
| mum |                |     |                |     |                |
|     |                |     |                |     |                |
|   5 |                |     |                |     |                |
|     |                |     |                |     |                |
|   c |                |     |                |     |                |
| har |                |     |                |     |                |
| act |                |     |                |     |                |
| ers |                |     |                |     |                |
|     |                |     |                |     |                |
|  in |                |     |                |     |                |
|     |                |     |                |     |                |
|  fi |                |     |                |     |                |
| rst |                |     |                |     |                |
|     |                |     |                |     |                |
|     |                |     |                |     |                |
| fie |                |     |                |     |                |
| ld, |                |     |                |     |                |
|     |                |     |                |     |                |
|   m |                |     |                |     |                |
| axi |                |     |                |     |                |
| mum |                |     |                |     |                |
|     |                |     |                |     |                |
|   4 |                |     |                |     |                |
|     |                |     |                |     |                |
|   c |                |     |                |     |                |
| har |                |     |                |     |                |
| act |                |     |                |     |                |
| ers |                |     |                |     |                |
|     |                |     |                |     |                |
|  in |                |     |                |     |                |
|     |                |     |                |     |                |
|     |                |     |                |     |                |
| the |                |     |                |     |                |
|     |                |     |                |     |                |
|     |                |     |                |     |                |
| sec |                |     |                |     |                |
| ond |                |     |                |     |                |
|     |                |     |                |     |                |
|     |                |     |                |     |                |
| fie |                |     |                |     |                |
| ld. |                |     |                |     |                |
|     |                |     |                |     |                |
| -   |                |     |                |     |                |
|  En |                |     |                |     |                |
| ter |                |     |                |     |                |
|     |                |     |                |     |                |
|     |                |     |                |     |                |
| the |                |     |                |     |                |
|     |                |     |                |     |                |
|   c |                |     |                |     |                |
| oun |                |     |                |     |                |
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|  or |                |     |                |     |                |
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|     |                |     |                |     |                |
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|     |                |     |                |     |                |
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| ope |                |     |                |     |                |
|     |                |     |                |     |                |
|     |                |     |                |     |                |
| (Ar |                |     |                |     |                |
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|     |                |     |                |     |                |
|   F |                |     |                |     |                |
| orc |                |     |                |     |                |
| es) |                |     |                |     |                |
|     |                |     |                |     |                |
| -   |                |     |                |     |                |
|  AP |                |     |                |     |                |
|     |                |     |                |     |                |
|   P |                |     |                |     |                |
| aci |                |     |                |     |                |
| fic |                |     |                |     |                |
|     |                |     |                |     |                |
|     |                |     |                |     |                |
| (Ar |                |     |                |     |                |
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+-----+----------------+-----+----------------+-----+----------------+

**List A-2**

**APO/FPO Postal Codes**\*

+-------+---------+--------------+---------+----------+---------------+
| AP    | First 3 | Geographic   | APO/FPO | First 3  | Geographic    |
| O/FPO | digits  | Area         |         | digits   | Area          |
|       | of ZIP  |              | Code    | of ZIP   |               |
| Code  | Code    |              |         | Code     |               |
+-------+---------+--------------+---------+----------+---------------+
| *     | 090-092 | Germany      | **AA -- | 340      | Central,      |
| *AE - |         |              | Ame     |          | South         |
| Eur   |         |              | ricas** |          | Americas      |
| ope** |         |              |         |          |               |
+-------+---------+--------------+---------+----------+---------------+
|       | 094     | United       |         |          |               |
|       |         | Kingdom      |         |          |               |
+-------+---------+--------------+---------+----------+---------------+
|       | 095     | Atlantic     | **AP -- | 962      | Korea         |
|       |         | Ocean/       | Pa      |          |               |
|       |         | M            | cific** | 963      | Japan         |
|       |         | editerranean |         |          |               |
|       |         | Sea Ships    |         |          |               |
+-------+---------+--------------+---------+----------+---------------+
|       | 096     | Italy, Spain |         | 964      | Philippines   |
+-------+---------+--------------+---------+----------+---------------+
|       | 097     | Other Europe |         | 965      | Other Pacific |
|       |         |              |         |          | and Alaska    |
+-------+---------+--------------+---------+----------+---------------+
|       | 098     | Middle East, |         | 966      | Pacific and   |
|       |         | Africa       |         |          | Indian Ocean  |
|       |         |              |         |          | Ships         |
+-------+---------+--------------+---------+----------+---------------+

\* APO/FPO Codes (State Codes) are not valid for State of Licensure.
Refer to List A-1.

**List B**

**Occupation/Field of Licensure Codes**

+------------------------+---------------------+-----------------------+
| **603 Chiropractor**   | **Pharmacy Service  | **Technologist**      |
|                        | Provider**          |                       |
| **Counselor**          |                     | 500 Medical           |
|                        | 050 Pharmacist      | Technologist          |
| 621 Counselor, Mental  |                     |                       |
| Health                 | 055 Pharmacy Intern | 505 Cytotechnologist  |
|                        |                     |                       |
| 651 Professional       | 060 Pharmacist,     | 510 Nuclear Medicine  |
| Counselor              | Nuclear             | Technologist          |
|                        |                     |                       |
| 654 Professional       | 070 Pharmacy        | 520 Radiation Therapy |
| Counselor, Alcohol     | Assistant           | Technologist          |
|                        |                     |                       |
| 657 Professional       | 075 Pharmacy        | 530 Radiologic        |
| Counselor,             | Technician          | Technologist          |
|                        |                     |                       |
| Family/Marriage        | **Physician**       | **Other Health Care   |
|                        |                     | Practitioner**        |
| 660. Professional      | 010 Physician (MD)  |                       |
|      Counselor,        |                     | 600 Acupuncturist     |
|      Substance Abuse   | 015 Physician       |                       |
|                        | Intern/Resident     | 601 Athletic Trainer  |
| 661. Marriage and      | (MD)                |                       |
|      Family Therapist  |                     | 615 Homeopath         |
|                        | 020 Osteopathic     |                       |
| **Dental Service       | Physician (DO)      | 618 Medical Assistant |
| Provider**             |                     |                       |
|                        | 025 Osteopathic     | 624 Midwife, Lay      |
| 030 Dentist            | Physician           | (Non-Nurse)           |
|                        | Intern/Resident     |                       |
| 035 Dental Resident    | (DO)                | 627 Naturopath        |
|                        |                     |                       |
| 606 Dental Assistant   | **Physician         | 639                   |
|                        | Assistant**         | Orthotics/Prosthetics |
| 609 Dental Hygienist   |                     | Fitter                |
|                        | 642 Physician       |                       |
| 612 Denturist          | Assistant,          | 647 Perfusionist      |
|                        | Allopathic          |                       |
| **Di                   |                     | 170 Psychiatric       |
| etician/Nutritionist** | 645 Physician       | Technician            |
|                        | Assistant,          |                       |
| 200 Dietician          | Osteopathic         | 699 Other Health Care |
|                        |                     | Practitioner - Not    |
| 210 Nutritionist       | **Podiatric Service | Classified, Specify,  |
|                        | Provider**          | \_\_\_\_\_\_\_\       |
| **Emergency Medical    |                     | _\_\_\_\_\_\_\_\_\_\_ |
| Technician (EMT)**     | 350 Podiatrist      |                       |
|                        |                     |                       |
| 250 EMT, Basic         | 648 Podiatric       |                       |
|                        | Assistant           |                       |
| 260 EMT,               |                     |                       |
| Cardiac/Critical Care  | ####### **          |                       |
|                        | Psychologist/Psycho |                       |
| 270 EMT, Intermediate  | logical Assistant** |                       |
|                        |                     |                       |
| 280 EMT, Paramedic     | 371. Psychologist   |                       |
|                        |                     |                       |
| **Eye and Vision       | 372. School         |                       |
| Service Provider**     |      Psychologist   |                       |
|                        |                     |                       |
| 630 Ocularist          | 373. Psychological  |                       |
|                        |      Assistant,     |                       |
| 633 Optician           |      Associate,     |                       |
|                        |      Examiner       |                       |
| 636 Optometrist        |                     |                       |
|                        | **Rehabilitative,   |                       |
| **Nurse/Advanced       | Respiratory and     |                       |
| Practice Registered    | Restorative Service |                       |
| Nurse**                | Provider**          |                       |
|                        |                     |                       |
| 100 Registered         | 402 Art/Recreation  |                       |
| (Professional) Nurse   | Therapist           |                       |
|                        |                     |                       |
| 110 Nurse Anesthetist  | 405 Massage         |                       |
|                        | Therapist           |                       |
| 120 Nurse Midwife      |                     |                       |
|                        | 410 Occupational    |                       |
| 130 Nurse Practitioner | Therapist           |                       |
|                        |                     |                       |
| 140. Licensed          | 420 Occupational    |                       |
|      Practical or      | Therapy Assistant   |                       |
|      Vocational Nurse  |                     |                       |
|                        | 430 Physical        |                       |
| 141. Clinical Nurse    | Therapist           |                       |
|      Specialist        |                     |                       |
|                        | 440 Physical        |                       |
| **Nurse Aide, Home     | Therapy Assistant   |                       |
| Health Aide and Other  |                     |                       |
| Aide**                 | 450 Rehabilitation  |                       |
|                        | Therapist           |                       |
| 148 Certified Nurse    |                     |                       |
| Aide/Certified Nursing | 663 Respiratory     |                       |
| Assistant              | Therapist           |                       |
|                        |                     |                       |
| 150 Nurses Aide        | 666 Respiratory     |                       |
|                        | Therapy Technician  |                       |
| 160 Home Health Aide   |                     |                       |
| (Homemaker)            | **300 Social        |                       |
|                        | Worker**            |                       |
| 165 Health Care        |                     |                       |
| Aide/Direct Care       | **Speech, Language  |                       |
| Worker                 | and Hearing Service |                       |
|                        | Provider**          |                       |
| 175 Certified or       |                     |                       |
| Qualified Medication   | 400 Audiologist     |                       |
| Aide                   |                     |                       |
|                        | 460 Speech/Language |                       |
|                        | Pathologist         |                       |
|                        |                     |                       |
|                        | 470 Hearing         |                       |
|                        | Aid/Hearing         |                       |
|                        | Instrument          |                       |
|                        | Specialist          |                       |
+------------------------+---------------------+-----------------------+

**List C**

**Specific Allegation Codes\***

+----------------------------------+-----------------------------------+
| **Failure to Take Appropriate    | 328 Wrong Medication Dispensed    |
| Action**                         |                                   |
|                                  | 329 Wrong Medication Ordered      |
| 100 Failure to Use Aseptic       |                                   |
| Technique                        | 330 Wrong Body Part               |
|                                  |                                   |
| 101 Failure to Diagnose (i.e.,   | 331 Wrong Blood Type              |
| Concluding That Patient Has No   |                                   |
|                                  | 332 Wrong Equipment               |
| Disease or Condition Worthy of   |                                   |
| Follow-Up or Observation)        | 333 Wrong Patient                 |
|                                  |                                   |
| 102 Failure to Delay a Case When | 334 Wrong Procedure or Treatment  |
| Indicated                        |                                   |
|                                  | **Unnecessary/Contraindicated     |
| 103 Failure to Identify Fetal    | Procedure**                       |
| Distress                         |                                   |
|                                  | 400 Contraindicated Procedure     |
| 104 Failure to Treat Fetal       |                                   |
| Distress                         | 401 Surgical or Procedural        |
|                                  | Clearance Contraindicated         |
| 105 Failure to Medicate          |                                   |
|                                  | 402 Unnecessary Procedure         |
| 106 Failure to Monitor           |                                   |
|                                  | 403 Unnecessary Test              |
| 107 Failure to Order Appropriate |                                   |
| Medication                       | 404 Unnecessary Treatment         |
|                                  |                                   |
| 108 Failure to Order Appropriate | **Communication/Supervision**     |
| Test                             |                                   |
|                                  | 500 Communication Problem Between |
| 109 Failure to Perform           | Practitioners                     |
| Preoperative Evaluation          |                                   |
|                                  | 501 Failure to Instruct or        |
| 110 Failure to Perform Procedure | Communicate with Patient or       |
|                                  | Family                            |
| 111 Failure to Perform           |                                   |
| Resuscitation                    | 502 Failure to Report on Patient  |
|                                  | Condition                         |
| 112 Failure to Recognize a       |                                   |
| Complication                     | 503 Failure to Respond to Patient |
|                                  |                                   |
| 113 Failure to Treat             | 504 Failure to Supervise          |
|                                  |                                   |
| **Delay In Performance**         | 505 Improper Supervision          |
|                                  |                                   |
| 200 Delay in Diagnosis           | **Continuity of Care/Care         |
|                                  | Management**                      |
| 201 Delay in Performance         |                                   |
|                                  | 600 Failure/Delay in Admission to |
| 202 Delay in Treatment           | Hospital or Institution           |
|                                  |                                   |
| 203 Delay in Treatment of        | 601 Failure/Delay in Referral or  |
| Identified Fetal Distress        | Consultation                      |
| **Error/Improper Performance**   |                                   |
|                                  | 602 Premature Discharge from      |
| 300 Administration of Blood or   | Institution                       |
| Fluids Problem                   |                                   |
|                                  | 603 Altered, Misplaced or         |
| 301 Agent Use or Selection Error | Prematurely Destroyed Records     |
|                                  |                                   |
| 302 Complementary or Alternative | **Behavior/Legal**                |
| Medication Problem               |                                   |
|                                  | 700 Abandonment                   |
| 303 Equipment Utilization        |                                   |
| Problem                          | 701 Assault and Battery           |
|                                  |                                   |
| 304 Improper Choice of Delivery  | 702 Breach of Contract or         |
| Method                           | Warranty                          |
|                                  |                                   |
| 305 Improper Management          | 703 Breach of Patient             |
|                                  | Confidentiality                   |
| 306 Improper Performance         |                                   |
|                                  | 704 Equipment Malfunction         |
| 307 Improperly Performed         |                                   |
| C-Section                        | 705 Failure to Conform with       |
|                                  | Regulation, Statute, or Rule      |
| 308 Improperly Performed Vaginal |                                   |
| Delivery                         | 706 Failure to Ensure Patient     |
|                                  | Safety (e.g., from Assault,       |
| 309 Improperly Performed         | Falls,                            |
| Resuscitation                    |                                   |
|                                  | Burns, Elopement, etc.)           |
| 310 Improperly Performed Test    |                                   |
|                                  | 707 Failure to Obtain Consent or  |
| 311 Improper Technique           | Lack of Informed Consent          |
|                                  |                                   |
| 312 Intubation Problem           | 708 Failure to Protect a Third    |
|                                  | Party (e.g., Failure to Warn or   |
| 313 Laboratory Error             |                                   |
|                                  | Protect from Violence)            |
| 314 Pathology Error              |                                   |
|                                  | 709 Failure to Test Equipment     |
| 315 Medication Administered via  |                                   |
| Wrong Route                      | 710 False Imprisonment            |
|                                  |                                   |
| 316 Patient History, Exam, or    | 711 Improper Conduct              |
| Workup Problem                   |                                   |
|                                  | 712 Inadequate Utilization Review |
| 317 Problems With Patient        |                                   |
| Monitoring in Recovery           | 713 Negligent Credentialing       |
|                                  |                                   |
| 318 Patient Monitoring Problem   | 714 Practitioner with             |
|                                  | Communicable Disease              |
| 319 Patient Positioning Problem  |                                   |
|                                  | 715 Product Liability             |
| 320 Problem with Appliance,      |                                   |
| Prostheses, Orthotic,            | 716 Religious Issues              |
| Restorative,                     |                                   |
|                                  | 717 Sexual Misconduct             |
| Splint, Device, etc.             |                                   |
|                                  | 718 Third Party Claimant          |
| 321 Radiology or Imaging Error   |                                   |
|                                  | 719 Vicarious Liability           |
| 322 Surgical or Other Foreign    |                                   |
| Body Retained                    | 720 Wrongful Life/Birth           |
|                                  |                                   |
| 323 Wrong Diagnosis or           | **899 Cannot Be Determined from   |
| Misdiagnosis (e.g., Original     | Available Records**               |
| Diagnosis                        |                                   |
|                                  | **999 Allegation -- Not Otherwise |
| is Incorrect)                    | Classified,**                     |
|                                  |                                   |
| 324 Wrong Dosage Administered    | **Specify\_\_\_\_\_\_\_\_\_\_\_\  |
|                                  | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_** |
| 325 Wrong Dosage Dispensed       |                                   |
|                                  |                                   |
| 326 Wrong Dosage Ordered of      |                                   |
| Correct Medication               |                                   |
|                                  |                                   |
| 327 Wrong Medication             |                                   |
| Administered                     |                                   |
+----------------------------------+-----------------------------------+

\* These codes were adapted from code lists developed by The Risk
Management Foundation of the Harvard Medical Institutions and the
Physician Insurers Association of America.

##