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pdfEntity: MMPR ENTITY (ATLANTA, GA) | User: user
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REPORT INPUT FORM
Medical Malpractice Payment Report
Individual Subject: Initial Report
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.
Do not print this page. A printable copy of your report submission will be provided after submission.
OMB # 0915-0126 expiration date 12/31/13
Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to
respond to, a collection of information unless it displays a currently valid OMB control number. The
OMB control number for this project is 0915-0126 (NPDB). Public reporting burden for this collection of
information is estimated to average 45 minutes to complete the forms, including the time for reviewing
instructions, searching existing data sources, and completing and reviewing the collection of
information. Send comments regarding this burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600
Fishers Lane, Room 14-22, Rockville, Maryland, 20857.
PRACTITIONER INFORMATION
Personal Information
Practitioner Name
Last Name
SMITH
First Name
JOHN
Add another name used
Is Subject Deceased?
No
Unknown
Yes
Gender
Male
Female
Unknown
Birth Date (MMDDYYYY)
Home Address/Address of Record
Street Address:
Middle Name
Suffix (Jr, III)
Address Line 2:
City:
State:
CHOOSE ONE FROM LIST
ZIP Code:
-
Country:
(if U.S., leave blank)
Work Information
here if the practitioner's work information is the same as your organization.
Check
Organization
Name:
Click
for information on filling out non-U.S. and military addresses.
Address
Street Address:
Address Line 2:
City:
State:
CHOOSE ONE FROM LIST
ZIP Code:
-
Country:
(if U.S., leave blank)
Social Security Numbers (SSN)
Add another SSN
Drug Enforcement Administration (DEA) Numbers
Add another DEA Number
Professional Schools Attended
The form will suggest schools as you type. Please choose the matching school or enter the
complete school name.
Year of
School Name:
Graduation (YYYY)
Add
another
Professional School
Occupation And State Licensure Information
(Provide at least one license. Check 'No License' if the subject does not have a State License
Number. Use the Add Additional License/Occupation button to provide more than one license.
Up to 60 licenses may be provided.)
1. State License
Number:
State of Licensure:
OR
CHOOSE ONE FROM LIST
No License
Occupation/Field of
Physician (MD)
Licensure:
Add Additional License/Occupation
Hospital Affiliation(s)
Name
City
State
CHOOSE ONE FROM LIST
Add another Hospital Affiliate
Payments by This Payer for This Practitioner
Amount of This Payment for This
Practitioner:
$
(Format NNNNN.NN)
Date of This Payment:
(MMDDYYYY)
This Payment Represents:
A Single Final Payment
One of Multiple Payments
Total Amount Paid or to Be Paid by This
Payer for This Practitioner:
$
(Format NNNNN.NN)
Payment Result of:
Judgment
Settlement
Payment Prior to Settlement
Date of Judgment or Settlement:
If any (MMDDYYYY)
Adjudicative Body Case Number:
(If applicable)
Adjudicative Body Name:
(If applicable)
Court File Number:
(If applicable)
Description of Judgment or Settlement and Any Conditions, Including Terms of Payment
Note: Do not reference any personal identification information (e.g., names) of anyone other
than the subject of this report.
There are 4000 characters remaining for the description.
Spell Check
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: $
(Format NNNNN.NN)
(Including the Amount Specified Above for
This Practitioner)
Number of Practitioners for Whom This
Payer Has Paid or Will Pay in This Case:
Payment Information
Relationship of
Entity to This
Practitioner:
CHOOSE ONE FROM LIST
Classification of Act(s) or Omission(s)
Patient Information
Patient's Age at Time of Initial Event:
Days (if less than 1 month)
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)
Note: Do not reference any personal identification information (e.g.,
names) of anyone other than the subject of this report.
There are 4000 characters remaining for the description.
Spell Check
Description of the Procedure Performed
Note: Do not reference any personal identification information (e.g., names) of anyone other
than the subject of this report.
There are 4000 characters remaining for the description.
Spell Check
Allegation
Nature of Allegation:
CHOOSE ONE FROM LIST
Specific Allegation:
CHOOSE ONE FROM LIST
Date of Event Associated With
Allegation or Incident:
(MMDDYYYY)
Add another Allegation
Outcome
Outcome:
CHOOSE ONE FROM LIST
Description of the Allegations and Injuries or Illnesses Upon Which the Action or Claim Was
Based
Note: Do not reference any personal identification information (e.g., names) of anyone other
than the subject of this report.
There are 4000 characters remaining for the description.
Spell Check
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 Bank, but it will be provided on copies of the report sent to queriers.
Entity Internal Report
Reference:
(e.g., claim number)
Customer Use
This optional field may be used by the submitter to identify this transaction. This information is
returned without modification and only appears on the response returned to your organization.
Customer Use:
Send e-mail notification when this and any future responses are available.
Check this box if you wish to add/update this subject in your subject database for
use in future queries and/or reports. Duplicate entries in your subject database may
result in duplicate queries. You will be notified of potential duplicate entries prior to
completing this subject entry.
Continue
Validate Without Submitting
Store as a Draft
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Entity: MAG MUTUAL INSURANCE COMPANY (ATLANTA, GA) | User: user
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REPORT INPUT FORM
Medical Malpractice Payment Report
Report Correction
To submit a correction to previously submitted report DCN 7930000076906092, complete all
necessary modifications in the form below, and press Submit to Data Bank.
The report entered here will replace the original report, so please ensure that all known data is entered
in its entirety. Failure to provide sufficient information to permit identification of a single subject may
result in the report being rejected, necessitating resubmission.
Do not print this page. A printable copy of your report submission will be provided after submission.
OMB # 0915-0126 expiration date 12/31/13
Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to
respond to, a collection of information unless it displays a currently valid OMB control number. The
OMB control number for this project is 0915-0126 (NPDB). Public reporting burden for this collection of
information is estimated to average 15 minutes to complete the forms, including the time for reviewing
instructions, searching existing data sources, and completing and reviewing the collection of
information. Send comments regarding this burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600
Fishers Lane, Room 14-22, Rockville, Maryland, 20857.
PRACTITIONER INFORMATION
Personal Information
Practitioner Name
Last Name
SMITH
First Name
JOHN
Add another name used
Is Subject Deceased?
No
Unknown
Yes
Gender
Male
Female
Unknown
Birth Date (MMDDYYYY)
05051950
Home Address/Address of Record
Middle Name
Suffix (Jr, III)
Street Address:
123 FAKE STREET
Address Line 2:
City:
FAIRFAX
State:
VA Virginia
ZIP Code:
20120
-
Country:
(if U.S., leave blank)
Work Information
Check here if the practitioner's work information is the same as your organization.
Organization
Name:
Click
for information on filling out non-U.S. and military addresses.
Address
Street Address:
Address Line 2:
City:
State:
CHOOSE ONE FROM LIST
ZIP Code:
-
Country:
(if U.S., leave blank)
Social Security Numbers (SSN)
*****1234
Add another SSN
Edit
Drug Enforcement Administration (DEA) Numbers
Add another DEA Number
Professional Schools Attended
The form will suggest schools as you type. Please choose the matching school or enter the
complete school name.
COLLEGE UNIVERSITY
2000
Year of
Graduation (YYYY)
School Name:
Add
another
Professional School
Occupation And State Licensure Information
(Provide at least one license. Check 'No License' if the subject does not have a State License
Number. Use the Add Additional License/Occupation button to provide more than one license.
Up to 60 licenses may be provided.)
1. State License
Number:
State of Licensure:
123 ABC
OR
AK Alaska
No License
Occupation/Field of
Physician (MD)
Licensure:
Add Additional License/Occupation
Hospital Affiliation(s)
Name
City
State
CHOOSE ONE FROM LIST
Add another Hospital Affiliate
Payments by This Payer for This Practitioner
Amount of This Payment for This
Practitioner:
$ 500.00
(Format NNNNN.NN)
Date of This Payment:
(MMDDYYYY)
02022013
This Payment Represents:
A Single Final Payment
One of Multiple Payments
Total Amount Paid or to Be Paid by This
Payer for This Practitioner:
$ 500.00
(Format NNNNN.NN)
Payment Result of:
Judgment
Settlement
Payment Prior to Settlement
Date of Judgment or Settlement:
If any (MMDDYYYY)
Adjudicative Body Case Number:
(If applicable)
Adjudicative Body Name:
02022013
(If applicable)
Court File Number:
(If applicable)
Description of Judgment or Settlement and Any Conditions, Including Terms of Payment
Note: Do not reference any personal identification information (e.g., names) of anyone other
than the subject of this report.
DESCRIPTION
There are 3989 characters remaining for the description.
Spell Check
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: $
(Format NNNNN.NN)
(Including the Amount Specified Above for
This Practitioner)
Number of Practitioners for Whom This
Payer Has Paid or Will Pay in This Case:
Payment Information
Relationship of
Entity to This
Practitioner:
Insurance Company - Primary Insurer
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 Judgment Fund Made a Payment for This Practitioner in
This Case, or Is Such a Payment Expected to Be Made?:
Yes
No
Unknown
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 Insurance
Company/Companies Made Payment(s) for This Practitioner in This Case, or Is/Are Such
Payment(s) Expected to Be Made?:
Yes
No
Unknown
Classification of Act(s) or Omission(s)
Patient Information
Patient's Age at Time of Initial Event:
Days (if less than 1 month)
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)
Note: Do not reference any personal identification information (e.g.,
names) of anyone other than the subject of this report.
DESCRIPTION OF THE MEDICAL CONDITION
There are 3964 characters remaining for the description.
Spell Check
Description of the Procedure Performed
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
There are 3962 characters remaining for the description.
Spell Check
Allegation
Nature of Allegation:
Specific Allegation:
010 Anesthesia Related
100 Failure to Use Aseptic Technique
Date of Event Associated With
Allegation or Incident:
01012013
(MMDDYYYY)
Add another Allegation
Outcome
Outcome:
01 Emotional injury only
Description of the Allegations and Injuries or Illnesses Upon Which the Action or Claim Was
Based
Note: Do not reference any personal identification information (e.g., names) of anyone other
than the subject of this report.
DESCRIPTION OF THE ALLEGATIONS AND INJURIES OR ILLNESSES
UPON WHICH THE ACTION OR CLAIM WAS BASED
There are 3903 characters remaining for the description.
Spell Check
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 Bank, but it will be provided on copies of the report sent to queriers.
Entity Internal Report
Reference:
(e.g., claim number)
Customer Use
This optional field may be used by the submitter to identify this transaction. This information is
returned without modification and only appears on the response returned to your organization.
Customer Use:
Send e-mail notification when this and any future responses are available.
Continue
Validate Without Submitting
Store as a Draft
Return to Options
| File Type | application/pdf |
| Author | hannonn |
| File Modified | 2013-03-22 |
| File Created | 2013-03-22 |