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CIPS Team Member Reporting

CIPS Team Member Report

Important Notice about HIPPA and PHI


This form is for use by CSEMS Critical Incident Provider Support Team members only. Please complete one form for each intervention made.

This website is not compliant with the Health Insurance Portability and Accountability Act (HIPAA). Therefore, please do not submit Protected health information (PHI) in this form. PHI under US law is any information about health status, provision of health care, or payment for health care that is created or collected by a "Covered Entity" (or a Business Associate of a Covered Entity), and can be linked to a specific individual. This is interpreted rather broadly and includes any part of a patient's medical record or payment history.
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Location of Intervention
City
State/Province
Zip/Postal

Number of Responders Present

Submitted By

Certification Statement

Sending