Critical Incident Report Form


  1. At onset of an incident, notify your supervisor; your supervisor will need to confirm with Dr. Craig Pierce, at (505) 604-4589, to determine if a situation is considered “Critical.”
  2. If confirmed to be a Critical Incident, you must report the incident within 24 HOURS to the appropriate persons and agencies. If you need further assistance, please contact Raana Azad at (505) 205-5641.
  3. First verify if your client has one of the following valid Codes of Eligibility (COE) in the NM-HSD Medicaid Portal: 001, 003, 004, 081, 083, 084, 090, 093, 094, 095, 100w/NFLOC, 200w/NFLOC, only 1/10 SWFGC clients.
  4. If YES, you will report the critical incident to the following website:; using SWFGC username and password, submit report online and store the confirmation number provided to you on the NM-HSD site
  5. If NO, which is true for 90% of our clients, follow the instructions below:
    1. Verify the client’s funding source or the correct MCO.
    2. DOWNLOAD AND COMPLETE FORM using Internet Explore or use this link CIR Form (Sept 2018)
      1. Right-click on the above link to the document
      2. Select “Save Target As” or “Save Link As”
      3. Save the document to your hard drive
      4. Open with Acrobat Reader
  6. After CIR Form is completed and reviewed by supervisor, fax to the appropriate Managed Care Organization (MCO), and all other entities involved that are listed on this HSD Form.


    ACS-Medicaid (505) 827-3126
    Presbyterian Healthcare/Magellan (505) 843-3011
    Blue Cross Blue Shield (BCBS) (972) 766-3320
    Western Sky/ Centene TBD
    United Healthcare (866) 751-2449
    Optum Healthcare (Non-Medicaid) (877) 950-9545
    Molina Healthcare (855) 260-8737
  7. Upload electronic copy of the completed CIR into client’s electronic health record (i.e., Welligent), and print a copy and file into client’s chart.
  8. Submit electronic copy of the completed CIR to Lori Tseng, Quality Assurance Manager, at