AGOCRIMES Case Management System

OFFICE OF THE ATTORNEY GENERALMEDICAID FRAUD CONTROL UNIT

Eform Web Submission

SUBMITTING The INforMaTIoN We Need

| WebForm Submission

http://www.agjimhood.com/eformclient/eformintake.aspxWebForm Submission

What is an Eform?An Eform is a secure web based form that submits data directly to the AGO CRIMES Case Man-agement System. The submission once saved will allow you to print what you have submitted via a Pop-Up window and/or in addition, if you so choose, will independently send you an e-mail with the data you submitted for your records which you may also print independently of the pop-up.

Will I still need to call?The Mississippi Vulnerable Adults Act still requires that you notify our office within 24 hours by telephone and 7 hours by written report. The form we would complete with you on the phone is now available to you online. If you complete the form and then call we can review the report much faster and assure the information is captured accurately as you have reported it. Should we review the form before you make telephone contact we would call you back should there be a need for clarification.

How will I know you received the submission?Once you submit the form, the page will refresh, you will then receive a message at the top left of the window indicating that the form was saved successfully. As indicated above you will get a pop-up and a return e-mail. These will also return what is called a Record ID Number or a refer-ence number. This number will uniquely identify the form you submitted. If you contact us by phone, mail or fax and identify either yourself or the documents forwarded with this Record ID number we can quickly reference your submission or place the documents in the correct file. This ID number is only issued once the record has been received.

What do I need to have in order to submit online?The form was designed to be used with Internet Explorer. So all you need is you browser, an Internet Connection and a few minutes to type your information. The form is best used if your screen resolution is set to 1024X768 or 1280X720.

http://www.agjimhood.com/eformclient/eformintake.aspx

AGO CRIMES Case Management |

http://www.agjimhood.com/eformclient/eformintake.aspxWebForm Submission

Who can I call if I need help?If you need assistance of any kind or just have a few questions please feel free to contact Randolph Brown at 601-359-4212. If he is unavailable to take your call at that moment leave a message. His voice mail will contact him even if he is away from his desk at which point he will return your call as quickly as possible.

http://www.agjimhood.com/eformclient/eformintake.aspx

http://www.agjimhood.com/eformclient/eformintake.aspxhttp://www.agjimhood.com/eformclient/eformintake.aspx

4 | WebForm Submission

INSTRUCTIONSWebForm Submission

1.

2.Complainant Information

Complete the General Section paying close attention to the fields with the dotted green line. The dotted green line fields are required to have data in order for the Eform to save success-

fully. The first field is the County in which the incident took place. Moving to the left the next field asks if you have reported this to the Department of Health - Licensure and Certification (DLC). Select the appropriate radial button. The next Yes/No data field (Resident on Resident) radial button is to be selected if the incident was be-tween two or more residents/patients of the facility, as opposed to staff on resident. The Date of Incident field is not required since sometimes this date is unknown. If you do know the date please insert it. The Photo field is actually a question we use internally. We would normally mark this if we were talking to the complainant. Since you are completing the Eform select Yes if you have taken a photo of an injury or leave it blank if you believe this field to be not applicable. Finally, we have the narrative field. This data field can hold up to 10,000 characters. We would ask that you type a good description of the events in the best manner utilizing complete sentences. If there is information that you have that is not asked via a data field you should include it in your narrative. For example, there is more than one victim or suspect. You can list the additional victim or suspect in the narrative field. The form, by section title, only allows for one victim or suspect name. Remember the narra-tive field is the best place to include all information that the form does not ask for or will not allow you to docu-ment. If you feel it important, write it in the narrative. The more information we have the better decisions can be made on behalf of the resident/patient.

The Complainant information is to identify the person completing the form, not the person who is making the allegation. We use this section as the means to identify the person at the facility that we may call in order to ask follow up questions or utilize as a contact to assist in the gathering of documents or other rel-evant information.

This section includes a field identified as e-mail to get confirmation. If you put your proper e-mail address and it matches your confirm e-mail data field, you will get an e-mail from the AGO CRIMES system with a date/time stamp including all the information by field that you entered on the eform. Most importantly, we will issue you a reference number, such as D######, identifying the exact form of submitted data. If you would include this reference number on any follow up documents you forward to our office it will assist us in easily placing those documents in the appropriate file.

AGO CRIMES Case Management | 5

INSTRUCTIONSWebForm Submission

3.

4.Once the Eform

is complete click SAVE to Submit the form to us.

The next three sections (Facility, Victim & Family/Responsible Party) are necessary in order to contact witnesses or family members in case background information is needed. The Facil-ity is where the victim is currently residing. Normally it is the same place that the incident took place, but not always. If the victim was in a different location/facility (i.e. on pass, medi-cal treatment facility, restaurant, etc.) you could describe location in the narrative.

Remember, green dotted fields are required so you have to at a minimum identify a facility as well as the first and last name of the victim in order for the Eform to save successfully. If you know the information being asked for please complete the data field. The more identifiable information we have the better we can match the participants to those already in our database. This type of linking assists us in matching older information with newer updated information. It also allows us to identify or establish patterns or links to information received from other sources.

Suspect is not a required field but is important none the less. We understand that the identifica-tion of a suspect is nothing more than an allegation. However, we still need all the information that you can provide especially the Date of Birth and the Social Security Number. This infor-mation allows us to perform a background check prior to making contact. We can also check the home address for unrelated incidents allowing for better safety for or investigators. If the Responsible Party is also the Suspect you can identify this in the narrative. It would be better to

complete the participant as a Suspect since we can capture more relevant data such as SS# and DOB that is not found in the Responsible Party fields.

NOTE: If you do not know the information asked for in the data field such as DOB, SS#, Middle Name etc, leave the data field blank. Please do not enter N/A, None or dont know. If you leave the field blank we will take that as if you did not know or do not have the information.

6 | WebForm Submission

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Once you click the SAVE button your screen will refresh and at the top you will see this message printed in green. Additionally you may find that your systems Pop-Up blocker has activated. If this happens it will look like this. As soon as

you click SAVE the Eform tried to pop-up a window to show you the infor-

mation you typed on the form. If you right-click this pop-up window you can print a copy of the typed information for your records. We would suggest you close all pop-ups when submitting an Eform to our office. Our recommendation is to add our web site to your trusted sites. By doing so you can choose custom settings and turn off pop-ups only for your trusted sites. Refer to your local computer administrator for help with this process.

After receiving a warning from your pop-up blocker you have two choices to close the message or click it to see the Pop-Up. If you choose to see the Pop-Up you will get this message. If you choose RETRY you will actually re-send the Eform to our office for a second time, thus causing the system to accept the submission and assign a second Document Reference Number (D######). This is why you get two e-mails with a different refer-ence number. The reference numbers will always be in sequential order. We would ask that you turn off your Pop-Up or click CANCEL so as not to re-send the Eform. The duplicate submission looks like this on our end:

AGO CRIMES Case Management | 7

NOTE: If you completed the e-mail for confirmation in the Complaintants Information section, you will receive an e-mail documenting what you typed as well as receiving the refer-ence #. This is in addition to the Pop-Up, for quick printing, so there is no problem with choos-ing CANCEL once you are warned by the Pop-Up.

We designed the Eform to func-tion a specific way for those who may enter more than one eform at a time. Since each submission is specific to one incident, we caused the Eform to maintain the data entered in the COMPLAINANT and FA-CILITY sections. The other four sections, to include GENERAL INFORMATION, will clear out the data in any field where text had been previously captured. We understand that the com-plainant and Facility will be the same and it would be redundant for you to re-type your specific information. So, if you notice this picture to the left. The form has been saved successfully and the Pop-Up blocker has issued a warning, however I would

like to draw your attention to the COMPLAINANT and FACILITY fields. You see that the previously entered information is still present, but the GENERAL INFORMATION has been cleared out. Once you dismiss the Pop-Up you could begin typing your second separate Efrom should you have one. Once you click SAVE the form does REFRESH. It happens quickly and sometimes people think it did not SAVE. Check for the message in GREEN at the top. If you see Form Information has been Successfully Saved you can rest assured that we got the Eform. If you enter your e-mail address and confirm the entry you will also get an immediate response via e-mail thus assuring you that we received the submission. If something is wrong with the eform data entry you will get a RED box around that data field and a message at the top of the screen like this:All you need to do is correct the identified problem and then click SAVE. If all is well you should get a Pop-Up (Printable Win-dow) then a confirmation e-mail for proof of submission for your records.

AGOCRIMES Case Management System

ThaNk YoU for YoUr WeBforM SUBMISSIoNS

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