Potential Quality Issue (PQI) Referral Form
Complete this form to report a potential quality or patient safety concern about the care or services provided to a Veteran by a provider. The Optum Clinical Quality Management team will investigate the concern.
Because all reported potential quality issues are confidential, we won’t be able to provide responses, updates or discuss the concern.

 PQI Referral Form Download

 Instructions
How to complete the form:
  • Use your mouse or tab on the keyboard to advance to the next field.
  • Fields with a red outline are required to be completed at a minimum to submit the PQI Referral Form.
  • Complete as much detail as possible.
Instructions for Web Submission:
  • Download the PQI Referral Form from the link above.
  • Complete the form
    • Use your mouse or tab on the keyboard to advance to the next field
    • Fields with a red outline are required to be completed at a minimum to submit the PQI Referral Form.
  • Save to your local drive.
  • Attach the completed PDF form from your local drive.
  • You can attach up to 5 PDF documents with your PQI referral form.
  • When the submitted file is successfully received by the system you will receive a confirmation message.
  • Delete the saved PQI PDF file from your local drive.
Instructions for Email Submission:
  • Download the PQI Referral Form from the link above.
  • Complete the form
    • Use your mouse or tab on the keyboard to advance to the next field
    • Fields with a red outline are required to be completed at a minimum to submit the PQI Referral Form.
  • Save to your local drive.
  • Create a new email with the following in the 'To' field: FaxClinicalQuality1@OptumServe.com
  • Attach the completed PDF form and other documents from your local hard drive.
  • Send email. You will not receive a response.
  • Remove the form from your local drive and email sent folder.
Instructions for Fax Submission:
  • Download the PQI Referral Form from the link above.
  • Complete the form
    • Use your mouse or tab on the keyboard to advance to the next field
    • Fields with a red outline are required to be completed at a minimum to submit the PQI Referral Form.
  • Save to your local drive.
  • Print the completed form.
  • Fax the completed form to: 1-833-675-2481
  • Remove the completed PDF form from your local hard drive and shred the printed form.
Instructions for Mail Submission:
  • Download the PQI Referral Form from the link above.
  • Complete the form
    • Use your mouse or tab on the keyboard to advance to the next field
    • Fields with a red outline are required to be completed at a minimum to submit the PQI Referral Form.
  • Save to your local drive.
  • Print the completed form.
  • Mail the completed form to:
  • VA Community Care Network
    Clinical Quality Management MS-41
    3237 Airport Road
    La Crosse, WI 54603
  • Remove the completed PDF form from your local hard drive and shred the printed form.
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 PQI Referral Form Upload