Compliance Hotline Form - Reporting Concerns/Incidents

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A Message from the Compliance Team: The Compliance Hotline will now be used for Named as well as anonymous entries. You may also still make submissions via email at compliance@cliffordbeers.org. If you wish to make an anonymous entry, simply leave the field blank!

You have accessed the Clifford Beers Community Health Partners Compliance Hotline! Confidentiality regarding employee concerns and problems will be maintained at all times, insofar as legal and practical, informing only those personnel who have a need to know. Employees who report concerns in good faith will not be subjected to retaliation, retribution, or harassment. No employee is permitted to engage in retaliation, retribution or any form of harassment against another employee for reporting compliance-related concerns. Any retribution, retaliation or harassment will be met with disciplinary action. Employees cannot exempt themselves from the consequences of wrongdoing by self-reporting, although self-reporting may be taken into account in determining the appropriate course of action.

Please Note: If the submission you are making is something you would like us to contact you about, do not report anonymously, we won’t know who you are! You can email us directly at compliance@cliffordbeers.org

Name (If you wish to remain anonymous, leave blank)

If you wish to remain anonymous, leave this and the E-Mail and Phone (ext.) questions blank

NOTE: While all compliance inquiries are kept confidential, not providing contact info - while permissible - makes follow-up and investigation significantly more difficult.

Affiliate *

Phone or Extension

Date you are Reporting Issue *

YYYY

Compliance Issue *

Please select the type of issue that you are reporting

EHR Documentation Issues (e.g., treatment plan, scheduling, progress notes, entering information into incorrect client medical record, etc.)

HIPAA Privacy & Security and Confidentiality issues

Human Resources

Improper compensation of vendors or physicians (kickbacks, bribes, improper gifts to physicians)

Inappropriate Billing (e.g., incidences of selecting incorrect CPT code, time, duration; billing for a higher code than service performed)

Legal

Quality of care or quality of life issues

Serious or recurring abuse of official authority

Suspected Fraudulent Activity

Violation of Clinic Policy and/or Code of Conduct

Other:

Compliance Issue Details *

This field is crucial in your reporting. Please give as much detail as possible while avoiding line breaks or excess spacing to ensure accuracy. (Format as a singular paragraph. The length of the paragraph is unlimited)

Client Medical Record Number

If reporting a specific client, enter MRN

Submit

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