MedPOINT Compliance Concern

Despite what everyone would like, things happen that must be brought to the attention of the compliance officer. This form will keep track of any compliance concerns you may have in such a situation.

Remember, this form is COMPLETELY CONFIDENTIAL (You may choose to include your contact information for a response to the given situation or conflict). This form allows you to write down any situation and all witnesses, participants, problems, or additional comments. 
 
 

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* 1. Today's date:

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* 2. State your concern: (Please provide as much information as possible so that we may consider all of the available facts.)

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* 3. Describe the situation (who, what, where):

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* 4. Date this occurred:

Optional*

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* 5. *Your Name:

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* 6. *Names of people (including witnesses) involved in the alleged compliance concern:

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* 7. *If you would like to discuss concerns/issues- please provide best time/day along with contact information:

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* 8. *Add additional information to an existing complaint and/or additional comments/concerns:

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