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1. Reporting Concerns related to Compliance

This is a confidential mechanism for team members to submit concerns related to Compliance including Fraud, Waste and Abuse, HIPAA Privacy, HIPAA Security, Billing or other business practices at CHC.  You may also contacted the Corporate Compliance Officer, Cheryl Viadero, at (407) 929-6517 or email c.viadero@chcfl.org.

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* 1. Report Submission Request

Option 1: Confidentiality & anonymity is not requested. You may contact me for additional information and I do not place any restrictions on the release of my contact information. Please fill out the contact form below.

Option 2: I wish to remain Confidential. You may contact me for additional information, but please keep my information confidential. Our policy is to honor requests for confidentiality and not to release any data that would identify such individuals unless required to do so by order of law (e.g., court order/subpoena). Please fill out the contact form below.

Option 3: I wish to remain Anonymous. If you choose to remain anonymous, it is not necessary to fill out the contact information. It is important to note that we will not be able to contact you if we need additional information about your complaint.

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* 2. Contact Information

If you selected Option 1 or Option 2 above, please complete the information below.

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* 3. I have feedback regarding one of the following

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* 4. What CHC location are you reporting a concern for

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* 5. What date did this event occur

Date

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* 6. Please list the names of the persons invovled AND/OR patient account numbers

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* 7. Please describe in detail the compliance issue.

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* 8. Have you discussed your concerns with anyone at CHC?  If yes, please share the details.

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