COMPLIANCE HOTLINE

Hamilton-Madison House fully encourages our employees, vendors, and patients to engage in open dialogue regarding any compliance concerns or questions that may arise. However, we recognize that some individuals may prefer to report or convey information in a confidential or anonymous manner. In order to provide our employees, vendors and patients an opportunity to report compliance concerns anonymously and without fear of retaliation. Hamilton-Madison House provides an alternative method for reporting concerns and access to The Compliance Hotline a confidential, anonymous way for you to report known or suspected improper conduct.

Check this box if you want to report and remain anonymous

Today’s Date:

(*)Reporter’s Name:

Approximate Date of Incident:

(*)Reporter’s Phone #:

Submission Related To

Reporter’s Email:

Reporting As:

Severity:

Location:

(*)Incident Summary:

(*)Describe the details including what happened, who were involved, and where it happened. Provide as much detail as possible to assist with the review and remediation of the issue:

Attach any relevant pictures or other documentation here that could provide additional information regarding the incident and would help in review and resolution.

Attach Documents:

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