Complaint-Incident Report Fill out our electronic form to file a report with our Compliance Officer. Report of:*Type of report Incident Complaint Other Problem This report involves:*Who or what prompted this report Hospital Employee Business Associate Performance of Service First & Last Name Involved Personnel*Name of employee or hospital associate involved in this event or action. Description of Event*Summarize the event you are reporting. There is an opportunity to upload additional documentation at end of this form.Date*Enter the date the event occurred MM slash DD slash YYYY Time*Enter approximate time of incident or encounter. : Hours Minutes AM PM Category*Choose the category that best fits the circumstances of this event or incident:Anti-Kickback/StarkCertificate of Medical NecessityClinicalCoding/Billing/PaymentsCompliance ProgramDocumentationEmergencyFinanceFormsHIPAAHIPAA PrivacyHIPAA SecurityHRSAHuman ResourcesInpatientLegalMiscellaneousOSHAQualityReasonable & Necessary ServicesRiskTraining & EducationDepartment*Choose the department your report is associated with.ADMINISTRATIONADMISSIONS / REGISTRATIONAMBULANCEANESTHESIABONE DENSITYBUSINESS OFFICEC-TCENTRAL SERVICESCOMPLIANCEDATA PROCESSING/ACCOUNTINGDIETARYDR BOCK CLINICDR TILLEY CLINICE.R. PHYSICIANSECHOCARDIOGRAMEMERGENCY ROOMHOUSEKEEPINGINPATIENT PHYSICIANINTENSIVE O/P THERAPY / MENTAL HEALTHITLABLAUNDRY / LINENMAGNETIC RESONANCE TECHNOLOGY (MRI)MAMMOGRAPHYMEDICAL RECORDSNURSINGOCCUPATIONAL THERAPYOUTPATIENT/TREATMENT (IV THERAPY)OUTPATIENT SCHEDULINGPATIENT TRANSPORTATIONPHARMACYPHYSICAL THERAPYPLANT OPERATIONSPURCHASING / RECEIVINGIMAGING / RADIOLOGYRESPIRATORY THERAPYSOCIAL SERVICESSPEECH THERAPYST FRANCIS GASTROENTEROLOGYST FRANCIS OPTHAMOLOGY CLINICST FRANCIS PAIN MANAGEMENT CLIST FRANCIS PEDIATRIC CLINICST FRANCIS PRIMARY CARE CLINICST FRANCIS SPECIALTY CLINICULTRASOUNDUTILIZATION REVIEWWOUND CARE CLINICNOT LISTEDName*Of Person Filing Report First Last Email*Required only for communication regarding this report. Will only be used by the Compliance Committee for purposes of obtaining more information or reporting action taken. Enter Email Confirm Email Upload file(s)To provide additional documentation on this report. Drop files here or Select files Accepted file types: pdf, png, gif, jpg, txt, Max. file size: 50 MB, Max. files: 3. CAPTCHAEmailThis field is for validation purposes and should be left unchanged.