Providers
Locations
Specialties
Cardiology
Dermatology
Endocrinology
Gastroenterology
Gynecology
Primary Care
Nephrology
Neurology
Podiatry
Pulmonology
Rheumatology
Urology
Lab & Imaging
Careers
Patient Portal
Contact Us
About Us
Billing & Insurance
Patient Rights and Responsibilities
Forms
Research
Radiology Prep Guide
Providers
Locations
Specialties
Cardiology
Dermatology
Gastroenterology
Gynecology
Nephrology
Neurology
Plastic Surgery
Podiatry
Primary Care
Rheumatology
Urology
Lab & Imaging
Careers
Patient Portal
Contact Us
About Us
Contact Us
Patient Portal
Billing & Insurance
Patient Rights and Responsibilities
Forms
Research
Radiology Prep Guide
Compliance Reporting Form
Premier Medical Group of The Hudson Valley, P.C. maintains a comprehensive Compliance Program that sets forth the standards of conduct that all employees are expected to follow during their course of employment.
This form may be completed to report suspected misconduct, possible violations of Federal or State laws or regulations, or possible violations of the Compliance Program to the Compliance Officer. While giving your name will be helpful if more information is needed, employees are not required to include it and may report anonymously.
If you prefer to email our Compliance Officer directly, please send an email to
compliance@premiermedicalhv.com
Report Date
(Required)
MM slash DD slash YYYY
Date of Incident
(Required)
MM slash DD slash YYYY
Enter Your Location Here
(Required)
Nature of Incident (please explain what you are reporting and why)
(Required)
Did you directly observe the Incident?
(Required)
Yes
No
How were you made aware of the incident?
(Required)
Have you discussed the Incident with anyone else?
(Required)
Yes
No
Tell us to whom you discussed
(Required)
Name of Party(ies) being reported, if applicable:
Can we contact you:
(Required)
Yes
No
Enter your email:
(Required)
CAPTCHA
