FRAUD WASTE AND ABUSE COMPLIANCE
PROGRAM REPORTING FORM

NOTICE:  YOU ARE NOT REQUIRED TO REVEAL YOUR IDENTITY.  IN ADDITION TO
CONSULTING WITH THE COMPLIANCE OFFICER OR YOUR SUPERVISOR, YOU MAY REPORT
ANY COMPLIANCE CONCERN YOU HAVE BY:

- Calling the anonymous Compliance Hotline at
845.791.1515

- Mailing or Faxing a compliance report to the Compliance Officer at
P.O. Box 777, Rock Hill, NY 12775
or Fax 845.791.1045

- Completing this anonymous Compliance Reporting Form

- Completing a Compliance Reporting Form and depositing in the
Compliance Report Box
Today's Date:
Do you wish to remain anonymous?
YES             NO
If you answered YES, do NOT complete personal information!
What is your concern?
How should this issue
be resolved?
PERSONAL
INFORMATION

Name:

Position:

Phone Number:

Direct Supervisor:
If you revealed your identity,
do you prefer that we keep
your identity confidential?
YES                    NO
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