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
- 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
Do you wish to remain anonymous?
If you answered YES, do NOT complete personal information!
What is your concern?
How should this issue
If you revealed your identity,
do you prefer that we keep
your identity confidential?