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:

Rock Hill Pharmacy
ATTN: Compliance Officer

P.O. Box 777

Rock Hill, NY 12775

- Completing a Compliance Reporting Form and depositing it in the Compliance Report Box

- Completing this anonymous Compliance Reporting Form: