Healthicity Audit and Compliance Solutions

Rothman Orthopaedics

Reporter Section

Are you entering this concern anonymously (do you not want your name identified)?

If Not Anonymous- Name of Reporter Completing Form

Contact Phone Number for Person Completing this Form

Would you like to receive status updates on the progress of this incident report? (notification of when the report is received, under review, and when a resolution has been reached) Answering yes to this, provides you the opportunity to provide any additional comments and you can rate your satisfaction with the resolution.

Concern Information

Date observed or first noticed

Date of Complaint

Office Location

Who or what was affected?

Patient Name

Patient Date of Birth

Doctor / Nurse Practitioner / Physician Assistant's Name

Specialty

Description of event(s) or concerns

Risk Management Section

Incident Title/Name

Your submission will be sent to the appropriate person who can help you. Please allow 3 business days to hear back from a Risk Management Specialist. Please advise this form does not go directly to your provider and is not monitored after hours or weekends. If you have general questions regarding your current treatment or have a question for your provider, please utilize the Patient Portal or call 800-321-9999.

Compensation Request (and/or balance waive request)

Amount (If not applicable N/A)