Compliance Occurrence Reporting Compliance Occurrence ReportingSacred Circle Healthcare (SCHC) is committed to the timely identification and resolution of all issues that may adversely affect employees, patients, or the organization. Therefore, SCHC has established communication channels to report problems and concerns. The report below is an avenue by which individuals or interested parties may report any issue or question associated with any of SCHC’s policies, conduct, practices, or procedures believed by the individual to be a potential violation of criminal, civil, or administrative law, or any unethical conduct. All individuals are protected from non intimidation and nonretaliation for good faith participation in SCHC’s Compliance Program. You may complete this form without identifying yourself and leave the “Observers Name” section blank. However, many times more information is needed from an individual to perform a complete investigation. So, you are encouraged to leave your name for follow-up. Rest assured your identity will be kept confidential.Observers First Name (Optional)Observers Last Name (Optional)Date of OccurrenceLocation of Occurrence- Select -Fairbourne ClinicMain ClinicIbapah ClinicPamela's Place ClinicWest Valley ClinicSpecific Department (if known)- Select -AdministrationBehavioral HealthDentalInformation TechnologyOptometryPharmacyPhysical TherapyPrimary CareSecurityTransportationCompliance Type- Select -Inappropriate codingInappropriate charging/billingInappropriate charge code selection/chargemasterInappropriate claims submissionOverpaymentsMedical necessity issuesCost-reporting issuesFalse or fraudulent documentation issuesRequests from fiscal intermediary/carrierHIPAA or patient privacy issuesEMTALA issuesFailure to follow policies and proceduresFailure to follow Code of ConductDrug diversion (i.e., illegal sale or redistribution of drugs)Physician relationship issues such as potential violations of the Stark Law or Anti-Kickback StatutePotential violations of the Anti-Kickback Statute related to vendors (e.g., inappropriate gifts)Provider or supplier excluded from the federal or state healthcare programsInappropriate conflict of interestRetaliation or intimidationOtherExplain OtherDescription (Who, What, How)Rest assured your identity will be kept confidential.Submit Form
