Healthicity Audit and Compliance Solutions

Powerback Rehab

Date observed or first noticed

Are you reporting for yourself?

If "No" above, please indicate name of the person you are reporting on behalf of

Type of Incident

Please be as specific as possible. Include dates, names, center/site involved where appropriate. Provide any evidence you have to support the information provided.

Description of event(s) or concerns

Who or what was affected?

Location

State (Please use 2 letter abbreviation)

Line of Business

Have you notified other Powerback staff about this situation?

If so, who and when?

Describe what actions, if any, have been taken to address the situation.

Please be aware that if you choose to remain anonymous when reporting a concern, the scope of our investigation may be limited, as we may be unable to obtain additional details or clarification that could be important to resolving the matter.

Are you willing to discuss this issue with us further? Yes (Compliance or HR Team May Contact Me)No (Remain Anonymous - Do Not Contact Me)

Do you want to save a copy of this report to your device? YesNo