Compliance Complaint

Contact Information:

First Name (optional)

Last Name (optional)

Phone Number (optional)

Email (optional)

*Please note: This form may be submitted anonymously.

	If you have provided contact information, may we contact you?
Yes	Yes
No	No

Complaint:

Which County Department does it pertain to?

Date/Time of the Incident:

Please provide the details of the complaint:

Due to the nature of healthcare information, we may not be able to inform you of the result off an investigation. However, please be assured that St. Lawrence County takes Healthcare Compliance extremely seriously. All complaints received will be thoroughly investigated and, if warranted, corrective action will be taken.

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