Fillable LifeWays Community Mental Health REPORT OF SUSPECTED NON-COMPLIANCE (Lifeways Community Mental Health)

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LifeWays Community Mental Health REPORT OF SUSPECTED NON-COMPLIANCE (Lifeways Community Mental Health)

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LW# 01-08.02-A 06/2020
LifeWays Community Mental Health
REPORT OF SUSPECTED NON-COMPLIANCE
This form may be used to report any suspected incident of non-compliance involving LifeWays
Community Mental Health staff or provider staff under contract with LifeWays. This form may be
submitted to the LifeWays Compliance Officer by email (ken.berger@lifewayscmh.org), by mailing it to
the LifeWays Compliance Office (1200 N. West Ave., Jackson, MI, 49202). A report may also be made
by calling the Compliance Reporting Hotline (517-789-2485). PLEASE NOTE: YOU MAY REPORT
ANONYMOUSLY BY MAIL OR PHONE AND OMIT YOUR NAME/CONTACT INFORMATION.
Name of Person/Agency you are reporting
Date the Incident/Action occurred
Address of Person/Agency you are reporting
Date of this report
Your name Not required if anonymous
How to contact you Not required if anonymous
Please describe the type of incident/action that you are reporting on: Illegal, Improper, or
Unethical Conduct; Medicaid Fraud, Waste, Abuse, or Improper Claims for Service; Health
Insurance Portability and Accountability Act (HIPAA) Privacy or Security; Other type of
incident/action.
Please describe the incident/action in as much detail as possible, especially if you are reporting
anonymously. Attach additional pages if necessary
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LifeWays Community Mental Health REPORT OF SUSPECTED NON-COMPLIANCE (Lifeways Community Mental Health)

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Completed 5 March 2021

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