Compliance Reporting – Zeldis Research Associates

Introduction

Thank you for coming forward. Your report will help us uphold our commitment to regulatory compliance and best business practices. Please use the form below to report suspected compliance violations concerning Fraud, Waste and Abuse, HIPAA, data security and other areas such as ethics and code of conduct. To help us address the issue, please supply as much detail of the suspected violation as you can on the below form. You may also contact our compliance team at compliancedept@zeldisresearch.com.
Filing Status
Filing Status*
- Confidentiality and Anonymity is not requested. – Zeldis may contact you for additional information regarding the complaint and there are no restrictions placed on the release of your contact information.
- I wish to remain Confidential. – You agree to be contacted by Zeldis in order to confirm receipt of your complaint and if necessary, obtain additional information. Zeldis will maintain your request for confidentiality and will not share any identifying information with anyone outside of the Zeldis Confidentiality & Security Team (CST) unless required to do so by order of law (e.g., court order/subpoena).
- I wish to remain Anonymous. If choosing to remain anonymous, it is not necessary to fill out the contact information. However, it is important to note that we will not be able to confirm receipt of your complaint or contact you if we need additional information.
Reporter Contact Information
Name*
First Last
Telephone Number*
Email Address*
Suspected Violation
Please select which best describes the violation you believe occurred.*
- Fraud, Waste and Abuse, as per CMS guidelines (such as bribery/kickbacks, false insurance claims, theft, threats of violence/assault, and violation of laws, regulations, policies and procedures)
- HIPAA Privacy
- Corporate Data Security
Person/Business suspected of the violation
Name*
full business name or first and last name of the individual
Physical Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Telephone Number*
Email Address*
Violation Description

Please provide details of the issue you believe to be a violation. The more specific details you provide the better able we will be to respond to your complaint.
Remember to tell us:
· Who you believe committed a violation,
· What they did,
· Where the violation occurred,
· When the violation occurred,
· How it happened, and
· If you know why the person committed the violation.
Violation Description*
Witness Information

Please provide the following information for any individuals who may have witnessed the violation you are reporting.
Name
First Last
Telephone Number
Email Address
How they witnessed the violation
Additional Information

Please provide any additional information that may aid in our investigation of your complaint.
Additional Information
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Introduction

Filing Status

Reporter Contact Information

Suspected Violation

Person/Business suspected of the violation

Violation Description

Witness Information

Additional Information