Report a Compliance Concern

Alliance Physical Therapy Partners is committed to providing our patients the highest quality care while remaining compliant with federal and state laws. This form is being provided to ensure that both staff and patients have an opportunity to have their concerns heard and addressed. If you would like to report anonymously, please leave the name and contact information fields blank. If you choose to remain anonymous, please provide as much detail as possible so that we may conduct an appropriate investigation.

Date and Location of Incident - If you only remember a month or year, please include as much detail as you are able.

Please describe the type of incident you are reporting and explain your concern in detail. What happened? Where did it happen? Who was involved?

If you are an employee, have you reported your concern to a supervisor or anyone else?

YesNoI am not an employee

If you are a patient, have you reported your concern to your therapy provider or anyone else?

YesNoI am not a patient

Use this section to provide additional details regarding to whom you reported your concern, how they responded, and any actions taken to resolve your concern.

Name (leave blank if you wish to remain anonymous) Remember, if you choose to submit this report anonymously, we will not be able to contact you for more information.

If you would like us to contact you, please leave a phone number or email address below.

Contact Information