Healthicity Audit and Compliance Solutions

Evolve Restorative Center

Privacy Violation

Please use this form to report a privacy violation or concern.

Date observed or first noticed

Where did the incident happen?

Who or what was affected?

Description of event(s) or concerns

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)

* Preferred contact method

phoneemail

* Name

Telephone

Email

Address/City/State/Zip Code

Can we leave messages?

Yes

No

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