Are you a:*Patient or patient representativeEmployeeOther, please specify belowPlease specify for the above*Type of alleged compliance concern:*Health Insurance Portability & Accountability Act (HIPAA)/ Patient PrivacyMedicare Fraud, Waste & AbuseEmployee Code of ConductOccupational Safety & Health Act (OSHA)OtherDate of incident* Please provide the details of your complaint below. Your submission will remain anonymous. If you would like to be contacted, please include your name and telephone number.*It is the intent of Laser Eye Surgery of Erie, Inc. to adhere to all laws and regulations that apply to the organization. The underlying purpose of this submission is to support the organizational goal of compliance. Your report will be taken seriously and investigated thoroughly. The investigation may include individual interviews. The rights to confidentiality will be respected consistent with the company’s legal obligations and with the necessity to investigate allegations of misconduct and to take corrective action when this conduct has occurred. This iframe contains the logic required to handle Ajax powered Gravity Forms.