Compliance Reporting Tool

This Compliance Reporting Tool is operated by agilon health and has been provided to give you an opportunity to report any compliance concerns related to agilon health or any of its business partners, including Independent Practice Associations, or Direct Care Entities. This tool allows you to report anonymously or to provide your contact information for follow up. If you decide to remain anonymous, no one will know that you have made a report. In order to assist with the investigation, please be as detailed as possible in your responses.

The information you submit below will be transmitted to the agilon health Compliance Department who will follow up on the report. All efforts will be made to maintain confidentiality during the investigation*. agilon health has a non-retaliation policy. This means that you do not need to fear making a report in good faith. agilon health relies on individuals like you to let them know when something is wrong. If you are a patient, or a family member of a patient, your or your family member’s medical care will not be negatively impacted as a result of the report. If you feel that you are being retaliated against, please call the agilon health Compliance Officer toll free at (833) 668-8638.

* = Required

Name of Entity *

What is your relationship to the entity? (For Instance, Patient, Family Member of Patient, Provider, Provider Staff)

Is your report about a provider? *

YesNo

Provider First Name *

Provider Last Name *

Provider Type (For Instance, Internal Medicine, Cardiologist, Physical Therapy)

Where are you located?

How would you classify this incident or communication? *

Witness First Name

Witness Last Name

Attachment

Maximum file size: 20MB
Valid file types: .gif, .jpg, .jpeg, .png

Have you reported this incident to any other employee, agency, or regulatory body? *

YesNo

Details of your concern (Please as many details as possible to assist in the investigation) *

Where did this happen? (For Instance, in the providers office, on the phone, etc.)

Do you want to leave your name and/or contact information? *

YesNo

First Name *

Last Name *

Phone Number

Email *

Enter CAPTCHA

*If the investigation progresses and a Federal agency or other government authority becomes involved, they may ask to speak to the reporting party and that individual’s identity may become known as part of the investigation