This form is a secure method to privately report any concerns or issues that you may have seen or experienced at one of our clinical sites. All reports will be reviewed by our Ethics and Compliance Officer. First Name (Optional) Last Name (Optional) Email Address (Optional) Are you a patient or an employee?: (Optional) Patient Family Member Employee Former Employee Friend of Patient Who are you reporting?* Reception/Front Office Billing or Eligibility Nursing Staff Doctor, NP, PA Dentist Dental Hygienist, Assistant Laboratory Cleaning/Maintenance Security Officer Management Board Member Other If Other selected above, please provide detailsSelect Location*Select LocationBrownwood, 104 Southpark Dr.Brownwood, 3804 Hwy. 377 S.De Leon, 1100 W. Reynosa Ave.Stephenville, 135 River North Blvd..Date the problem occurred* MM slash DD slash YYYY Time observed: (Optional) Hours : Minutes AM PM Subject* Please describe your concern. Please be as detailed as possible.*THANK YOU FOR CHOOSING ACCELHEALTH!NameThis field is for validation purposes and should be left unchanged.