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Report Form

Please complete the following information.

Contact Information is Optional

For your privacy and those you may be contacting IHS on behalf of: DO NOT include Personally Identifiable Information (PII) or Protected Health Information (PHI). Examples of PII and PHI are your phone number, address, health condition, social security number, date of birth (DOB), patient name (if not your own) and patient registration number. PII and PHI are protected by the Health Insurance Portability and Accountability Act and the Privacy Act.

Summary of Allegations:

Please review all information before you submit. Please do not submit multiple reports for the same instance.