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What is your relationship to Medical Mutual or its family of companies?

  
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If Other, please explain:
 
Do you want to leave your name and/or contact information? Please remember that this is completely optional. However, if you wish to remain anonymous, the investigation may be limited by the information you have provided here.

  
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Name (First Name, MI, Last Name):
 
Telephone Number:
 
Home / Work Address:
 
Email Address:
 
Preferred Contact Time:
 
Please select your location.       

  
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Are you calling with an idea or suggestion for the company?

  
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If Yes, please explain:
 

Please Describe your concern:



  
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Is there a way for the company to verify any of this information?

  
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If Yes, please explain:
 
Are there any witnesses or is there anyone else who might be willing to contact the helpline or speak with the company?

  
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Name (First Name, MI, Last Name):
 
Name (First Name, MI, Last Name):
 
Name (First Name, MI, Last Name):
 
Name (First Name, MI, Last Name):
 
Name (First Name, MI, Last Name):
 
Are there any documents, specifically, that you have or know of?

  
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Why do you feel it is important that this matter is acted upon?

  

 
Have you reported, or tried to report, this matter through the management channels at Medical Mutual?

  


 
Please describe the details of your report:
 
Was the report verbal or written?
 
When did you communicate it?

   
 
What is the name of the person it went to (First Name, MI, Last Name)?
 
What is the position of the person it went to?
 
What did you say?
 
What was the response?
 
Do you have any concerns about being retaliated against for having made the report though the management channels?

  
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With respect to the concern you are reporting, what do you feel should be done and by whom?

  

 
Before you complete the interview, is there any additional information you’d like to provide that would assist the company’s management in understanding your concern or in taking appropriate action?

  

 
Do you want to leave a phone number where someone from the company can call you back and either leave a message or talk to you in person? Again, please remember that this is completely optional.

  

 
Do you have a preferred time when you would like someone from the company to call you?

  


 
If Yes, what is the preferred time?
 
Thank you for contacting Medical Mutual's Compliance Connection Helpline. For a response from the company, please check back in three business days. Please be sure to have your report number and password.


Please attach here any documents, videos, etc.