I certify that:
I have read and understand the Corporate Compliance Plan and the Code of Conduct.
I pledge to act in accordance with the Corporate Compliance Plan and the Code of Conduct.
I will promptly report any conduct that I believe to be illegal or in violation of the Corporate
Compliance Plan or the Code of Conduct in accordance with the compliance concern reporting steps.
I will seek advice from my supervisor or the Compliance Officer concerning appropriate actions that I may need to take in order to comply with the Corporate Compliance Plan or the Code of Conduct.
I understand that failure to comply with this Code of Conduct may result in disciplinary action, up to and including termination of employment or affiliation.
_____________________________________ Print Name
Relationship to the Hospital:
Non-Employed Medical Staff Member
Non-Employed Allied Health Professional
Member Board of Directors
NOTE (For Employees): The Corporate Compliance Plan Acknowledgement can be signed/acknowledged online via My HR. Please visit My HR at https://lawpb.c0tf.netaspx.com/lawson/portal (or click the My HR icon located on your computer’s desktop) to log in*. Once logged in, select the Forms link, then select the Compliance Plan-CH link.
CORPORATE COMPLIANCE PLAN 5/6/10
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