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Information on the Suspected Member or Provider:
First Name
Last Name
Middle Initial
Suffix
Provider or Practice Name
Street Address
Suite
City
State
Zip
Telephone
ext
About the suspected member or provider:
Enter any information about the suspected member or provider:
Tell us about the activity that may be waste, fraud or abuse:
Give details that tell us who, what, when, where, why and how.
Some examples are:
Billing for services you did not receive
Someone using your identity to receive medical services.
How can we contact you?
Your First Name
Your Last Name
Your Middle Initial
Suffix:
Your Street Address
City
State
Zip
Your Telephone
ext
Your Email Address
Clear form
Submit