Fraud & Abuse

* Required Fields

Fraud and Abuse Reporting Form

Please correct the errors below before submitting the form.

* I suspect (Name)

of fraud.

* This person's address is

* City

* State

Zip Code

* Is this person a doctor?

What is the name of their practice?

Phone (No spaces or dashes necessary)

* Please tell us why you suspect this person of wrong doing. For example, what did the person do, when did it happen, etc.?

Optional information: You don’t need to give us your name or contact information. But if you do, we’ll keep it confidential. You can also choose to give us just your contact information and not your name.

If you choose not to give your contact information, our review will be only about the information you’re reporting. It’s important that you give us as much information as you can. It will help us do a complete and correct investigation.

First Name

Last Name

Street Address

City

State

Zip Code

Phone (No spaces or dashes necessary)

Ext

Email Address

Provider results

Fraud & Abuse

Please correct the errors below before submitting the form.

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