Fraud & Abuse

* indicates a required field*

Name of Provider or Member

Provider or Member ID:

*Last Name:

*First Name:

MI:

Suffix:

Organization Name:

Address of Provider or Member:

Address 1:

Address 2:

City:

State:

ZIP Code:

*Phone:

Ext:

*Please describe the suspected waste, fraud or abuse (e.g.; billing for a more expensive service than was actually rendered, billing for a services that were not rendered or ordered by the practitioner, etc.) Please provide as many details as possible - who, what, when , where, why and how:

Contact Information: Provide your name, phone number and/or e-mail address so that we may contact you for more information if necessary.

(You do not have to submit your contact information).

Last Name:

First Name:

MI:

Suffix:

Organization Name:

Address 1:

Address 2:

City:

State:

ZIP Code:

Telephone (Day):

Telephone (Evening):

Fax: