Report of Possible Fraud, Waste or Abuse

Use this form to report any known or suspected activities. All reports received are confidential and you will never experience retaliation as a result of making a good faith report. You may also report anonymously by calling the Fraud Hotline at (800) 392-9249.

Name and contact information of individual reporting the alleged fraud or abuse.

Name of Reporter

Phone of Reporter

Email of Reporter

Classification of Reporter*

Description of Complaint and/or Allegation*

Complaint Source*
(How did the reporter find out about this issue?)

I prefer not to be contacted

Has the reporter previously reported this issue?
Yes No

Who is suspected of committing fraud, waste or abuse?

Classification of Suspect*

Please complete the below sections with as much information as possible.

First Name

Last Name

Street Address

City

State

Zip Code

Phone Number

Contract Number

Company Name

Phone Number

First Name

Last Name

Street Address

City

State

Zip Code

Provider NPI

Provider TIN

Company Name

Phone Number

First Name

Last Name

Street Address

City

State

Zip Code

Vendor Number

Type of Caller

First Name

Last Name

Street Address

City

State

Zip Code

Phone Number