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Report Suspected Fraud and Abuse

Please complete the following form if you suspect an incident of fraud or abuse has occurred.
Who do you suspect is committing fraud?
Name:*
Type of Physician:  (If Applicable)
Address:*
City:*
State:*
Zip Code:*
Phone Number: 
What fraudulent activity occurred? (Please describe in as much detail as possible.) *
 
Contract Number:  (If the fraud involves services provided to you.)
Any additional comments?
 
May we contact you? (If additional information is necessary.)
Name:
Daytime Phone Number:
E-mail Address:

* Indicates Required Fields