Fraud Suspect Activity Form

If you wish to report a provider or entity that you feel may be involved in a potentially fradulent activity, please enter the required information below including the suspected activity type, date, suspect's name, address, phone number and description of suspected activity. You do not have to include your contact information if you wish to remain anonymous.

Information

If you prefer NOT TO COMPLETE THIS FORM, you may provide your complaint to The Health Plan's FWA/Compliance Hotline at 1.877.296.7283. Anyone can report abuse (i.e., employee, volunteer, provider, member, Board of Directors members).



  1.  




  2.  
Suspect Demographics
  1.  
  2.  



  3.  
Contact Information