Skip to content

Healthcare Fraud Complaint Form

Please do not include social security numbers, medical information, or any other private information

Person or Company Suspected of Fraud:
Name:  (Required)
Address:
City:
State:
Zip:
Phone:
Date of Incident(s):
Details of Complaint:  (Required)
   
Insured's Information:
(Information about the person who carries the insurance.)
Name:
Address:
City:
State:
Zip:
Phone:
   
Your Information:
(This section is OPTIONAL if you choose to remain anonymous.)
Name:
Address:
City:
State:
Zip:
Home Phone:
Work Phone:
Email Address: