Follow the steps to complete your complaint form effectively.

1. Press the ‘Get Form’ button to access the complaint form and open it in your chosen editor.
2. Indicate whether your complaint pertains to a Medicare Advantage issue (Part C), a Prescription Drug Benefit issue (Part D), or both by selecting the appropriate option.
3. Provide your contact information in the 'Complainant Contact Information' section. Include your name, fax number, phone number, and email address.
4. Specify who is submitting the complaint by selecting the appropriate option (Plan, PBM, UPIC, or Other). If you are submitting on behalf of another person or organization, include their details.
5. Fill in the complainant organization’s name, city, address, state, and zip code, if applicable.
6. Complete the ‘Beneficiary Information’ section by providing the relevant details about the beneficiary, including their name, phone number, HICN, MBI, address, city, date of birth, primary language, state, and Medicare plan name.
7. Answer whether the beneficiary is subject to the complaint by selecting 'Yes' or 'No'. Additionally, indicate if you have any contact reports regarding the beneficiary.
8. In the 'Description of Subject/Suspect of Fraud' section, detail one subject or suspect at a time by entering their NPI, tax ID, name, Medicare provider number, DEA number, phone number, business name, state, city, address, and zip code.
9. Provide specific details about the complaint, including potential Medicare program exposure, any prior MEDIC case numbers, and monetary amounts related to Part C and Part D program exposure.
10. Indicate whether the matter has been forwarded to law enforcement and, if applicable, specify the type of agency involved.
11. Describe the findings or allegations thoroughly. Ensure that you attach any detailed descriptions of the fraud issue, including evidence and relevant documentation.
12. Once completed, save your changes. You can download, print, or share the form as needed.

Complete the Qlarant Investigations MEDIC Complaint Form online today and help combat fraud in Medicare programs.