Follow the steps to complete and submit your complaint online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the provider's information. Fill in the provider’s first and last name, followed by their street address, city, state, and zip code. Include the business or clinic name and the associated phone number.
3. If applicable, provide the claim number related to the fraud being reported.
4. Indicate the type of fraud you are reporting by checking all that apply. Options include billing for services not provided, double billing, billing for non-covered services as a covered service, and misrepresentation of dates, location, or provider of service.
5. In the 'Summary of Complaint' section, provide a clear and concise description of the issues you are reporting.
6. You will be asked if you have any documentation to support your complaint. Select 'Yes' or 'No'. If you select 'Yes', be sure to attach your documentation to the email when you submit the form.
7. If there are other people we should contact for further information regarding your complaint, provide their names, phone numbers, and email addresses as prompted.
8. Finally, enter your own contact information, including your name, phone number, and email address.
9. After completing all sections of the form, you can save your changes, download a copy for your records, print it, or share it as needed.

Complete your provider fraud complaint online today!