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* Required Information
Name of the Provider or Member
	* Last Name:	Suffix:
	* First Name:	Middle Initial:
	Organization Name:

Address of Provider or Member:
	Address Line 1:
	Address Line 2:
	City:
	State:
	Zip Code:
	* Telephone Number:	Ext:

Additional information about the provider or member (Identification Number, license number, telephone number, etc.):


*	Please describe the suspected fraud or abuse (e.g. billing for a more expensive service than was actually rendered, billing for a services that were not rendered or ordered by the practitioner, etc.). Please provide as many details as possible - who, what, when, where, why and how:


Optional Information : Provide your name, phone number and/or e-mail address so that we may contact you for more information if necessary. You may also submit your information anonymously. Thank you.

	Last Name:	Suffix:
	First Name:	Middle Initial:
	Organization Name:
	Address Line 1:
	Address Line 2:
	City:
	State:
	Zip Code:
	Daytime Phone:	Ext:
	Evening Phone:	Ext:
	Fax Number:
	Email Address:

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