Medicare Fraud Reporting Form

Please fill-in all required (*) fields to submit the request.

[Click to expand] Your Information
Date: Select a Date
* First Name:
* Last Name:
* Are you a: Beneficiary
Friend/Relative of Beneficiary
Supplier
Employee of Supplier
Other
If you are not the beneficiary, do you have permission to file this report Yes No
* Medicare #
* Address:
* City:
* State:
* Zip Code:
* Phone:
* Email Address:
* Has anyone previously contacted our office regarding this matter? Yes No
[Click to expand] Supplier Information
* Supplier Name:
* Address:
* City:
* State:
* Zip Code:
* Phone:
* NPI Number:
Is the supplier accredited: Yes No
If so, by whom:
[Click to expand] Other Person involved with this complaint (physicians/clinicians)
First Name:
Last Name:
Company Name:
Address:
City:
State:
Zip Code:
Phone Number:
[Click to expand] Nature of complaint
Date of service: Select a Date
Product Codes(s) billed to Medicare:
Date of Billing: Select a Date
* Did Beneficiary: Receive a bill and pay?
Receive this item or service?
Cancel the item or service?
Refuse delivery?
Return the item being billed for?
Use the item or accept the service?
Date item was no longer used: Select a Date

Date supplier was contacted: Select a Date
[Click to expand] Reason for complaint
* Reason: Inappropriate equipment
Improper fitting
Unable to use in the home
Billed for a specific item, yet supplied with another different item
My physician never ordered the equipment
Not needed
Knowledge of bribes, kickbacks or rebates to supplier or physician
Other (explain):