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About Reporting Medicare Fraud
Submit a Medicare Fraud Report
Contact FEAT
Medicare Fraud Reporting Form
Please fill-in all required (*) fields to submit the request.
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Your Information
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:
(Choose One)
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
* Zip Code:
* Phone:
* Email Address:
* Has anyone previously contacted our office regarding this matter?
Yes
No
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Supplier Information
* Supplier Name:
* Address:
* City:
* State:
(Choose One)
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
* Zip Code:
* Phone:
* NPI Number:
Is the supplier accredited:
Yes
No
If so, by whom:
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Other Person involved with this complaint (physicians/clinicians)
First Name:
Last Name:
Company Name:
Address:
City:
State:
(Choose One)
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code:
Phone Number:
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Nature of complaint
Date of service:
Product Codes(s) billed to Medicare:
Date of Billing:
* 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:
Date supplier was contacted:
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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):