Medicare Fraud Reporting Form

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

[Click to expand] 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:
* 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:
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:

[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):