Fraud Prevention Program

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Fraud Prevention Program

Fraud, Abuse and Waste Referral Form

Report suspected health care fraud, abuse and waste, by completing the online form. Fields marked with an asterisk (*) are required. The form will be automatically routed to our Fraud Prevention Program, once you have completed the form and hit the submit button. Please note, the form will not be accepted if the required fields are not completed.

If you would rather mail us the completed Fraud, Abuse and Waste Referral Form, please click here to download a copy in a PDF format.

PERSON OR COMPANY SUSPECTED OF FRAUD, ABUSE, AND WASTE:

*Name (Individual/Company):

*Address 1:

Address 2:

*City:	*State:	*Zip:

* Daytime Telephone Number:

*Profession:

LIST VICTIM(S); IF OTHER THAN YOURSELF:

Name:

Address 1:

Address 2:

City:	State:	Zip:

Daytime Telephone Number:	VISTA Member # (if applicable):

NAME OF PERSON FILING THE COMPLAINT:

*Your Name:

*Address 1:

Address 2:

*City:	*State:	*Zip:

*Daytime Telephone Number:	VISTA Member # (if applicable):

Email Address:

WITNESSES:
Please list anyone that may provide information relating to the potential fraud, abuse and waste. If you have more witnesses than the space allows, please use the description section of this form.

Witness Name:

Address 1:

Address 2:

City:	State:	Zip:

Daytime Telephone Number:

Witness Name:

Address 1:

Address 2:

City:	State:	Zip:

Daytime Telephone Number:

*DESCRIPTION OF SUSPECTED FRAUD, ABUSE, OR WASTE:

Please include as much detail as possible.