Report of Possible Fraud, Waste or Abuse

Use this form to report any known or suspected activities. All reports received are confidential and you will never experience retaliation as a result of making a good faith report. You may also report anonymously by calling the Fraud Hotline at (800) 392-9249.

Name and contact information of individual reporting the alleged fraud or abuse.

Reporter Information

 Yes  No

Who is suspected of committing fraud, waste or abuse?

Please complete the below sections with as much information as possible.