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?
Date item was no longer used: Select a Date
Date supplier was contacted: Select a Date
Use the item or accept the service?
[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):
Features
Medtrade
Fraud Eradication Advisory Team
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