Report of Possible Fraud, Waste or Abuse

First Name

Last Name

Employee ID

Employee Department

First Name

Last Name

Phone Number

Street Address

City

State -- Any State -- Louisiana Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Federated States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Zip

Contract Number

Company Name

Phone Number

First Name

Last Name

Street Address

City

State -- Any State -- Louisiana Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Federated States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Zip

Provider TIN

Provider NPI

First Name

Last Name

Phone Number

Producer Number

Company Name

Phone Number

First Name

Last Name

Street Address

City

State -- Any State -- Louisiana Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Federated States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Zip Code

Vendor Number

Type of Caller

First Name

Last Name

Phone Number

Street Address

City

State -- Any State -- Louisiana Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Federated States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Zip Code