Fraud and Abuse Reporting Form

Please use this form to report suspected fraud or abuse of services paid for by Integral Quality Care. Please complete as much of the requested information as you can below.

* = Required Fields

1. *I suspect (Name) of fraud.
2. This person’s address is
3. *City
4. *State -- Select State -- Alaska Alabama Arkansas Arizona California Colorado Connecticut D.C. Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming
5. Zip Code
6. Phone
7. *Is this person a doctor? -- Select One -- Yes No
8. What is the name of their practice?
9. Please tell us why you suspect this person of wrong doing.
   

You do not have to give us your name. But if you do, we will keep it confidential. It will help if we can talk to you.

1. Name
2. Address
3. City
4. State -- Select State -- Alaska Alabama Arkansas Arizona California Colorado Connecticut D.C. Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming
5. Zip Code
6. Phone
7. Ext
8. Email

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