Fraud Alert Form

What is the complaint regarding?

Healthcare Fraud

Fraud, waste or abuse by an HWC employee

Whistleblower retaliation

Grant/Contract fraud

Quality of Care

Medical Identity theft

OtherOther

Facility

Date activity occurred

Is the activity still occurring?

Yes

When did the activity end?

Has the concern been previously reported?

Yes

Identify the party responsible for the activity you are reporting.

Business

Individual

Unsure

Name(s) of Individual

Is there anyone who can corroborate the report?

Yes

Contact Information

Please describe the fraudulent activity in your own words.

Any helpful documents (or evidence)

Maximum file size: 4.19MB

Please upload any supporting files here.

Consent to disclose your identity

No restrictions. Confidentiality and anonymity is not requested. If necessary, you may contact me for additional information and there are no restrictions on the release of my contact information.

I wish to remain Confidential. You may contact me for additional information, but please keep my name confidential and do not share it outside of the HWC Compliance Office. I also understand that HWC may still need to disclose my identity if required by law or if deemed necessary to the investigation.

I wish to remain Anonymous. I understand that HHS-OIG will not be able to contact me and, as a result, may not be able to thoroughly investigate or resolve my complaint.

Name

Phone

Address, City, State

Email Address

Date of Birth

If you are human, leave this field blank.

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