Fraud Alert Form

OtherPlease indicate what this complaint is regarding.

Facility *

Date activity occurred *

Is the activity still occurring? *YesNo

When did the activity end? *

Name(s) of Individual *

Is there anyone who can corroborate the report?YesNo

Contact Information

Please describe the fraudulent activity in your own words. *

Any helpful documents (or evidence)

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

Street Address

City

State/Province

Email Address

Date of Birth

This health center receives HHS funding and has Federal Public Health Service (PHS) deemed status with respect to certain health or health-related claims, including medical malpractice claims, for itself and its covered individuals. For more information, click here.

Please do not submit confidential medical information through this portal. For questions about your healthcare, including prescriptions, lab results, or providers, please contact us via MyChart or by calling 1 (800) 640-9741.

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Stigler Health & Wellness Center, Inc. is part of an organized health care arrangement including participants in OCHIN. A current list of OCHIN participants is available at www.ochin.org. As a business associate of Stigler Health & Wellness Center, Inc., OCHIN supplies information technology and related services to Stigler Health & Wellness Center, Inc. and other OCHIN participants. OCHIN also engages in quality assessment and improvement activities on behalf of its participants. For example, OCHIN coordinates clinical review activities on behalf of participating organizations to establish best practice standards and assess clinical benefits that may be derived from the use of electronic health record systems. OCHIN also helps participants work collaboratively to improve the management of internal and external patient referrals. Your personal health information may be shared by Stigler Health & Wellness Center, Inc. with other OCHIN participants or a health information exchange only when necessary for medical treatment or for the health care operations purposes of the organized health care arrangement. Health care operation can include, among other things, geocoding your residence location to improve the clinical benefits you receive.

The personal health information may include past, present, and future medical information as well as information outlined in the Privacy Rules. The information, to the extent disclosed, will be disclosed consistent with the Privacy Rules or any other applicable law as amended from time to time. You have the right to change your mind and withdraw this consent, however, the information may have already been provided as allowed by you. This consent will remain in effect until revoked by you in writing. If requested, you will be provided a list of entities to which your information has been disclosed.