Fraud Alert Form

What is the complaint regarding? *Healthcare FraudFraud, waste or abuse by an HWC employeeWhistleblower retaliationGrant/Contract fraudQuality of CareMedical Identity theftOther

OtherPlease indicate what this complaint is regarding.

Program *AdministrationHead StartOptometryMedicalDentalSubstance Use DisorderPharmacyOther

Other ProgramPlease define other program.

Facility *Select OneChecotahEufaulaPoteauMcAlesterSallisawStiglerWarnerWilburtonChecotah PharmacyEufaula PharmacyHoover DrugHead Start - BriggsHead Start - ChecotahHead Start - Grand ViewHead Start - HartshorneHead Start - McAlester EarlyHead Start - McAlester WashingtonHead Start - McCurtainHead Start - WoodallHead Start - QuintonHead Start - RolandHead Start - RyalHead Start - Sallisaw EarlyHead Start - SallisawHead Start - Stigler EarlyHead Start - StiglerHead Start - Tahlequah EarlyHead Start - TahlequahHead Start - TenkillerHead Start - VianHead Start - Westville EarlyHead Start - WestvilleHead Start - WilburtonHead Start - Stigler AdministrationHead Start - Tahlequah Administration

Date activity occurred *

Is the activity still occurring? *YesNo

When did the activity end? *

Has the concern been previously reported? *YesNo

Identify the party responsible for the activity you are reporting. *BusinessIndividualUnsure

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)

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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.

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City

State/Province

Email Address

Date of Birth

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