Online Insurance Fraud and Abuse Report Form

To report suspected Fraud, Waste and/or Abuse, please complete the information requested below.

Please be as specific as possible about the dates and details that will help support your allegation(s).

You can submit an anonymous complaint to report Fraud, Waste and/or Abuse to the Special Investigation Unit, or you may make a report of possible unethical or improper actions through our third-party vendor, EthicsPoint. Please submit separate entries for each suspect.

Only items marked with an asterisk (*) are required.

Person or Company Suspected of Committing the Fraud or Abuse

Name (Individual or Company):

Address Line 1:

Address Line 2:

City:

State:

Zip Code:

Telephone Number:

Profession:

Professional License#(if known):

Victim(s) (if other than Yourself)

Name:

Address Line 1:

Address Line 2:

City:

State:

Zip Code:

Daytime Telephone Number:

BCBSF Contract # (if applicable):

Complainant (Yourself)

Your Name:

Address Line 1:

Address Line 2:

City:

State:

Zip Code:

Daytime Telephone Number:

Email Address:

Have you attempted to contact the person(s) suspected of committing the fraud/abuse concerning your complaint?

Yes No

If Yes,when?

Witnesses

Please list all individuals who may have knowledge concerning the activity that may be fraudulent or abusive. If you need to list additional witnesses, please do so in the comments section of this report. Please give full name, address and phone number(s).

Witness Name:

Address Line 1:

Address Line 2:

City:

State:

Zip Code:

Home Number:

Work Number:

Describe the Fraud/Abuse

Please provide as much information as possible concerning your complaint. Be sure to include all details such as dates,times, where it took place, etc.

Description of Fraud or Abuse:*

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FB FRD 002 NF 102022

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Online Fraud and Abuse Report Form

To report suspected Fraud, Waste and/or Abuse, please complete the information requested below.

Person or Company Suspected of Committing the Fraud or Abuse

Victim(s) (if other than Yourself)

Complainant (Yourself)

Witnesses

Describe the Fraud/Abuse