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. Items marked with an asterisk (*) are required.

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SUSPECT OF COMMITING THE FRAUD/ABUSE:

Name (Individual or Company):Optional

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Address Line 1:Optional

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Address Line 2:Optional

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City:Optional

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State:Optional

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ZIP Code:Optional

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Telephone Number:Optional

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(xxx)xxx-xxxx

Profession:Optional

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Professional License#(if known):Optional

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LIST VICTIM(S) IF OTHER THAN YOURSELF:

Name:Optional

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Address Line 1:Optional

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Address Line 2:Optional

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CityOptional

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State:Optional

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ZIP Code:Optional

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Daytime Telephone Number:Optional

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(xxx)xxx-xxxx

BCBSF Contract # (if applicable):Optional

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COMPLAINANT(Yourself):

Your Name:Optional

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Address Line 1:Optional

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Address Line 2:Optional

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City:Optional

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State:Optional

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ZIP Code:Optional

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Daytime Telephone Number:Optional

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(xxx)xxx-xxxx

Email Address:Optional

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example@aol.com

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

Yes No

If Yes,when?Optional

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WITNESSES ( Please give full name, address and phone number):

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.

Witness Name:Optional

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Address Line 1:Optional

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Address Line 2:Optional

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City:Optional

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State:Optional

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ZIP Code:Optional

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Home Number:Optional

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Work Number:Optional

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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:* Required

This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.