Provider Fraud Complaint (F262-289-000). Provider Fraud Complaint (F262-289-000) 2025

1. Click ‘Get Form’ to open the Provider Fraud Complaint (F262-289-000) in the editor.
2. Begin by filling out the 'Provider Information' section. Enter the provider’s name, street address, city, state, zip code, business/clinic name, and phone number. If applicable, include the claim number.
3. In the 'Fraud Reporting' section, check all types of fraud you are reporting. Options include billing for services not provided, double billing, and misrepresenting service details.
4. Provide a detailed 'Summary of Complaint' that outlines your concerns clearly and concisely.
5. Indicate whether you have documentation to support your complaint by selecting 'Yes' or 'No'. If 'Yes', ensure to attach it when submitting.
6. If there are other contacts for further information, fill in their names, phone numbers, and email addresses as needed.
7. Finally, enter your own contact information at the bottom of the form before submitting it via email.

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