SIU Incident Report Form | Firstcare


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FirstCare Health Plans
Special Investigations Unit
Incident Report Form

First Name: *

Last Name: *

Address:

City:

State:

Zip:

Telephone: *

Email: *

Type of Incident:

Medicaid Fraud

Medicare Fraud

HMO/PPO

Internal or Other fraud incident

Alleged Person's Medicare No. (if available) :

Alleged Person's Medicaid No. (if available) :

Member ID No.:

Member Group No.:

Date of Occurrence:

City of Occurrence:

State of Occurrence:

First Name:

Last Name:

Address:

City:

State:

Zip:

Telephone:

Email:

Alleged Subject is a:

First Name:

Last Name:

Address:

City:

State:

Zip:

Telephone:

Email:

Please explain the nature of the complaint/ allegation exactly as it occurred. Please provide detailed information on the alleged fraudulent incident in the space provided below. Please be as detailed as possible on this form. Thank you for reporting this matter to the FirstCare -SIU.

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