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Reporting Fraud and Abuse

Please complete the following form if you suspect an incident of fraud or abuse has occurred.

Who do you suspect is committing fraud?

Member
Physician	Physician speciality:
Other provider	Provider speciality:
Other	Please describe:

Name:
ID Number:
Address:
City:
State:
Zip Code:
Home Phone:

What fraudulent activity occurred? (Please describe in as much detail as possible.)

You may contact me if additional information is necessary.
I wish to remain anonymous.

Name:
Address:
City:
State:
Zip Code:
Home Phone:
Work Phone:
Cell Phone:
Best Time to Call:
E-mail Address:

Please review before submitting. To make changes, click "Edit". When complete, click "Submit".

Who do you suspect is committing fraud?

Member
Physician
Other provider
Other

Name:
ID Number:
Address:
City:
State:
Zip Code:
Home Phone:

What fraudulent activity occurred? (Please describe in as much detail as possible.)

You may contact me if additional information is necessary.
I wish to remain anonymous.

Name:
Address
City:
State:
Zip Code:
Home Phone:
Work Phone:
Cell Phone:
Best Time to Call:
E-mail Address:

Thank you for your report. It has been forwarded to BCBSAZ's Special Investigations Unit.

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