Please be aware that all information submitted through the form is not confidential. Any information you provide will be referred to appropriate CHCAA corporate members, and may result in administrative and/or enforcement activity. It will also be used to identify emerging fraud schemes and trends. As a result, should you choose to leave your contact information, your identity cannot be protected.
If you want to remain anonymous, do not submit any personal information on the form!
REPORT DETAILS
Please fill in as much information in the following fields as you have about the incident or activity you wish to report.
· Fraud Details
· If you know the name of the health care provider or claimant engaging in fraudulent activity
· Do you have a phone number for the health care provider or claimant?
· Do you have an address for the health care provider or claimant?
· Do you know the claimant’s date of birth?
· What is the name of the party being defrauded?
· If you have a specific date related to this incident
OPTIONAL
If you would like us to contact you regarding this report, you can submit your contact information. Otherwise, this tip will be left anonymous. Not even your IP address will accompany this tip.
· Name
· Email
· Phone
· Contact Instructions
Please visit www.chcaa.org/report to fill up the actual form and submit your report to us
*Note: By submitting the form, you accept the [Mollom privacy policy](https://mollom.com/web-service-privacy-policy).