Reporting Suspected Fraud, Waste, or Abuse

Please notify Community Health Options® if you suspect healthcare fraud, waste, or abuse has taken place. Community Health Options' Fraud Waste and Abuse team will begin researching materials such as claims records. All information received is strictly confidential. As specified under the HIPAA regulation, section 164.512 (f), Community Health Options may make referrals to law enforcement agencies for further investigation.

Request for Confidentiality^*

Confidentiality and Anonymity not requested. If necessary, Health Options may contact me for additional information and I do not place any restrictions on the release of my contact information.

I wish to remain Confidential. Health Options may contact me for additional information, but will keep my information confidential and not release any data that would identify me unless required to do so by law (e.g. court order/subpoena).

Patient Involved Information

FIRST NAME*

LAST NAME*

ADDRESS*

CITY/TOWN*

ZIP CODE*

STATE*

MEMBER ID*

PHONE NUMBER*

Person Submitting the Form

Click the checkbox if the information you provided above is the same

FIRST NAME*

LAST NAME*

PHONE NUMBER*

Person or Healthcare Provider Involved

RENDERING PRACTITIONER FIRST NAME*

RENDERING PRACTITIONER LAST NAME*

ADDRESS*

CITY/TOWN*

ZIP CODE*

STATE*

DATE OF SERVICE

GROUP OR FACILITY NAME*

CLAIM NUMBER

PHONE NUMBER*

ISSUE/CONCERN*

Reporting Suspected Fraud, Waste, or Abuse

Request for Confidentiality*

Patient Involved Information

Person Submitting the Form

Person or Healthcare Provider Involved

Request for Confidentiality^*