Fraud and Abuse Response Form

Please use this form to report suspected fraud or abuse of services paid for by Maryland Physicians Care. Please complete as much of the requested information as you can below.

* = Required Fields  

*Name:
*Provider or Practice Name:
Address:
City:
*State:	-- Select State -- Alaska Alabama Arkansas Arizona California Colorado Connecticut D.C. Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming
ZIP Code:
Phone:
Ext:
Please include other information about the suspected member or provider. This may include their ID number, license number, etc.:
*Please describe the activity that may be fraud or abuse. Some examples are: billing for services you did not receive, billing for services that were not provided, or someone using your identity to received medical services. Please provide details that tell us 'who, what, when, where, why and how.':
Optional information: We would like to be able to discuss your response with you. Please provide your name, phone number, address and/or email address below. We will contact you for more information if needed. If you provide your contact information, your identity will be protected to the extent allowed. Thank you for helping Maryland Physicians Care’s efforts to detect fraud and abuse.
Name:
Address:
City:
State:	-- Select State -- Alaska Alabama Arkansas Arizona California Colorado Connecticut D.C. Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming
ZIP Code:
Phone:
Ext:
Email: