Fraud & Abuse Tip Referral Form

Please complete this form if you believe that fraud and/or abuse may have occurred to you, a family member, or a coworker. Any individual, entity, or group that is employed by or provides a service on behalf of AmeriHealth (including employees, subscribers, professional providers, employees of a provider, facilities, or billing companies) may be the subject of the complaint.

The form will be forwarded to the Corporate and Financial Investigations Department for review/evaluation. You will receive a response to your complaint, unless you choose to remain anonymous.

Your information – not required

First name:

Last name:

Address:

Address 2:

City:

State:

ZIP:

Email address:

Phone number:

Subject you are reporting (* required fields)

* First name:

* Last name:

* Type:

TAX ID# / PBS ID#:

* Health plan:

* Street address 1:

Street address 2:

* City:

* State:

* ZIP:

* Phone number:

* Summary of complaint:

* Would you like to remain anonymous?

Yes No