Anti-Fraud

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:
Street Address 1:
Street Address 2:
City:
State:
Zip:
Email Address:
Phone Number:

Subject You Are Reporting

First Name:
Last Name:
Type: Provider
Member
Employee
Group
Other
TAX ID# / PBS ID#:
Health Plan:
Street Address 1:
Street Address 2:
City:
State:
Zip:
Phone Number:

Summary of Complaint

*Summary of Complaint:

*Would you like to remain anonymous? Yes
No

To ensure your privacy, all information will be sent via a secure connection. AmeriHealth will not disclose any personal information to outside persons or entities unless we have written consent or unless authorized by law.

Please see our Notice of Privacy Practices for more information.