Special Investigations Referral Form

Required Fields

First name This field does not match the required pattern. MI Last name This field does not match the required pattern.
Phone number This field does not match the required pattern. Email This field does not match the required pattern.
Address 1 Address 2
City State Select Alaska Alabama Arkansas Arizona California Colorado Connecticut Washington DC Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming ZIP code This field does not match the required pattern.

Tell us about the situation you're reporting

Is the member involved a Medicare member? Yes No I don't know
Is the member involved a Medicaid member? Yes No I don't know
Subject to be investigated Provider Provider name(s) Patient Patient name(s) Agent Agent name(s) Other person or group Other person or group name(s)
Describe the situation
Describe how you became aware of this issue