# CID#\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**FRAUD AND ABUSE REFERRAL FORM DATE:**

**Medicaid (MA) Fraud Unit \[\] Medicare Part A \[\] Medicare Part B
\[\] DMERC Region B \[\] Other:**

**Dept. of Justice United Gov. Services WPS AdminaStar Federal
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**P.O. Box 7857 1515 N. Rivercenter Dr. P.O. Box 1787 P.O. Box 6128
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Madison, WI 53707-7857 Milwaukee, WI 53212 Madison, WI 53701
Indianapolis, IN 46206 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**From: (Your Name) Organization: County:**

**Address: City: State: Zip:**

**Phone: (With Area Code) Fax \# E-Mail (If Applicable)**

**Beneficiary Name: Medicare #: Medicaid #:**

**Address: Phone #: (With Area Code)**

**City: State: Zip:**

**Beneficiary Can Be Contacted at:**

**Between \_\_\_\_\_\_ a.m. and \_\_\_\_\_\_\_\_ p.m.**

**Complaint Against: (Name of facility, provider, physician, lab,
supplier, etc.) Claim \# (If appropriate)**

**Date(s) of Service:**

**Business Address: Phone: (With Area Code)**

**Provider Number:**

**City: State: Zip:**

Please describe your complaint. If known, include procedure code and/or
description of service, amounts billed, amount you paid, etc. You may
continue on the next page if you need more room. If you feel you were
billed for services or supplies that were not provided, continue on with
the non-rendered service section below.

CID \# Page 2

Description of Complaint (Continued)

Non-rendered Services Section:

**Did you see any provider that day? \_\_\_\_\_\_\_\_\_\_\_\_\_\_ If
yes, who? (Physician's Assistant, Nurse, Lab, X-ray Technician)**

**Was the service(s) provided on another day?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ If yes, when?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Have you ever seen the provider
listed?\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ If yes, when?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

## Have you contacted the provider/supplier regarding this billing? \_\_\_\_\_\_ Yes \_\_\_\_\_ No

**If yes, to whom did you speak and what was the result of the
conversation?**

## Release of Information: Please read carefully and sign where indicated

**I,
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_,
hereby authorize
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ and**

**[The Coalition of Wisconsin Aging Groups]{.underline}\_ to discuss my
complaint with
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ for the
purpose of investigating possible fraud or abuse.**

**I understand that, except for action already taken, I may revoke this
authorization at any time. I also understand that a photocopy of this
authorization has the same effect as the original. I further understand
that the parties named above will not disclose this information to
anyone else without my consent. This authorization expires one (1) year
from the date on which it is signed.**

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Signature Date**

Important: Please attach the appropriate Medicare and/or Medicaid
Explanation of Benefits relating to this incident. Also attach any other
information you feel may be important to this complaint. When completed
mail to: CWAG, 5900 Monona Drive Suite 400, Madison, WI 53716.