MEDICARE FYI

**FRAUD AND ABUSE REFERRAL FORM** Date:

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| Blue     | United    | A         | United    | Office of | Other     |
| Cross    | H         | dminaStar | G         | the       |           |
| Blue     | ealthcare | Federal,  | overnment | Attorney  |           |
| Shield   | Ins. Co.  | Inc.      | Services  | General   |           |
| of MN    |           |           |           |           |           |
|          | Medicare  | DMEFC     | Be        | Medicaid  |           |
| Medicare | Part B    | Region B  | neficiary | Fraud     |           |
| Part A   | A         |           | Services  | Division  |           |
| An       | nti-Fraud | Clea      |           |           |           |
| ti-Fraud | Unit      | ringhouse | 1515 N    | 445       |           |
| Unit     |           | Unit      | Ri        | Minnesota |           |
|          | 8120 Penn |           | vercenter | Street    |           |
| PO Box   | Avenue    | PO Box    | Drive     |           |           |
| 64357    | South     | 6128      |           | St. Paul, |           |
|          |           |           | M         | MN 55101  |           |
| St.      | Blo       | Indi      | ilwaukee, |           |           |
| Paul, MN | omington, | anapolis, | WI        | \(651\)   |           |
| 55       | MN 55431  | IN 46206  | 5         | 296-7575  |           |
| 164-0357 |           |           | 3212-3953 |           |           |
|          | \(612\)   | \(800\)   |           | Fax:      |           |
| \(651\)  | 885-2921  | 270-8313  | \(414\)   | (651)     |           |
| 456-8000 |           |           | 226-5000  | 297-4139  |           |
|          | Fax:      | Fax:      |           |           |           |
| Fax:     | (612)     | (317)     | Fax:      |           |           |
| (651)    | 885-2900  | 841-4600  | (414)     |           |           |
| 456-1050 |           |           | 226-5226  |           |           |
+----------+-----------+-----------+-----------+-----------+-----------+

**From: (Name of Person Filling Out Form)** Organization:

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City State Zip

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(inc. area code) Fax \# Email:

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Contact me at: between: a.m. and p.m.

**Regarding: (Beneficiary Name)** Medicare #:

Medicaid #:

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Address: Phone (inc. area code)

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City: State County Zip

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Ethnicity: Gender:

This information is voluntary for internal reporting purposes only.

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Contact me at: between: a.m. and p.m.

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**Complaint Against: (Name of facility, Provider, physician, lab,
supplier, etc.)**

Date(s) of Service:

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Business Name Phone (inc. area code)

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Address:

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City State Zip

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What prompted you to make a referral: Medicare FYI Fraud & Abuse Forum

Health Insurance Counseling Program

Outreach (radio, brochure, TV ad etc.)

Own initiative

Other

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 there is insufficient room on this
page.

\*If service(s) were allegedly not provided, please complete the
non-rendered service questionnaire in the following area.

**Description of Complaint (continued)**

**\*Non-rendered Services Questionnaire:**

Did you see anyone else for service that day?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ If yes, who? (Physician's Assistance,
Nurse, Lab/X-ray)

Technician, etc.
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Was the service(s) done on another day?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ If yes, on what day?
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Did you have any other services that day?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ If yes, what type of service and
where?

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**Did you already contact the provider/supplier regarding your
complaint? \_\_\_\_\_\_ Yes \_\_\_\_\_\_ No**

**If yes, who did you speak to and what did he/she say?**

**Do you have a copy of the Medicare Benefit Notice and/or bill relating
to this incident? \_\_\_\_\_\_ Yes \_\_\_\_\_\_ No**

**If yes, please send a copy with this report.**

Please attached any information pertaining to this complaint. A
completed authorization to release information is necessary to provide
information to anyone other than the beneficiary or his/her
Representative Payee.

**For Agency Use Only:**