reportfwa

Report of Possible Fraud, Waste or Abuse

Use this form to report any known or suspected activities. All reports received are confidential and you will never experience retaliation as a result of making a good faith report. You may also report anonymously by calling the Fraud Hotline at (800) 392-9249.

Name and contact information of individual reporting the alleged fraud or abuse.

Name of Reporter

Phone of Reporter

Email of Reporter

Classification of Reporter*

Description of Complaint and/or Allegation*

Complaint Source* (How did the reporter find out about this issue?)

I prefer not to be contacted

Has the reporter previously reported this issue?

Who is suspected of committing fraud, waste or abuse?

Classification of Suspect*