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Health Care Fraud & Abuse Referral Form

Date: ____________________________ Please attach all necessary documentation Name of Beneficiary: ____________________________________________________________ Address: ______________________________________________________________________ City: _______________________________________    State: ____    Zip: _________________ Phone #: (_____)__________________________ Medicare #: ___________________________    Medicaid #: ____________________________ Provider: ______________________________________________________________________ Provider Address: _______________________________________________________________ City: _______________________________________    State: ____    Zip: _________________ Date(s) of Service: ______________________________________________________________ Nature of Complaint: ____________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

Attachments:	Mail or Fax:
[  ] EOMB Explanation of Medical Benefits	[  ] Medicare A
[  ] Medicare Summary Notice	[  ] Medicare B
[  ] Bills or statements	[  ] Medicaid Fraud Unit
[  ] Consent Form	[  ] Durable Medical Eqmt.

Name of Counselor: ____________________________________________________________ Site Address: _________________________________________________________________ Phone #: (_____)__________________________    Fax#: _____________________________ [  ] Copy to:      Protecting Quality Health Care-New Hampshire Senior Advocacy Program      2 Industrial Park Drive      Concord, NH 03301      228-0223/1-877-228-0223