Healthicity Audit and Compliance Solutions

Community First Health Plans

Provider Suspicious Activity Report

Use this form to report fraud, waste, or abuse (or any suspicious activity) by a Community First Health Plans Provider. Please provide detailed information about the suspicious activity or possible FWA and send all additional documentation to SIURequests@CFHP.com.

You may remain anonymous if you prefer. But if we need more information, it is best to be able to contact you so that we can complete our investigation as thoroughly as possible. All information received or discovered by Community First Special Investigations Unit (SIU) will be treated as confidential, and the results of investigations will be shared only with persons having a legitimate reason to know the information.

Date observed or first noticed

Who or what was affected?

Reporter: Please fill in the information below about the person providing this information.

Name of Person Reporting:

Department (if internal)

Street Address:

City:

State:

Zip Code:

Email:

Work Telephone:

Fax Number:

Physician/Provider/Healthcare worker/Group/Facility: Please fill out this section to report a physician, provider, healthcare worker, group or facility. If not reporting a physician, provider, healthcare worker, group or facility this section can be left blank.

Group/Facility Name:

PROVIDER NAME:

PROVIDER TYPE:

SPECIALTY:

TPI or Vendor Facility Number (if known)

License No.

Provider Street Address:

Provider City:

Provider State:

Provider Zip Code:

Provider Phone:

Provider Fax:

Summary of Events: Please provide the details of the suspicious activity.

Type of Complaint

Program Plan

Description of event(s) or concerns

Do you have additional supporting documents/medical records? If so, send attachments to SIURequests@CFHP.com.

For more information about fraud, waste, and abuse, or to make a report using our online form, please go to: CommunityFirstHealthPlans.com/fraud-waste-abuse.

Please provide detailed information about the suspicious activity or possible FWA and send all additional documentation to SIURequests@CFHP.com.