Healthicity Audit and Compliance Solutions

Community First Health Plans

Member Suspicious Activity Report

Use this form to report fraud, waste, or abuse (or any suspicious activity) by a Community First Health Plans Member. 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?

Name of Person Reporting:

Department (if internal)

Street Address:

City:

State:

Zip Code:

Email:

Work Telephone:

Fax Number:

Program Plan

Type of Complaint

Member/Patient Name:

Date of Birth:

Member ID Number:

Member/Patient Street Address:

Member/Patient City:

Member/Patient State:

Member/Patient Zip Code:

Member/Patient Phone Number:

Member/Patient Email:

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.