Anti-Fraud

Fraud and Abuse Tip Referral Form

Please complete this form if you believe that fraud and/or abuse may have occured to you, a family member, or a coworker. Any individual, entity, or group that is employed by or provides a service on behalf of Independence Blue Cross (including employees, subscribers, professional providers, employees of a provider, facilities, or billing companies) may be the subject of the complaint.

The form will be forwarded to the Corporate and Financial Investigations Department for review/evaluation. You will receive a response to your complaint, unless you choose to remain anonymous.

(* Required fields)

Your Information — Not Required

Your First Name:

Your Last Name:

Your Phone Number:

Address:

Address 2:

City:

State:

ZIP:

Email Address:

Subject You Are Reporting

* First Name:

* Last Name:

* Address:

Address 2:

* City:

* State:

* ZIP:

* Phone number:

* Type:

Tax ID# / PBS ID#:

* Health plan:

* Summary of Complaint:

* Would you like to remain anonymous?

Yes
No