FirstCare Health Plans
Legal Department
HIPAA Violation Form

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Section 1: Complainant's Information First Name * First Name is required. Last Name *   Address City State Texas New Mexico ZIP Telephone * Email * Date of Occurrence     * Indicates required fields.   Section 2: The Allegation   Please explain the nature of the complaint/ allegation exactly as it occurred. Please provide detailed information on the alleged fraudulent incident in the space provided below. Please be as detailed as possible on this form. Thank you for reporting this matter to the FirstCare -SIU.