FirstCare Health Plans
Special Investigations Unit
Incident Report 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 *   * Indicates required fields.   Section 2: Complaint Information Type of Incident Medicaid Fraud Medicare Fraud HMO/PPO Internal or Other fraud incident   If reporting Medicare/Medicaid Fraud Please Provide:   Alleged Person's Medicare No. (if available)   Alleged Person's Medicaid No. (if available)   If reporting HMO/PPO Fraud Please Provide:   Member ID No.   Member Group No.   Occurrence Details   Date of Occurrence   Location of Occurrence   City   State Texas New Mexico   Alleged Subject Information   First Name   Last Name   Address   City   State Texas New Mexico   Zip   Telephone   Email   Alleged Subject is a: Member Physician PAC RN/Nurse Other   Other Parties who are suspected of Fraud.   First Name   Last Name   Address   City   State Texas New Mexico   Zip   Telephone   Email   Section 3: 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.