SIU Incident Report Form

FirstCare SIU Incident Report Form

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(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: who, what, when, where, why and how. Thank you for reporting this matter to the FirstCare-SIU.)

Privacy Questions or Concerns?

Questions or concerns about your rights to privacy under HIPAA or NOPP? Call the FirstCare Compliance Hotline at 1.866.399.8161 or write to:
 
FirstCare Health Plans
Attn: Privacy Officer
12940 N. Hwy 183
Austin, TX 78750

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