Cover TN Recipient Fraud

REPORT COVERTN RECIPIENT FRAUD OR ABUSE

Send to:

STATE OF TENNESSEE
DEPARTMENT OF FINANCE & ADMINISTRATION
OFFICE OF INSPECTOR GENERAL
POST OFFICE BOX 282368
NASHVILLE, TENNESSEE 37228
FRAUD TOLL FREE HOTLINE 1-800-433-3982 · FAX (615) 256-3852
E-Mail Address: Tenncare.Fraud@state.tn.us

Please provide as much information as possible

If it is your desire, you can remain anonymous; however, if you wish to speak with an OIG representative, please check here: . If so, please provide a daytime phone number, including area code or email address:

Person You are Reporting:

(Always Provide Approporiate Zip Codes Whenever Possible)

Name

Other Names Used

Social Security Number

- -

Street Address

Apartment #

City

Zip

Other Address Used

Home Phone

Work Phone

Employer's Name

Emp. Address

Emp. City

Zip

Emp. Phone

What is your complaint?

(In your own words, describe the complaint, 1000 characters max)

What event led you to feel there was a Problem?

(In your own words, describe the event, 1000 characters max)

Have you notified the Managed Care Organization of this Problem?

No Yes

Who did you notify?

Name

Phone

Have you notified anyone else?

Name

Phone

PERSON MAKING COMPLAINT (This is Optional)

PERSON MAKING COMPLAINT ZIP CODE