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Report Suspected Provider Fraud
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Today's Date
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Your Last Name:
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Your First Name:
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Your Telephone Number:
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Your Email Address:
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Please describe the suspected fraud, waste and/or abuse you would like to report:
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When did the event occur?
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DD
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Name of Provider:
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Your answer
Business Address of the Provider
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Provider Telephone Number:
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First and Last Name of Colorado Health First (Medicaid) Member, if known:
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Member Street Address:
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Member ID:
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Member Telephone Number:
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Member Email Address:
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