Dwc Medical Unit Report Of Suspected Medical Care Provider Fraud
Download a blank fillable Dwc Medical Unit Report Of Suspected Medical Care Provider Fraud in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Dwc Medical Unit Report Of Suspected Medical Care Provider Fraud with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3PRINT CLEAR
SAVE
DWC Medical Unit
P.O. Box 71010
Oakland, CA 94612
Report of Suspected Medical Care Provider Fraud
Labor Code section 3823 requires any insurer, self-insured employer, third-party administrator, workers' compensation
administrative law judge, audit unit, attorney, or other person that believes that a fraudulent claim has been made by any person or
entity providing medical care, as described in Labor Code section 4600, to report the apparent fraudulent claim in the manner
prescribed by the reporting protocols adopted by the administrative director of the Division of Workers’ Compensation.
Complaining party (Please check the box that best describes you. Insurers, self-insured employers or
third-party administrators should not use this form. These entities should use the Department of insurance
suspected fraudulent claim referral form (FD-1).):
Person submitting the complaint:
Injured worker
Attorney
Physician
Other
Name:
Company:
Address:
City:
State:
Zip Code:
Home telephone number: (
)
Work telephone number: (
)
E-mail:
Preferred place to contact you: (check one) Home_____ Work _____
Complaint against (
If more than one provider is involved, please attach additional sheets identifying each one):
Name:
Company:
Address:
City:
State:
Zip Code:
Type of health care provider: ____________________________________________________________
DWC Form SMBFR 1115 (Rev.3/2006)
1
ADVERTISEMENT
0 votes
Related Articles
Related forms
Dd Form 2951 - Initial Report Of Suspected Child Sexual Abuse In Dod Operated Or Sponsored Out-of-home Care Activities
Business
Confidential Report Of Suspected Dependandent Adult / Elder Abuse - State Of California - Health And Human Services Agency
Legal
Related Categories
Parent category: Legal