Dwc Medical Unit Report Of Suspected Medical Care Provider Fraud Page 2
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3Description of the alleged fraudulent activity: Please provide as much detail as possible, including the
nature of the unlawful act, why you believe that the activity you are reporting constitutes fraud, names, dates
and documents.
Please attach additional sheets if necessary and provide a copy of any relevant
documentation you have. PLEASE DO NOT ATTACH ORIGINAL DOCUMENTS.
DWC Form SMBFR 1115 (Rev.3/2006)
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