Dwc Medical Unit Report Of Suspected Medical Care Provider Fraud Page 3
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3Claim information (If more than one injured worker’s care is involved, please attach additional sheets):
Date of injury: ___________________ WCAB case number(s) (if known): ________________________
Name of injured worker: ________________________________________________________________
Address: _____________________________________________________________________________
City: _________________________________________ State: _____________ Zip Code: ___________
Injured worker’s Social Security number (if known): __________________________________________
Injured worker’s date of birth (if known): __________________________________________________
Name of employer at date of injury:
Address:
City: _________________________________________ State: _____________ Zip Code: ___________
Location where injury occurred:
Name of insurer or third party administrator:
Address:
City: _________________________________________ State: _____________ Zip Code: ___________
Claims administrator’s claim number (if known): ____________________________________________
Reports to other agencies Has the suspected fraudulent activity been reported to any law enforcement or
professional licensing board? If so, please identify the agency, contact person and telephone number.
Report submitted by
Signature: _________________________________________________ Date: ____________________
Please print your name:
Where to report (Send this completed form and photocopies of relevant supporting documents to):
Division of Workers’ Compensation-Medical Unit
P.O. Box 71010
Oakland, CA 94612
DWC Form SMBFR 1115 (Rev.3/2006)
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