Unison Health Plan - Fraud, Waste, and Abuse

Information we receive from this form is strictly confidential. Other than the responses you submit on this form, our system will not obtain your email address, computer name, or any other personally identifiable information.

I Am Reporting A :

Employee Suspected of Fraud:
Name:
ID Number:
Address:
City:	State: Zip:
Phone:
Incident Date(s):
Complaint:

Your Information:
Name:
Address:
City:	State: Zip:
Home Phone:	Work Phone:
Email Address: