Forms - Health Choice Utah

SPECIAL INVESTIGATIONS UNIT (SIU)
FRAUD, WASTE, AND ABUSE (FWA) REPORTING FORM

All referalls will be submitted directly to the Special Investigations Unit (SIU). Please complete this form with as much detail and information as possible.

Date Submitted: 3/21/2023

Referral Source Information
(Please select who is making the referral)

First Name:

Middle Name:

Last Name:

Organization/Company:

Address/City/State/Zip:

Phone Number:

Email:

Subject Information
(Please select who the complaint is about)

First Name:

Middle Name:

Last Name:

Organization/Company:

Address/City/State/Zip:

Phone Number:

Email:

Allegation Information

Date or Date Range of the Incident:

From:

To:

When did you become aware of the allegation?

How did you become aware of the allegation?

Are there other winesses to this incident?

Yes

No

Allegation Details (please be as specific as possible by providing detailed information, and the who, what, where, why, and how).

Supporting Documentation and/or attachments

Select file #1 :

+ Add New Attachment