Fraud, Waste, and Abuse Referral Form

To submit a FWA referral directly to Clever Care’s Special Investigations Unit (SIU), fill out this form and provide as much detail as possible. If you wish to report anonymously, you do not have to provide your personal information.

 

NOTE: No attempt will be made to discover the identity of someone making an anonymous report. However, be aware if a referral does not have sufficient information, we may not be able to take further action.

Referral Source Information (If you wish to report anonymously, you do not have to provide your information)

Type of Issue

Member Involved

Provider Involved

Claim Information (if applicable)

Description of Findings/Allegations