Application For Healthcare Fraud Complaint Form - Division Of Professional Licensure
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1
2DIVISION OF PROFESSIONAL LICENSURE
OFFICE OF INVESTIGATIONS
Application for Healthcare Fraud Complaint
617-727-7406
Date Received (stamp):
Docket #:_________-_____-_______
Entered into the Database (Date): ______/ ______/ _____
Acknowledgement letter sent (Date): _____/ _____/ _____
Signature: ________________________
-----------------------------------------------------------------------------------------------------------------------------------------------
Please complete this form as fully as possible.
Please type or print legibly in ink.
(PLEASE DO NOT WRITE ABOVE LINE.)
SUBMITTED BY (INCLUDE COMPANY NAME IF AN INSURANCE COMPANY, ETC.):
/
Name:
______________________________
Last Name
First Name
COMPANY
Address:
Number
Street
Phone
City
State
Zip Code
Alternate Phone (optional)
E-mail:_________________________________
LICENSEE SEEKING COMPLAINT AGAINST (use separate form for each licensed individual/business AND
if complaint involves multiple patients, you must submit a separate form for each patient):
Name:
Last Name
First Name
M.I.
Address:
______________________
Number
Street
Daytime Phone
___________________________
City
State
Zip Code License Number/Type Class
_________________________________________________________________________________
Business Name
______________________
Business Address
Daytime Phone
_____________________________
_____________________________
City
State
Zip Code
Business License # / Type Class
Please check the trade or profession that this application for complaint pertains to:
____Audiologist/Speech Language Pathologist
____Chiropractor
____Occupational Therapist
____Optometrist
____Physical Therapist
____Podiatrist
____Psychologist
____Mental Health Counselor
____Social Worker
____OTHER:___________________________
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