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Anti-Fraud Fraud & Abuse Tip Referral Form

Please complete this form if you believe that fraud and/or abuse may have occured to you, a family member, or a coworker. Any individual, entity, or group that is employed by or provides a service on behalf of Independence Blue Cross (including employees, subscribers, professional providers, employees of a provider, facilities, or billing companies) may be the subject of the complaint.

The form will be forwarded to the Corporate and Financial Investigations Department for review/evaluation. You will receive a response to your complaint, unless you choose to remain anonymous.

Your Information – Not Required








« Required
« Required


Subject You Are Reporting



Provider
Member
Employee
Group
Other









Summary of Complaint



Yes
No