Benefits Administration

Report Fraud or Abuse of a State of Tennessee Sponsored Insurance Program

Please complete as much information as possible.

If it is your desire, you can remain anonymous; however, if you wish to speak with someone regarding your complaint, please indicate below and provide contact information.

Please contact me regarding this complaint.
Daytime phone
E-mail
Are you reporting Doctor Health Care Professional Individual
Person you are reporting
Name
Other names used (if known)
SSN (if known)
Street address
Apartment #
City, State, Zip
Other addresses used
Home phone (include area code)
Work phone (include area code)
Employer's name
Employer's address
Employer's phone
What is your complaint? (In your own words, explain the problem)
What event led you to feel there was a problem?
Have you notified anyone of this problem?	Yes No
Who have you notified? (provide name and phone number, if known)
Have you notified anyone else? (provide name and phone number, if known)
Person Making Complaint (optional)