SMP HAWAII FRAUD REPORTING AND REQUEST FOR COUNSELING FORM


YOU DO NOT HAVE TO COMPLETE THIS FORM ENTIRELY. IF YOU PREFER, YOU MAY GIVE ONLY YOUR NAME AND PHONE NUMBER OR EMAIL ADDRESS. LATER, SMP MAY NEED ADDITIONAL INFORMATION IF WE ARE TO ASSIST YOU.


Complainant Information (Person Making the Report):


Beneficiary Information (Person With Medicare)


MEDICARE (Original MEDICARE: Part A and/or Part B)


Nature of Complaint (type "N/A" if the nature of the complaint does not apply to you)


Subject of Complaint (Whom the Complaint Is About)


SMP HAWAII WILL NOT CONTACT THIS INDIVIDUAL OR BUSINESS WITHOUT GETTING YOUR PERMISSION FIRST.


THE INFORMATION ON THIS FORM WILL BE TRANSMITTED SECURELY TO SMP HAWAII AND WILL ONLY BE SEEN BY SMP HAWAII AND LAW ENFORCEMENT AUTHORITIES TO WHICH SMP HAWAII MAY REFER YOUR COMPLAINT FOR FURTHER ACTION.

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