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Fraud, Waste or Abuse complaint form

Reports can be made anonymously. You may share your contact information with Priority Health and request your name not be used. Your name will be left out of the investigation but if we need additional information it would allow us to contact you.

Mail: Fraud and Abuse Program
Priority Health, MS 3175
1231 East Beltline NE Grand Rapids, MI 49525-4501

Email: SIU@priorityhealth.com

Thank you!

1. Name (optional)

2. Phone number (optional)

3. Email (optional)

4. Would you like to remain anonymous *This question is required.

5. May Priority Health contact you? *This question is required.

6. Your status, are you a: *This question is required.

Member
Physician
Employer
Hospital
Law Enforcement
Other Please enter an 'other' value for this selection. * This question is required.

7. Your complaint is against: *This question is required.

Member
Physician
Employer
Hospital
Law Enforcement
Other Please enter an 'other' value for this selection. * This question is required.

8. Summary of complaint and individuals involved (Please list details of complaint including: Names, contact information including address and phone number, details of incident or services such as date of service/incident, copayment, etc. You can also include support materials such as Explanation of Benefits (EOB) that provide examples of your concern.) *This question is required.

9. Today's date *This question is required. This question requires a valid date format of MM/DD/YYYY.

calendar

10. If needed, please attach additional documents here.

File: {{filename}} delete