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Online Insurance Fraud and Abuse Report Form

To report suspected insurance fraud or abuse, please complete the information requested below. Items marked with an asterisk (*) are required. The report will not submit electronically if information in these fields is missing. Please be as specific as possible about dates and details, and include any information that will help support your allegation. If you would prefer to print the Report Form and submit it by mail, click here to download the form in PDF format and send it to:

Blue Cross and Blue Shield of Florida, Inc.
Special Investigation Unit
PO Box 44193
Jacksonville, FL 32231-4193

Please submit separate entries for each suspect. Items marked with an asterisk (*) are required.

SUSPECT OF COMMITTING THE FRAUD/ABUSE:
*Name (Individual or Company):
*Address Line 1:
Address Line 2:
*City:
 *State:
 *ZIP Code:
Telephone Number:
(xxx)xxx-xxxx
Profession:
 Professional License # (if known):


LIST VICTIM(S) IF OTHER THAN YOURSELF:
Name:
Address Line 1:
Address Line 2:
City:
 State:
 ZIP Code:
Daytime Telephone Number:
(xxx)xxx-xxxx 		BCBSF Contract # (if applicable):


COMPLAINANT (Yourself):
*Your Name:
*Address Line 1:
Address Line 2:
*City:
 *State:
 *ZIP Code:
*Daytime Telephone Number:
(xxx)xxx-xxxx 		Email Address:
example@aol.com
Have you attempted to contact the person(s) suspected of committing the fraud/abuse concerning your complaint?
Yes    No If Yes, when?  


WITNESSES (Please give full name, address and phone number):
Please list all individuals who may have knowledge concerning the activity that may be fraudulent or abusive. If you need to list additional witnesses please do so in the comments section of this report.
Witness Name:
Address Line 1:
Address Line 2:
City:
 State:
 ZIP Code:
Home Number:
(xxx)xxx-xxxx 		Work Number:
(xxx)xxx-xxxx
Witness Name:
Address Line 1:
Address Line 2:
City:
 State:
 ZIP Code:
Home Number:
(xxx)xxx-xxxx 		Work Number:
(xxx)xxx-xxxx


*DESCRIPTION OF FRAUD OR ABUSE:
Please provide as much information as possible concerning your complaint. Be sure to include all details such as dates, times, where it took place, etc.