<% Response.Buffer = True ' ///////////////////////////////////////////////////////////////////// ' ' Gary Gutierrez, April 15, 2004 ' ' Why: ' Level-3 pages are to display a footer with links based on the page's ' primary audience. The footer script sets the default value for ' Plans and Providers as they are the highest user of our web site. ' ' How: ' If Plans & Providers are the pages intended audience nothing need be done. ' Should the page need to display a footer for another of the available ' audience, place this script block at the top of the ASP page and set the ' displayFooter value as outlined below. ' ' Or ' ' Pass a footer value parameter in a variable named: ft ' Example: To display a Studies & Stats footer: /Publications/Manual/toc.asp?ft=3 ' ' === Generic Footer Links for Level-3 pages === ' 1 = Members & Applicants ' 2 = Plans & Providers [this is the default set in the footer script] ' 3 = Studies & Stats (aka Research) ' 4 = Contracts & RFPs ' //////////////////////////////////////////////////////////////////// Dim displayFooter displayFooter = 2 %> Referral for Preliminary Investigation

Referral for Preliminary Investigation

Referrer Information - Optional

IMPORTANT!
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The information you provide on this form will be submitted ANONYMOUSLY to the AHCCCS Office of Program Integrity (OPI) when you click the "Submit" button.  The sender cannot be identified from this e-mail.  If you wish to identify yourself or receive a call back from OPI, please supply your name and phone number in the spaces provided below:

Today's Date:
Your Name:
Title:
(if applicable)
Organization:
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Address 
Phone Number (where you can be reached between 7:30 am - 4:30 pm)
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Provider/Health Plan Information - If Applicable

Does the information you wish to provide concern a:

Health Care Plan Plan Name:
Health Care Provider Provider Name:
AHCCCS Member Member Name:
Other Specify Other:
 

Suspect Information - If Applicable 

Name of person(s) [Suspect] committing the fraud (if known):
Address of Suspect (if known):
 

Other Identifying Information of Suspect (if known):
AHCCCS Provider Number:
Social Security Number:
Date of Birth or Approximate age:
Amount of Loss to the AHCCCS program (if known): $

Narrative Description of Issue

Please describe the nature of the alleged fraud, waste, or abuse:

If the information above is correct, click the "Submit" button below to send the information to the AHCCCS Office of Program Integrity.  If you have made a mistake you may change the information before you submit it.  If you would like to clear all of the information on this form and begin again, click on the "Clear Form" button below.