Humana Military Program Integrity Referral Form
 
If you, in good faith, have a suspicion that a TRICARE provider or a beneficiary have committed an act of fraud or abuse, you may report this suspicion to Humana Military Program Integrity. All allegations of fraud and abuse are investigated to determine whether there is sufficient evidence to report the case to the government for further investigation.

Please complete as many of the following fields as you have knowledge. You may remain anonymous; however, it may be beneficial to the Program Integrity Unit to contact you for additional information, if possible.

   Referral Details
  Is the subject a beneficiary or a provider?
  Beneficiary  Provider 
         
  Name of Subject to be investigated:
 
First Name   Last Name
 
  Address 1 of Subject:  
  Address 2 of Subject:  (optional)  
  City:
  State:  Zip Code:  
 
  Telephone of Subject: ( ) -  Ext:  
  Federal Tax Identification Number:  
     
   Allegation Information
   
  Detailed Allegation (Please be as specific as possible, including dates, names, etc.) :
   
   
  How did you become aware of this allegation?
   
   
  Has any correspondence occurred between you and the subject that may be helpful to the investigation?
  Yes  No 
   
  If yes, what does this consist of?
   
   
  Are you aware of another individual who may be helpful to the investigation?
  Yes  No 
   
  If so, list name and contact information:
  Contact Name:
 
First Name   Last Name
 
  Contact Address 1:  
  Contact Address 2:  (optional)  
  City:
  State:  Zip Code:  
 
  Telephone: ( ) -  Ext:  
  Contact Email Address:  
     
   
  May Humana Military Program Integrity contact you to follow-up on this allegation?
  Yes  No 
   
  If so, list your name, address, phone and/or e-mail:
  Name:
 
First Name   Last Name
 
  Address 1:  
  Address 2:  (optional)  
  City:
  State:  Zip Code:  
 
  Telephone: ( ) -  Ext:  
  Email Address: