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Special Investigations Unit Online Fraud Complaint Form

United Concordia is committed to its members, the dental community and customers not to ignore fraud. Ignoring fraud results in higher insurance premiums.

If you have evidence that fraudulent activity may have occurred, please fill out the form below. Please provide as much information as possible pertaining to your complaint. Failure to provide sufficient information or documentation may prevent or delay the investigation of your complaint. The information will be used to determine whether a violation of the law has occurred. If a violation is substantiated, the information may be transmitted to federal or state law enforcement agencies.

Please complete this form as accurately as possible

  Name of Person Registering Complaint
  Relationship to Patient
  Patient's Name
Identification Number   (located on dental ID card)
Patient's Date of Birth
Your Daytime Telephone Number
  Email Address
  Street
  City
  State
Zip
  Name of Dental Office (required)
  Dental Office Phone Number
  Dental Office Address (required)
  In your own words, describe in as much detail as possible, the details, of the complaint including the date of the visits. (required)