United Concordia Co., Inc. E-Mail


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)

Special Investigations Unit Online Fraud Complaint Form

Please complete this form as accurately as possible