Presbyterian: Espanol

Informe sobre actividades sospechosas de fraude y abuso

Llene el siguiente formulario si considera que ha ocurrido un incidente de fraude o abuso. Este formulario inicia una solicitud de investigación en la Unidad Investigativa Especial (SIU) en Presbyterian Health Plan (PHP).

Usted NO será notificado sobre los resultados de la investigación, debido a las restricciones de confidencialidad.
Llene todas las secciones importantes y presione el botón SUBMIT (Enviar) que se encuentra en la parte inferior del formulario.

Tipo de problema:	Afiliado Proveedor No estoy seguro
Nombre de la persona o empresa que sospecha que puede haber cometido fraude:
Ubicación de la persona o empresa que sospecha que puede haber cometido fraude:
Dirección (calle o apartado postal):
Ciudad:
Estado:
Código postal:
Número de teléfono:
Nombre y apellido del afiliado (si corresponde):
Describa la actividad fraudulenta lo más detalladamente posible, incluya fechas y nombres: </td> </tr> <tr> <td class="BodyBold" colspan="2">Si tiene comentarios sobre algo que no se haya cubierto en estas preguntas, escríbalos en el siguiente campo:<br/> <textarea cols="40" id="comments" name="comments" rows="4"/></td> </tr> <tr> <td class="BodyBold" colspan="2">¿Tiene los archivos que desea enviarnos como documentación?</td> </tr> <tr> <td class="BodyBold">Cargar archivo 1</td> <td><input name="file1" type="file"/></td> </tr> <tr> <td class="BodyBold">Cargar archivo 2</td> <td><input name="file2" type="file"/></td> </tr> <tr> <td class="BodyPlain" colspan="2"> <p>o</p> <span class="BodyBold">Si quiere volver a enviar documentación de apoyo:</span> <ul> <li><span class="BodyBold">Envíe un FAX a:</span> (505) 923-5924</li> <li><span class="BodyBold">Teléfono:</span> (505) 923-5959 ó (800) 239-3147</li> <li><span class="BodyBold">Enviar por correo a:</span> PHP SIU PO Box 27489 Albuquerque, NM 87125-7489</li> </ul> </td> </tr> <tr> <td class="BodyPlain" colspan="2">Quizás necesitemos más información o mayores detalles para completar nuestra investigación. <p>Proporcione su nombre y número de teléfono diurno, o dirección de correo electrónico (si lo desea) para que podamos comunicarnos con usted.</p></td> </tr> <tr> <td class="BodyBold">Nombre:</td> <td><input class="BodyPlain" maxlength="40" name="userName"/></td> </tr> <tr> <td class="BodyBold">Número de teléfono diurno:</td> <td><input class="BodyPlain" maxlength="40" name="userPhone"/></td> </tr> <tr> <td class="BodyBold">Dirección de correo electrónico:</td> <td><input class="BodyPlain" maxlength="40" name="userEmail"/></td> </tr> </tbody> </table> <p align="center"><input type="submit" value="Enviar informe de fraude"/></p></form></p> </div> </div> <div id="right"> <div class="sectionBlock styleB"> <h3>Quick Links</h3> <div class="padd"> <ul> <li><a href="http://www.nlm.nih.gov/medlineplus/" target="_blank">Answer Your Healthcare Questions with MedlinePlus</a></li> <li><a href="/PHS/hospitals/urgent/index.htm">Urgent Care Locations</a></li> </ul> </div> </div><!--/sectionBlock styleB--> <div class="promo"> <a href="/PHS/healthplans/index.htm"><img src="/idc/groups/public/@phs/@marketing/documents/phsimage/pel_00064867.jpg" alt="php_skier"/></a> </div><!--/promo--> </div> </div> </div> <div id="footer"> <div id="footerNav"> <a href="/PHS/Contact/">Contact Us</a> \| <a target="_blank" href="/PHS/myPRES/">myPRES</a> \| <a href="/PHS/Vendors/">Vendors</a> \| <a href="/PHS/Foundation/Donate/MakeAGift/">Donate</a> \| <a href="/PHS/careers/employees/">Employees</a> \| <a href="/PHS/about/disclaimer/">Disclaimer and Privacy Policy</a> \| <a href="/PHS/about/contact/feedback/">Feedback</a> \| <a href="/PHS/Search/">Search</a> <!--end phsFooter--> <p class="legal"> © <script type='text/javascript'>var now = new Date();document.write(now.getFullYear());</script> Presbyterian Healthcare Services<br />All content on this site is copyrighted by Presbyterian Healthcare Services.<br />No images or content may be reproduced for commercial use or distribution without the written authorization of Presbyterian Healthcare Services. </p> <script type="text/javascript"> var gaJsHost = (('https:' == document.location.protocol) ? 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