Provider Complaint Form: Report Provider Fraud

Do you wish to file a complaint with L&I about a provider you believe is taking advantage of the workers' compensation system? Let us know by completing this form. We take action against fraud because it increases costs for everyone. Provide as much information as you can. We will need it to pursue your complaint.

Information about the provider you are reporting
Provider's First Name:
Provider's Last Name:
Street Address:
Address (cont.):
City, State, Zip +4    -
Country:
Work Phone:
- include area code		 000-000-0000
Provider Business/Clinic Name:
Provider Type:
Physician Physical/Occupational Therapist
Chiropractor Hearing Aid Provider
Pharmacy Nursing Services
Interpreter Mental Health
Home Care Durable Medical Equipment
Other
Types of Billing:
Double Billing Billing for services not provided
Upcoding Unrelated conditions treated
Unlicensed provider Unbundled services
Code manipulation    
Other
Summary:
Please summarize your complaint, providing any details not listed above.
Can you provide
evidence of fraud?
Yes No Possibly
Is the provider involved in any other type of fraudulent activity that you are aware of?
Yes No Possibly
Are you aware of any other people who have knowledge of the reported fraudulent behavior?
Yes No Possibly
L&I may need to contact you to pursue this fraud complaint. If you can, complete the contact information below. Note: We are occasionally required by law to disclose contact information. If you include your personal contact information in this fraud report and wish to remain anonymous, read and answer the following statement: I am requesting the Washington State Department of Labor and Industries withhold disclosure of my identity regarding this fraud report because I fear disclosure would endanger life, physical safety, or property, pursuant to RCW 42.56.240(2).

Yes No

Your Information  
Your Name:
Your Daytime Phone: - include area code 000-000-0000
Your Evening Phone:
- include area code		 000-000-0000
Your Address:
City, State, Zip +4 -
E-mail:
How did you learn about this referral page. Please select from the following:
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