Fraud & Abuse Form | TennCare Dental

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Person making the complaint...
Contact Name
Contact Phone Number
Contact Email Address
Provider or beneficiary suspected of fraud/abuse
If Other, please explain
Individual Name
Business Name
Address
Street Address City State
Relationship to Complainant
Date of Incident
Police Report Filed?
- Yes
- No
Please list details of the complaint.
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Fraud and Abuse Form

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