Fillable REPORTING SUSPECTED FRAUD HBEX 1007 Rev (05/20) Reporting (Covered California)

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REPORTING SUSPECTED FRAUD HBEX 1007 Rev (05/20) Reporting (Covered California)

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STATE OF CALIFORNIA
COVERED CALIFORNIA
REPORTING SUSPECTED
FRAUD HBEX 1007 Rev (05/20)
Reporting Suspected Fraud
Instructions:
Use this form for complaints of fraud, waste, or
abuse only. If you would like to file another type of
complaint such as problems with the website, service
c
enter representatives, or enrollment complaints,
please use the form located here and follow those
instructions.
Questions? If you need help in another
language or would like to file your complaint
over the phone, call Covered California at
1-888-217-9309
(TTY:1-888-889-4500)
Information about you
First Name
Last Name
Middle
Phone Number
Email Address
Street Address
State
Zip Code
Case ID (Optional)
Reason for review:
Reason for review: When making a report, provide as much detail as possible so that your report can be
fully assessed, such as: who, what, where and when.
Tell us how we can help you:
Use extra paper if you need more space to write.
Mail this form to:
Fax this form to:
Email this form to:
Call us at:
Covered California
Integrated Fraud
Management
1601 Exposition Blvd.,
Sacramento, CA 95815
1-916-228-8915
StopFraud@Covered.CA.gov
1-888-217-9309
(TTY 1-888-889-4500)
Privacy Statement
The information requested on this form is required by Covered California, Program Integrity Division, for
purposes of identification and document processing.
Legal references authorizing maintenance of this infor
mation include Government Code, Sections 1151 and
1153; Sections 6011 and 6051 of the Internal Revenue Code; and Regulation 4, Section 404.1256, Code of
Federal Regulations, under Section 218, Title II of the Social Security Act.
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REPORTING SUSPECTED FRAUD HBEX 1007 Rev (0520) Reporting (Covered California)

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Completed 19 May 2021

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