Local 1014 Medical Plan

Phone: 800-660-1014

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Prior or Retro Authorization

Fraud, Waste and Abuse Reporting Form

Please complete and submit the following form to report possible fraudulent activity to Local 1014 Medical Plan.

Describe the fraudulent activity you would like to report:

Description:

Claim number associated to this activity:

Patient name associated to this activity:

Member ID associated to this activity:

Submitter has documentation they are willing to provide if requested

Name of the individual or facility performing the potential fraudulent activity

Name of individual:

Facility or provider office name:

Address:

City, State:
,

ZIP Code:

Phone number:

Email:

Additional names involved:

Address:

City, State:
,

ZIP Code:

Phone number:

Submitter's name (optional) *

Name:

Address:

City, State:
,

ZIP Code:

Phone number:

Email:

*To remain anonymous, leave Submitter's information blank

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Contact Info
Local 1014 Medical Plan
3460 Fletcher Avenue
El Monte, CA 91731
800-660-1014
Claims Fax: 626-401-3406
Prior/Retro Auth Fax: 626-401-2407

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