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WorkSafeBC

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Service provider fraud allegation form

Please provide as much information as possible. Write "unknown" if you do not know the answer to a question.

1. Service provider information
First name
Last name
Address
Address (cont.)
City
Province
Postal code
Work phone
   

2.
Service provider business/clinic name:
 

3.
Service provider type:
  
Physician Chiropractor
Hearing aid provider Pharmacy
Mental health Durable medical equipment
Physical/Occupational therapist Nursing services
Other
   

4.
Is billing done at the service provider's office/location:
  
Yes No Unknown

If no, name and address of billing office/location:
 

5.
Name, title and phone number of person responsible for billing:
 

6.
Claim numbers and/or claimant names involved:
 

7.
Type of allegation:
  
Billing for services not provided Double billing
Unlicensed provider Unrelated conditions treated

Other

    
 

8.
Is the service provider involved in any other type of fraudulent activity you are aware of?
Yes No
 

9.
Are you aware of any other people who have knowledge of the reported fraudulent behaviour?
Yes No

If yes, please provide their names, phone numbers, and addresses (if known):
 

10.

How did you become aware of the alleged fraud?
 

11.

Please note any other information you have that may help us in our investigation.
12. Source information  
  Thank you for the information you have provided. It will be helpful if you leave your name and phone number in case we need further assistance. We will investigate this information whether you provide your name or remain anonymous.
  Do you wish to keep your name confidential?
Yes No
  Can we contact you for further assistance should it be necessary (the investigator may develop further questions)?
Yes No
  Provide this information:  
 
First name
Last name
Contact phone number(s):
E-mail
  Can you provide any physical evidence of fraud? e.g. documents, letters, videotapes
  Yes No Possibly
   
 

If yes or possibly, please describe the evidence: