Iowa SMP Fraud Reporting Form
You do not have to complete this form entirely.  If you prefer, you may give only your name (required field), phone number (required field) and email address (required field).  Later, SMP may need additional information if we are to assist you.

Iowa SMP will not contact this individual or business without getting your permission first.

The information on this form will be transmitted to the Iowa SMP and will only be seen by Iowa SMP and law enforcement authorities to which Iowa SMP may refer your complaint for further action.
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Complainant Contact Information
Person making the report.
Complainant Name
 *
Person making the report.
Complainant Address
Complainant City
Complainant State
Complainant ZIP
Complainant Phone
 *
Format: ###-###-####
Complainant Email 
 *
Beneficiary Contact Information
Person with Medicare.
Beneficiary Name
Person with Medicare.
Beneficiary Address
Beneficiary City
Beneficiary State
Beneficiary ZIP
Beneficiary Phone
Format: ###-###-####
Suspected Medicare Fraud
Type NA if the nature of the complaint does not apply to you.
Medicare Billing Error
Type NA if the nature of the complaint does not apply to you.
Healthcare-Related Scam
Type NA if the nature of the complaint does not apply to you.
Subject Contact Information
Whom the complaint is about.
Subject Name
Whom the complaint is about.
Subject Business Name
Subject Address
Subject City
Subject State
Subject ZIP
Subject Phone
Format: ###-###-####
Submit
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This form was created inside of State of Iowa.

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