Healthcare Fraud Questionnaire

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Healthcare Fraud Questionnaire

Think You Have A Case?
Please complete the confidential form below if you believe you have knowledge of fraud that has been, or is currently being, committed against the U.S. Government. Take your time to clearly describe your understanding of the situation. The more detailed the response, the more likely it is that we will be able to evaluate and determine if your potential case falls within our case requirements. IF IT DOES, WE WILL RESPOND TO YOU WITHIN 24 HOURS. (Names of potential defendants are not necessary at this point, should you feel more comfortable omitting them.) By law, all communications to us are 100% confidential.

Your information is sent directly to Nolan & Auerbach
Contact Information
Name:
State:
Phone Number:
Email for reply:
Please answer the following questions to the best of your ability.
When may we contact you?
What is the nature of the healthcare fraud (false claims, kickbacks, Stark violations, cost report violations, etc.) that you are aware of?
When did the healthcare fraud begin?
Is the fraud still going on?	Yes No
Please give applicable years:
How did you find out that there was healthcare fraud taking place?
Is your knowledge of the healthcare fraud first-hand knowledge, or did you find out from someone else?
Do you have in your possession any documents, papers, or other written proof that this was taking place?	Yes No If so, describe:
Are there other witnesses?	Yes No
If YES, would they be able to support your allegations?	Yes No
Was this healthcare fraud committed against the Federal Government?
Please estimate how much money is involved.
Were you an employee of the company committing the healthcare fraud?	Yes No
If YES, are you still an employee?	Yes No
If YES, did you tell anybody else in the company about the healthcare fraud?	Yes No
If NO, when were you last employed by the company?
Was management aware that there was fraudulent activity taking place?	Yes No Not Sure
Have you reported this healthcare fraud to anyone in the Government? Explain:
If YES, when did you report it?
Does the media, (television, newspapers, etc.) have any knowledge of this healthcare fraud? Explain:
Approximately how many employees work for the company? In how many states?
Assuming that your allegations have merit, would you be willing to come forward and formally file a False Claims Act suit against this company?	Yes No Not at this time
Any other comments or facts you would like us to know?
Please read the following statement and click "Send Form" below. Any response to your e-mail will be solely to communicate about our possible representation of you under the qui tam provisions of the Federal False Claims Act only. All emails submitted to us, whether we take your case or not, are 100% confidential. If we do not respond to your e-mail, then you have communicated information which we cannot address because it appears to fall outside of the Federal False Claims Act or our case requirements.

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Toll Free: 800-FRAUD 04
Do you think you have a claim? Contact Us

Nolan & Auerbach, P.A.
- 435 North Andrews Avenue, Suite 401, Ft Lauderdale, FL 33301
Tel: (954) 779-3943 | Fax: (954) 779-3937
Toll free: 800-FRAUD 04
Licensed in the State of Florida - Available Nationally

Overviews:
Qui Tam | Medicare Fraud | Health Care Fraud | Pharmaceutical Fraud
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