Report Of Suspected Medicare Provider Fraud {DWC SMBFR 1115}

DWC Form SMBFR 1115 - REPORT OF SUSPECTED MEDICAL CARE PROVIDER FRAUD. This form is used to report suspected fraudulent activity by medical care providers involved in California workers’ compensation claims. The form is intended for injured workers, attorneys, physicians, and other individuals—not insurers or administrators—to detail potential fraud related to treatment, billing, or other provider actions under Labor Code section 4600. It collects information about the complainant, the provider being reported, and any affected claims, along with a detailed description of the alleged fraudulent conduct. Complainants may attach supporting documentation and must indicate whether the matter has been reported to other agencies. Completed forms are submitted to the DWC Medical Unit for review. www.FormsWorkflow.com