Health Reporting Form

Fresno County Department of Behavioral Health

REPORTING FORM

Please complete the form below to report a violation or a suspected non-compliance issue with regards to Fraud, Waste and Abuse of Medi-Cal within the Fresno County Behavioral Health system of care. All reporting may be anonymous, however, if you wish to be contacted, please provide your contact information where indicated.

If you choose to remain anonymous, please provide sufficient, detailed, information about the violation or allegation so that we will be able to perform a thorough investigation.

After completing the form, click "Submit".

Provide detailed information of the violation or allegation below:

1. DBH program(s) affected: * * (required)

2. DBH employee(s) involved:

3. DBH Contracted Provider(s) involved:

4. Cost Center(s) affected (provide cost center # and name):

5. County employee(s) involved:

6. Contractor(s) involved:

7. Approx. date that violation or allegation was discovered: * * (required)

8. Detailed description of the violation or allegation: * * (required)

9. Additional information that may be helpful in our investigation:

If you wish to be contacted, provide your contact information below:

10. Name:

11. Phone:

ext:

12. Mailing Address:

13. Email:

Type the characters you see in the image below * (Required)

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Health Reporting Form

Fresno County Department of Behavioral Health

REPORTING FORM

After completing the form, click "Submit".

Provide detailed information of the violation or allegation below: