Fraud, Waste, and Abuse Reporting Form

Fraud, Waste, and Abuse Reporting Form
Instructions

ProMed Ambulance Company maintains a zero-tolerance policy for fraud, waste, and abuse. Staff are required to report suspected issues immediately. Reports may be made anonymously and without fear of retaliation, in compliance with the False Claims Act (31 U.S.C. §§ 3729–3733).

You may use this online form to document a concern and submit it to the Director of Revenue Cycle Management or the Compliance Officer. Alternatively, you may report concerns by phone or email listed below. All reports will be investigated promptly and confidentially.

Additional Contact Options

You may also report concerns directly via:
Email: compliance@promedambulance.net

Mail:
ProMed Ambulance Company

Compliance Officer

11600 Norton Coeburn Rd. Coeburn, VA 24230

Contact Information

This Section is Optional. Leave Blank to Remain Anonymous.
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Department

Incident Details
Date of Incident or Discovery*

MonthDayYear
Date
Location of Incident*
Individuals Involved*
Description of Concern (Check all that Apply)*

Billing fraud (false claims, duplicate billing, upcoding)Documentation falsificationKickback/ improper inducementPatient safety concern tied to billing/claimsMisuse of company resourcesOther
Description of Incident(please provide as much detail as possible – who, what, when, where, how)*
Attachments (If Any)Copies of billing records | Screenshots | ePCR excerpts | Emails or correspondence

Cancelof
Should be Empty: