SPECIAL INVESTIGATIONS UNIT (SIU)
FRAUD, WASTE, AND ABUSE (FWA) REPORTING FORM

All referalls will be submitted directly to the Special Investigations Unit (SIU). Please complete this form with as much detail and information as possible.


4/15/2024
Referral Source Information
(Please select who is making the referral)

Subject Information
(Please select who the complaint is about)

Allegation Information
Date or Date Range of the Incident:


Are there other winesses to this incident?

Allegation Details (please be as specific as possible by providing detailed information, and the who, what, where, why, and how).

Supporting Documentation and/or attachments
+ Add New Attachment


If you prefer to submit the Fraud, Waste, and Abuse Reporting Form by Mail or Email, feel free to send the information and all attachments to the following:

University of Utah Health Plans
Attention: Special Investigations Unit
6053 Fashion Square Dr., Suite 110
Murray, UT 84107
Email: HealthPlansReportFraud@utah.edu