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Spokane County Regional Behavioral Health (Administrative Services Organization) (SCRBH) Fraud & Abuse Suspected Violation Report

2. TO REPORT A SUSPECTED VIOLATION:
   Report suspected violations to the CSHCD SCRBH Compliance Officer at (509) 477-7561, or any member of the Compliance Committee, or the CSHCD Health Care Compliance Analyst at (509) 477-4516, OR call the OIG’s National Fraud Hotline 1 (800) 447-8477; Washington State Auditor’s Hotline 1 (866) 902-3900, OR submit a written or electronic report to the CSHCD SCRBH Compliance Officer via the SCRBH Compliance/Fraud & Abuse Report form below:
4. The SCRBH Compliance/Fraud & Abuse Report form can be printed here:
6. Report Form
   SCRBH Compliance/Fraud & Abuse Report Form

   Please mail form to: Attn: Compliance Officer, Spokane County CSHCD, 312 W. 8th Avenue, Spokane, WA 99204
8. Confidentiality:
   Individuals may report suspected violations anonymously. The SCRBH shall treat reports of suspected violations or misconduct as confidential to the greatest extent possible. The SCRBH shall take reasonable steps to maintain confidentiality of the identity of any person providing information to the SCRBH. However, the SCRBH cannot guarantee complete confidentiality of the identity of persons who make reports, due to the SCRBH’s obligations to investigate, take appropriate action to correct violations or misconduct, and its obligations to report certain issues to state and/or federal authorities. Additionally, the SCRBH cannot make promises regarding a person’s liability or steps the SCRBH may take in response to the report. By law, your employer may not retaliate against you for making good faith reports of potential violations.
10. SCRBH Compliance/Fraud & Abuse Report Form
    Please complete the following fields to report a suspected or known SCRBH Compliance/Fraud & Abuse violation:
12. Description of suspected violation*
14. Name of individual and/or group suspected of committing the violation*
16. Date(s) the suspected violation occurred or is occurring*
17. Date(s) the suspected behavior or violation was discovered*
19. Reason for believing a violation has occurred.*
21. Description regarding how the suspected violation was discovered*
23. Any other information that may be helpful to the investigation or understanding of the situation*
25. Providing your name and contact information is not required to submit a report. If you would like to do so, please complete the following fields:
27. First Name
28. Last Name
30. Phone Number
31. Email Address
Leave This Blank:


33. 1. Receive an email copy of this form.
34. Email address

    This field is not part of the form submission.

35. Submit Submit and Print

* indicates a required field