ADP FWA Tip Form

Are you *

Member

Provider

Avesis Employee

Anonymous *

Subject Information

Screenshot including all information needed is permitted.

Benefit Type *

Dental

Vision

State *

Provider Name (s) *

Practice Name (s)

Location Address (es)

Allegation

Reason for referral.

Provide as much information as possible:

File Upload

Drop your files here

Thank you for efforts to fight fraud. All reports of suspected fraud are taken seriously.

*

Send me a copy of my responses