WPS Health Insurance

To: Special Investigations Unit

Please note that not all of the following information is required (required information is marked with *), and if entered will remain confidential. Personal information will only be used if it is necessary to contact you for more information concerning the investigation of your filing.

Subject Information
Complaint Against*:
Subject Address:
Subject Telephone:	( )
Dates of Service:
Provider Tax ID#:
Personal Information
Member Name:
Member Number:
Address:

City:	State: ZIP:
Telephone:	( )
Best Time to Call:	From to
E-mail:
Complaint Details*: