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Program/Division:
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Contributors
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High Cost
Lifeline
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Your Name:
Your Company:
Your Phone:
E-mail Address:
( e.g: abc@xyz.com)
Enter a valid Email Address ( e.g: abc@xyz.com).
Person/Company being Reported:
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The Rule Violator Name field is required.
Their Classification:
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Applicant
Consultant
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Health Care Provider
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Other
Please select a Violator Type.
Rule Violation Details:
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Please describe the potential violation.
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Attachment 1 (Optional):
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Attachment 2 (Optional):
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