NP NS MZ OPT OP PH PT PA PO PS PY RD TH TPA UP MN Nurse Practitioner Nurse Specialist Office Administrator Ophthalmologist Optometrist Pharmacist Physical Therapist Physician’s Assistant Podiatrist Psychiatrist Psychologist Radiologist Therapist/Counselor Third Party / Law Enforcement Agency / MEDICAL TYPES Ambulance Service/Employee Billing Service / State Fraud Bureau / Iowa Division of Insurance / Iowa Insurance Fraud Bureau / /Interested Party / Medical Personnel Additional Subject /Interested Party / /
Person
LPN MT MH / Ring / Ophthalmologist Optometrist Pharmacist / CHI DS / / /
Position
attorney / Claimant Lawyer / Driver / Massage Therapist / Licensed Practical Nurse / Shop Claimant Insurance Company Employee Insured/Member Insurer Lawyer / Administrator / authorized representative / MS Dentist / GENERAL TYPES Adjuster Agent/Broker / Chiropractor / Medical Clinic/Outpatient Facility Medical Doctor Medical Specialist / /
UNIFORM SUSPECTED INSURANCE FRAUD REPORTING FORM For State Use Only Case No. State of Iowa Division of Insurance – Fraud Bureau