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Prescription Fraud Preliminary Report

Incident Information Prescription Fraud

Date of Incident
Time of Incident
MNPD Complaint#
Pharmacy Location/number
Complainant

Pharmacy Address
Phone Number
Name Suspect Used Address Suspect used

Suspect's Tag Suspect's Description

Identification SSN DL# Given

Suspect's Phone Numbers Home Work

Video Available? Yes No

Relationship to prescribee

Prescription Information

Drug Information Drug
Count
Dosage
Quantity
Prescriber's Information

Payment Information

How was prescription paid for?

Cash

Tenn Care

Tenn Care ID#

Other Insurer

Provider and subscriber#

Check

Check number and Bank

Manner Ordered

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Prescription Fraud Preliminary Report