FOR HEALTHCARE PROFESSIONALS TO REPORT SUSPICIOUS ACTIVITYPlease fill out the following form to report suspicious activity. You must have JavaScript enabled to use this form. Reporting Party Full Name Name of Pharmacy, Doctor's Office, or Agency Call Back Phone Number Email Address Date/Time of Most Recent Incident Location of Incident General Overview of Incident Subject Name Subject Date of Birth Subject Address Subject City and State Subject Phone Number Subject Description Type of Narcotics Involved Offense (Prescription Fraud, Doctor Shopping, Other, etc) Leave this field blank
