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Fraud Self-Disclosure Program

Individuals or entities who wish to voluntarily disclose self-discovered potential fraud to Defense Health Agency, Program Integrity office (DHA-PI) may do so under the Self-Disclosure Program (SDP).

Self-disclosure gives the health care industry the opportunity to avoid the costs and disruptions associated with a Government-directed investigation and civil or administration litigation.

DHA-PI endeavors to work cooperatively with disclosing parties who are forthcoming, thorough, and transparent in their disclosures in resolving thes matters. While DHA-PI does not speak for the Department of Justice or other Federal agencies, DHA-PI consults with those Federal agencies, as appropriate, regarding the resolution of SDP matters.

Disclosing parties that wish to make a submission to the SDP may do so using this online form or by sending a written submission as directed by the DHA-PI guidance. DHA-PI may have additional questions regarding your submission; however, this interactive for will begin your process and guide you through making a complete disclosure.

The public disclosure of personally identifiable information is restricted by the Privacy Act.

Notifications of someone else's improper conduct, non-health care related, are not appropriate and should be addressed to Defense Health Agency Office of Inspector General (OIG) Hotline or if military, to the Department of Defense OIG Hotline or the respective military service OIG Hotline.

SDP submissions must conform to the requirements outlined in the DHA Guidance. Incomplete or premature submissions will not be considered.

Privacy Act Statement

This statement serves to inform you of the purpose for collecting personal information required by the Defense Health Agency, Office of Program Integrity and how it will be used.

AUTHORITY: 10 U.S.C. Chapter 55, Medical and Dental Care; 32 CPR Part 199, Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); and E.O. 9397 (SSN), as amended.

PURPOSE: To collect information from you in order to inquire into the matters presented and/or to take/refer action to combat fraud, waste, and abuse.

ROUTINE USES: Your records may be disclosed to investigate waste, fraud, abuse, security and privacy concerns. Use and disclosure of your records outside of DoD may also occur in accordance with the DoD Blanket Routine Uses published at http://dpclo.defense.gov/Privacy/SORNsIndex/BlanketRoutineUses.aspx and as permitted by the Privacy act of 1974, as amended (5 U.S.C. 552a(b)).

Any protected health information (PHI) in your records may be used and disclosed generally as permitted by the HIPAA Privacy Rule (45 CFR Parts 160 and 164), as implemented within DoD. Permitted uses and disclosures of PHI include, but are not limited to, treament, payment, and healthcare operations.

DISCLOSURE: Voluntary. If you choose not to provide your information, no penalty may be imposed, but absence of the requested information may result in administrative delays or the inability to process your request.

 
Self-Disclosure Reporting
*Denotes Required Field
**Denotes Required Field when Country is United States

Provider/Entity Details

Provider or entity name is required Provider or entity city is required Provider or entity city is required Provider or entity state is required Provider or entity zip is required Provider or entity country is required Provider or entity organization is required Provider or entity individual NPI is required Provider or entity group NPI is required

Details About the Point of Contact (POC)

POC's name is required POC's address is required POC's city is required POC's state is required POC's country is required POC's zip is required POC's day time telephone is required POC's email address is required You must enter a valid email

Details About the Disclosure

List of issue(s) being disclosed is required Have issues previously been disclosed to another agency is required List of state or federal agencies contacted is required Has provider conducted internal investigation is required If yes, list of findings is required Have corrective measures been taken is required Does the submission contain an estimate of monetary damages is required List any program violations that were identified is required
You must certify the submission is true and accurate

DHA Address: 7700 Arlington Boulevard | Suite 5101 | Falls Church, VA | 22042-5101

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