FALSE CLAIMS ACT DISCLOSURE STATEMENT

Pursuant to 31 U.S.C. § 3730(b)(2)

CONFIDENTIAL - FILED UNDER SEAL

This document is filed under seal and may not be disclosed to any person other than the Department of Justice and the relevant United States Attorney's Office without court order.

UNITED STATES DISTRICT COURT

[DISTRICT NAME]

Case No.: _________________________________ (To be assigned)

Related Qui Tam Complaint: _________________________________

COVER PAGE

Date of Submission: _________________________________

Relator Name: _________________________________

Relator Attorney: _________________________________

Attorney Contact Information:

Phone: _________________________________

Email: _________________________________

Address: _________________________________

I. EXECUTIVE SUMMARY

A. Overview of Allegations

Provide a concise summary (1-2 paragraphs) of the fraudulent scheme:

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

B. Estimated Government Losses

Total Estimated Damages: $__________________

Time Period of Fraud: __________ to __________

Federal Programs Affected:

☐ Medicare
☐ Medicaid
☐ Department of Defense
☐ Department of Veterans Affairs
☐ Other: _________________________________

C. Key Defendants

II. RELATOR BACKGROUND AND QUALIFICATIONS

A. Employment History with Defendant

Employer Name: _________________________________

Position/Title: _________________________________

Dates of Employment: __________ to __________

Department/Division: _________________________________

Direct Supervisor: _________________________________

Job Responsibilities:

_____________________________________________________________________________

_____________________________________________________________________________

B. Relevant Qualifications and Expertise

Education:

_____________________________________________________________________________

Professional Licenses/Certifications:

_____________________________________________________________________________

Relevant Work Experience:

_____________________________________________________________________________

C. Access to Information

Describe how Relator had access to information about the fraud:

☐ Direct involvement in billing/claims submission
☐ Access to financial records and documents
☐ Supervisory role over relevant operations
☐ IT/systems access to relevant databases
☐ Participation in meetings where fraud was discussed
☐ Receipt of communications (emails, memos) evidencing fraud
☐ Other: _________________________________

Specific systems/databases accessed:

_____________________________________________________________________________

III. DETAILED FACTUAL ALLEGATIONS

A. Background of Defendant's Business Operations

Description of Defendant's Business:

_____________________________________________________________________________

_____________________________________________________________________________

Government Contracts/Programs:

B. Description of the Fraudulent Scheme

1. Nature of the Fraud

Type of False Claims (check all that apply):

☐ Billing Fraud
☐ Upcoding (billing for more expensive services than provided)
☐ Unbundling (billing separately for bundled services)
☐ Billing for services not rendered
☐ Duplicate billing
☐ False cost reports

☐ Kickback Schemes
☐ Illegal referral payments
☐ Improper physician compensation arrangements
☐ Disguised kickbacks through consulting agreements

☐ Quality of Care Fraud
☐ Substandard products/services
☐ Failure to meet contract specifications
☐ False certifications of compliance

☐ Grant Fraud
☐ Misuse of grant funds
☐ False progress reports
☐ Failure to perform required work

☐ Procurement Fraud
☐ Bid rigging
☐ Defective pricing
☐ Product substitution
☐ False certifications

☐ Other: _________________________________

2. How the Scheme Operated

Step-by-step description of how the fraud was carried out:

Step 1: _____________________________________________________________________________

Step 2: _____________________________________________________________________________

Step 3: _____________________________________________________________________________

Step 4: _____________________________________________________________________________

Step 5: _____________________________________________________________________________

3. Individuals Involved

4. Timeline of Fraudulent Conduct

C. Specific False Claims

Provide detailed information on specific false claims submitted:

False Claim #1:

Date Submitted: _________________________________

Claim Type: _________________________________

Claim Amount: $__________________

Government Program: _________________________________

How Claim Was False:

_____________________________________________________________________________

_____________________________________________________________________________

Supporting Documentation: ☐ Attached ☐ Available ☐ Described Below

False Claim #2:

Date Submitted: _________________________________

Claim Type: _________________________________

Claim Amount: $__________________

Government Program: _________________________________

How Claim Was False:

_____________________________________________________________________________

_____________________________________________________________________________

Supporting Documentation: ☐ Attached ☐ Available ☐ Described Below

False Claim #3:

Date Submitted: _________________________________

Claim Type: _________________________________

Claim Amount: $__________________

Government Program: _________________________________

How Claim Was False:

_____________________________________________________________________________

_____________________________________________________________________________

Supporting Documentation: ☐ Attached ☐ Available ☐ Described Below

(Attach additional pages as necessary)

D. Knowledge and Intent

Evidence that Defendant(s) acted knowingly:

☐ Written policies/procedures acknowledging proper requirements
☐ Training materials showing awareness of rules
☐ Internal audits identifying problems
☐ Compliance warnings ignored
☐ Emails/communications showing actual knowledge
☐ Prior government investigations/audits
☐ Industry standards and practices
☐ Other: _________________________________

Detailed description of evidence supporting knowledge:

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

E. Materiality

Why the false statements/claims were material to the government's payment decision:

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

IV. DOCUMENTARY EVIDENCE

A. Documents in Relator's Possession

B. Documents Known to Exist But Not in Relator's Possession

C. Electronic Evidence

Databases/Systems containing relevant evidence:

_____________________________________________________________________________

Email accounts with relevant communications:

_____________________________________________________________________________

Electronic records retention policies:

_____________________________________________________________________________

V. WITNESS INFORMATION

A. Witnesses with Direct Knowledge

B. Witness Statements

Summary of expected testimony from key witnesses:

Witness 1 - [Name]:

_____________________________________________________________________________

_____________________________________________________________________________

Witness 2 - [Name]:

_____________________________________________________________________________

_____________________________________________________________________________

Witness 3 - [Name]:

_____________________________________________________________________________

_____________________________________________________________________________

VI. DAMAGES CALCULATION

A. Methodology

Describe the method used to calculate damages:

_____________________________________________________________________________

_____________________________________________________________________________

B. Calculation

C. Supporting Financial Data

_____________________________________________________________________________

_____________________________________________________________________________

VII. PRIOR DISCLOSURES AND GOVERNMENT KNOWLEDGE

A. Public Disclosures

Has any information about this fraud been publicly disclosed?

☐ No public disclosure has occurred

☐ Yes - describe below:

Source of Disclosure: _________________________________

Date: _________________________________

Nature of Disclosure: _________________________________

Relator's Original Source Status:

_____________________________________________________________________________

B. Prior Government Investigations

Is Relator aware of any prior government investigations of this conduct?

☐ No

☐ Yes - describe:

Agency: _________________________________

Dates: _________________________________

Outcome: _________________________________

C. Prior Complaints

Has Relator or anyone else previously reported this conduct?

☐ No

☐ Yes - describe:

To Whom: _________________________________

Date: _________________________________

Response: _________________________________

VIII. INTERNAL COMPLAINTS AND RETALIATION

A. Internal Reporting

Did Relator report the fraud internally before filing this action?

☐ No
☐ Yes

If yes:

Date(s) of Report: _________________________________

To Whom: _________________________________

Method (written/verbal): _________________________________

Response Received: _________________________________

B. Retaliation

Has Relator experienced any retaliation?

☐ No
☐ Yes

If yes, describe:

Type of Retaliation:
☐ Termination
☐ Demotion
☐ Reduction in pay/benefits
☐ Hostile work environment
☐ Negative performance reviews
☐ Other: _________________________________

Date(s): _________________________________

Description:

_____________________________________________________________________________

_____________________________________________________________________________

IX. ADDITIONAL RELEVANT INFORMATION

A. Ongoing Nature of Fraud

Is the fraudulent conduct ongoing?

☐ No - ceased on approximately: _________________________________
☐ Yes - fraud is continuing

B. Other Relevant Information

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

X. RELATOR'S CERTIFICATION

I, _________________________ [Relator Name], hereby certify under penalty of perjury that:

1. The information contained in this Disclosure Statement is true and accurate to the best of my knowledge, information, and belief.

2. This Disclosure Statement contains substantially all material evidence and information I possess concerning the allegations in the accompanying Qui Tam Complaint.

3. I have not derived the allegations in this Disclosure Statement from any public disclosure.

4. I have direct and independent knowledge of the information contained herein.

5. I am voluntarily providing this information to the United States Government.

6. I understand that this Disclosure Statement is confidential and filed under seal.

7. I agree to cooperate fully with the United States Government's investigation of this matter.

Executed on: _________________________________

Location: _________________________________

_____________________________________________
Relator Signature

_____________________________________________
Printed Name

XI. EXHIBITS INDEX

STATE-SPECIFIC CONSIDERATIONS

California

Under the California False Claims Act (Cal. Gov. Code § 12652), similar disclosure requirements apply for state qui tam actions. California requires disclosure of "all material evidence and information" to the Attorney General. Parallel state and federal filings may be appropriate.

New York

New York State False Claims Act (State Finance Law § 190) requires service on the New York Attorney General with disclosure of substantially all material evidence. The disclosure should address state-specific programs affected, including New York Medicaid.

Texas

The Texas Medicaid Fraud Prevention Act requires disclosure to the Texas Attorney General's Medicaid Fraud Control Unit. Texas Health and Human Services Commission fraud should be documented separately from federal claims.

Florida

Florida False Claims Act (Fla. Stat. § 68.083) requires disclosure to the Florida Attorney General. Include specific information on Florida Medicaid or other state program fraud. Florida has additional protections for healthcare workers reporting fraud.

SUBMISSION CHECKLIST

☐ Disclosure Statement completed in full
☐ All relevant documents attached as exhibits
☐ Exhibits properly labeled and indexed
☐ Relator certification signed
☐ Attorney certification completed
☐ Qui Tam Complaint prepared for simultaneous filing
☐ Service copies prepared for:
☐ U.S. Attorney General
☐ U.S. Attorney for relevant district
☐ Filing fee or IFP application prepared

IMPORTANT NOTICES

CONFIDENTIALITY: This Disclosure Statement contains confidential information and is filed under seal pursuant to 31 U.S.C. § 3730(b)(2). Unauthorized disclosure may result in dismissal of the qui tam action and/or criminal penalties.

COOPERATION REQUIREMENT: Relators are expected to cooperate with the government's investigation. Failure to cooperate may affect the relator's share of any recovery.

DOCUMENT PRESERVATION: Relator should preserve all documents and evidence related to this matter. Destruction of evidence may constitute obstruction of justice.

This template is provided for educational purposes only and does not constitute legal advice. The disclosure statement is a critical document that must comprehensively present the relator's evidence. Consult with experienced False Claims Act counsel before filing.