Report Suspicious Activity RX

The below form is provided for health care providers (e.g. physician, pharmacist, hospital, etc.) and the general public to report suspicious activity involving prescription medication.

PA Prescription Drug Diversion: Suspicious Activity Report

The below form is provided for health care providers (e.g. physician, pharmacist, hospital, etc.) and the general public to report suspicious activity involving prescription medication. For example: fraudulent, stolen, or altered prescriptions, a suspicious doctor/pharmacy or an individual obtaining prescription drugs for any purpose other than the treatment of an existing medical condition, such as for purposes of misuse, diversion, or illegal distribution. =

"*" indicates required fields

Suspicious Person(s) Information (If Known)

Last Name

First Name

Address*

Street Address Address Line 2 City State

County*

Telephone

License/Registration/Certificate Number (if known)

Complaint Information

Complaint Type*

Briefly describe suspicious situation being reported – who, what, where and when:*

Business Establishment Involved (if any)

Name of Business/Practice

Business Address

Street Address Address Line 2 City State Zip Code

County

Phone

Your Information

First Name*

Last Name

Title

Email*

Daytime Phone Number*

Employer Information

Employer Name

Employer Address

Street Address Address Line 2 City State Zip Code

Employer Phone Number

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Region Sent To

Attorney General Sunday

Office of Public Engagement

Do Not Call List

Home Improvement Contractor Registration