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.

Suspicious Person(s) Information (If Known)
Last Name
First Name
Address * Required
Street Address Address Line 2 City State
County * Required
Telephone
License/Registration/Certificate Number (if known)
Complaint Information
Complaint Type * Required
Briefly describe suspicious situation being reported - who, what, where and when: * Required

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 * Required
Last Name
Title
Email * Required
Daytime Phone Number * Required
Employer Information
Employer Name
Employer Address
Street Address Address Line 2 City State Zip Code
Employer Phone Number
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PA Prescription Drug Diversion: Suspicious Activity Report

Suspicious Person(s) Information (If Known)

Complaint Information

Business Establishment Involved (if any)

Your Information

Employer Information