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Contact Us:
Medicaid Fraud Form:
Date:
List Name(s) of the Medicaid Provider(s) Against Whom the Complaint Is Being Filed:
List Address of Medicaid Provider, if Known:
State Nature of Fraud/Abuse/Neglect Which You Observed:
List Name(s) of the Medicaid Recipient(s)/Resident(s) Who was(were) the Victim(s) of these Fraudulent, Abusive or Negligent Actions by a Medicaid Provider(s):
List Your Name, Address and Telephone Number so That We May Contact You for Additional Information. Please Provide Both a Day and Evening Telephone Number, if Applicable:
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