Report Provider Medicaid Fraud and Abuse

If you wish to remain anonymous, you do not need to provide your personal information.
* Denotes required information

Personal Information
Email Address:    
First Name:    
Last Name:    
Street Address:  
Zip Code:  
Telephone Number:   - -
Other Telephone Number:   - -

Provider Information
First Name:    *
Last Name:    *
Type of Business:
(Office, Clinic, Pharmacy)
Street Address:  
City:    *
State:    *
Zip Code:    
Office Telephone:   - -  

Have you filed this complaint with any other agency, insurance company or person(s)? If yes, complete the information below.
Previous Complaint Filed
Agency Name:  
Contact Telephone:
  - -

Description of allegation: Provide a detailed description of the allegations. If appropriate, include recipient date(s) of birth, recipient names, recipient ID numbers, and how you became aware of the situation.
Fraud Details
Fraud Details:   *

Name of person(s) to contact for additional information:
Additional Contacts
Contact Number:   - -
Contact Number:
  - -

After completion of the form, you must select the SEND button.