Fraud and Abuse Complaint Form

Complainant (Your) Information

Do you wish to remain anonymous? If you wish to remain anonymous, you do not have to provide your personal information.
Your E-mail address:
First Name:
Middle Initial:
Last Name:
Steet Address:
City:
County:
State:
Zip Code:
Daytime Telephone (including area code) :
Evening Telephone (including area code):
Other Telephone (including area code):

Provider Information
Individual Provider
Is your complaint about a individual provider? If yes, enter the individual provider's information.
Individual Provider Number
Individual Provider NPI Number:
First Name:
Last Name:
Steet Address:
City:
County:
State:
Zip Code:
Office Telephone (including area code):

Group Provider
Is your complaint about a provider group/agency? If yes, enter the group/agency provider's information
Group Provider Number
Group Provider NPI Number:
Group/Agency Name:
Steet Address:
City:
County:
State:
Zip Code:
Office Telephone (including area code):

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

Fraud Details
Check Type of Medicaid Fraud, Waste or Abuse, if applicable and/or give brief description.
Medicaid recipient failed to report all income when applying for Medicaid
Medicaid recipient failed to report other insurance when applying for Medicaid
Non-Recipient uses a recipient’s Medicaid card with or without recipient’s knowledge
Provider’s credentials/qualifications are not accurate
Provider bills for services which were not rendered
Provider performs and bills for services not medically necessary
Provider alters claim forms and recipient records
Provider bills inappropriate or inaccurate codes than were actually performed
Other types of allegations not listed above
Description of allegation: Provide a detailed description for each type of allegation checked and for "other" allegations. If appropriate, include date(s) of service, Medicaid recipient names(s), Medicaid ID numbers(s), and recipient date(s) of birth. Please describe the specific Medicaid service involved (such as chiropractic or physician services, PCS in-home aide services, physical therapy, diabetic supplies, community support services, etc.


Additional Contacts
Name of person(s) to contact for additional information:
1. First Name:
Middle Initial:
Last Name:
Contact Telephone (including area code):
2. First Name:
Middle Initial:
Last Name:
Contact Telephone (including area code):

After completion of form, you must press the SEND button. If successfully sent you will receive an acknowledgement receipt to print for your record.

Complainant (Your) Information

Provider Information

Individual Provider

Group Provider

Previous Complaint Filed

Fraud Details

Additional Contacts

After completion of form, you must press the SEND button. If successfully sent you will receive an acknowledgement receipt to print for your record.