Your Contact Information Salutation --None--Mr. Mrs. Ms. Dr. * First Name Middle Name * Last Name * Address * City * State --None--IN AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Guam Northern Mariana Islands Puerto Rico U.S. Virgin Islands * Zip Code * Email Phone
Information about the Medicaid Provider Fraud * Provider Name Provider Street Address * Provider City * Provider State --None--IN AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Provider Zip Code * Provider County "If unknown, type N/A" * Provider Phone Number * Approximate date or timeframe of alleged fraud * Are you filing a Complaint against an Employer --None--Current Employer Former Employer Not an Employer * Description of alleged Medicaid Provider fraud. Please be as thorough as possible. * How did you learn of this fraud? If you have supporting documentation or materials related to this complaint that you would like to upload at this time, please check the box below. After you click the Submit button below you will be directed to another page where you can upload those files.