REPORT MEDICAID FRAUD
This complaint form is to report fraud by Medicaid providers only (i.e. Transportation Companies, Durable Medical Equipment Companies, Hospitals, Doctors, Dentists, Pharmaceuticals Companies, etc.). If you would like to report Medicaid recipient fraud, please contact the Family and Social Services Administration at 800.446.1993.
Please fill out the following form as completely and accurately as possible. The more detailed information you provide, the more efficient and effective our staff can be in their investigation of the incident reported.

Salutation

* First Name

Middle Name

* Last Name

* Address

* City

* State

* Zip Code

* Email

Phone

* Provider Name

Provider Street Address

* Provider City

* Provider State

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

* 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.

Your Contact Information

Information about the Medicaid Provider Fraud