Report Recipient Public Assistance Fraud or 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:  
City:    
State:  
Zip Code:  
Telephone Number:   - -
Other Telephone Number:   - -

Recipient Information
First Name:    *
Last Name:    *
Medicaid Number:    
Gender:    Male     Female *
Date of Birth :    
Address:  
City:    *
State:    *
Zip Code:    
Telephone Number:   - -  

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 allegation (describe the fraud or abuse). If possible, include specific dates, names, Social Security Number or Case number, date(s) of birth and how you became aware of the situation.
Fraud Details
Fraud Details:   *

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


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