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Medicaid Fraud Complaint Form

Please fill out the following form to report allegations of abuse, neglect, or financial exploitation. You can also download or print MFCU COMPLAINT FORM or call your local law enforcement office.

Online Medicaid Fraud Complaint Form

1. Reporting Party

Name:
Address:
City:	State: Zip:
Home Phone:		Work Phone:
Email:
When & where would be the best time for an investigator to contact you?

2. Victim/Patient

Name:
Address:
City:	State: Zip:
Home Phone:		Work Phone:
Date of Birth:	(mm/dd/yyyy)
SSN:
Medicaid Number:

3. Facility/Provider

Name:
Address:
City:	State: Zip:
Home Phone:		Work Phone:
Date of Birth:	(mm/dd/yyyy)
SSN:
Medicaid Number:

4. Alleged Perpetrator

Name:
Address:
City:	State: Zip:
Home Phone:		Work Phone:
Date of Birth:	(mm/dd/yyyy)
SSN:

5. Other Parties Involved

Name:
Address:
City:	State: Zip:
Home Phone:		Work Phone:

6. Allegation/Concern

Summary of your Complaint: (Describe briefly your complaint. Give specific details in the order they occurred including dates. Please send/fax copies of any paperwork involved in your complaint (cancelled checks, statement, etc.).

The Office of Attorney General and the Medicaid Fraud Control Unit have the authority to investigate and prosecute fraud and abuse by providers of service in the Medicaid Program. We also have the authority to investigate and prosecute physical abuse, neglect or exploitation of a disabled adult who resides in a facility receiving federal funding, regardless of their eligibility for Medicare or Medicaid. Neither the Attorney General or his staff can act as a private attorney for you. This office is prohibited by law from providing legal advice to private parties.

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