Medicaid Fraud, Abuse, and Neglect Complaint Form 1 - Reporting Party Full Name * required Required Phone * required Required Email 2 - Victim / Patient Full Name * required Required Phone 3 - Facility / Healthcare Provider Full Name City 4 - Alleged Suspect Full Name * required Required Address City State Phone 6 - Allegation / Concern 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.). Summary of your Complaint The Office of Attorney General and Medicaid FANS have the authority to investigate and prosecute Medicaid fraud and certain instances of abuse and neglect. Neither the Attorney General nor his staff can act as a private attorney for you. This office is prohibited by law from providing legal advice to private parties.
Medicaid Fraud, Abuse, and Neglect Complaint Form 1 - Reporting Party Full Name * required Required Phone * required Required Email 2 - Victim / Patient Full Name * required Required Phone 3 - Facility / Healthcare Provider Full Name City 4 - Alleged Suspect Full Name * required Required Address City State Phone 6 - Allegation / Concern 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.). Summary of your Complaint The Office of Attorney General and Medicaid FANS have the authority to investigate and prosecute Medicaid fraud and certain instances of abuse and neglect. Neither the Attorney General nor his staff can act as a private attorney for you. This office is prohibited by law from providing legal advice to private parties.
