REPORT MEDICAID FRAUD

COMPLAINANT (Reporting Person)(Required)

First Middle Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

COMPLAINT AGAINST (Provider Or Agency)(Required)

First, M.I., and Last or Business Name

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

COMPLAINT DETAILS(Required)

Please provide facts that clearly describe the date, location, and nature of the incident or issue that you are reporting:*

Please provide the names and contact information of any people who may have information about these allegations:

ADDITIONAL INFORMATION

Do you have any documents, records, or other information to submit?

Yes

Upload Document:

Drop files here or

Max. file size: 25 MB.

Criminal Justice Division