FILING AN ONLINE COMPLAINT

• Please fill out the form carefully; Include your name and contact information for follow-up.
• You may be contacted regarding this complaint. 
• Please call toll free (866) 428-0005 if you have further questions/concerns.
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  PERSON MAKING THE COMPLAINT
  Full Name: 
  Address:      
  City:            
  State:          
  Zip Code:    
  Telephone:    
  Medicaid ID:  (if applicable)
  Health Plan Name:  (if applicable)
  Other Information (if applicable):
  
  

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  PROVIDER OR BENEFICIARY SUSPECTED OF MEDICAID FRAUD/ABUSE
  Last Name: 
  First Name: 
  Address:   
  City:         
  State:       
  Zip Code:       
  Telephone:    
  Medicaid ID:  
  Group Name:   (if applicable)
  Date of Birth:   (if known)
  Case Number:  (if applicable)
  

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  BRIEF DESCRIPTION OF THE SUSPECTED FRAUD/ABUSE
  Date of Incident: 
  Description of Fraud/Abuse
  
  Police Report Filed?: No Yes