Medicaid fraud complaint form

Please complete this form with as much information and in as detailed a manner as possible.

Type of complaint

I am a:

Family member reporting an incident of patient abuse, neglect or mistreatment

Healthcare worker reporting patient abuse or neglect, infection control violations, or inadequate PPE

Your information

Full name

Street address

City/town

State

Zip code

Email

Phone number

Facility information

Type of facility

Assisted living

Hospital

Nursing home

Other

(please specify)

Type of facility (other)

Full name of facility

Street address

City/town

State

Zip code

Patient/resident information

Full name of patient/resident

Your relationship to the patient/resident

Are you the resident's health care proxy?

Yes

No

Name of health care proxy

Is the resident deceased?

Yes

No

Date and location of death

Date of death

Location of death

Is the resident still at the facility?

Yes

No

Date and location of transfer

Date of transfer

Location of transfer

Incident/issue details

Are you reporting a specific incident?

Yes

No, I have general concerns about a facility

Please describe your issue or concern about a facility

Date of incident

Description of incident

Was there any known injury to resident from this incident?

Yes

No

Medical treatment required, if any. (Include the name of any hospital where treatment was rendered)

Supporting documentation

Please upload supporting files as available, including records of communications, signed documents, images, or other relevant materials.

Maximum 4 files.
5 MB limit.
Allowed types: gif, jpg, jpeg, png, bmp, txt, pdf, doc, docx, xls, xlsx.