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:
Your information
Facility information
Type of facility
(please specify)
Patient/resident information
Are you the resident's health care proxy?
Is the resident deceased?

Date and location of death

Is the resident still at the facility?

Date and location of transfer

Incident/issue details
Are you reporting a specific incident?
Was there any known injury to resident from this incident?
Supporting documentation
Maximum 4 files.
5 MB limit.
Allowed types: gif, jpg, jpeg, png, bmp, txt, pdf, doc, docx, xls, xlsx.