Medicaid Fraud Control Unit Complaint Form

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

Type of Complaint
Your Information
Facility Information
Patient/Resident Information
Date and Location of Transfer
Date and Location of Death
Incident/Issue Details
COVID-19 Communications
Supporting Documentation

Please upload any documents, communications, photos or videos that are related to the incident you are reporting. If you have such material but cannot upload, please let us know in the “Incident/Issue Details” section.

Files must be less than 5 MB.
Allowed file types: gif jpg jpeg png bmp txt pdf doc docx xls xlsx.
Files must be less than 5 MB.
Allowed file types: gif jpg jpeg png bmp txt pdf doc docx xls xlsx.
Files must be less than 5 MB.
Allowed file types: gif jpg jpeg png bmp txt pdf doc docx xls xlsx.
Files must be less than 5 MB.
Allowed file types: gif jpg jpeg png bmp txt pdf doc docx xls xlsx.