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

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.