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?
Incident/issue details
Are you reporting a specific incident?
Supporting documentation
Maximum 4 files.
5 MB limit.
Allowed types: gif, jpg, jpeg, png, bmp, txt, pdf, doc, docx, xls, xlsx.