Report Suspected Provider Fraud

Report Suspected Provider Fraud, Waste and/or Abuse

Please answer the questions below to the best of your ability.

Part 1 – Your information. Please tell us how we can reach you in case we need more information.

Today's date

Year

Month

Day

Last Name:

First Name:

Telephone number:

Email Address:

Part 2 – What do you want to report?

Please describe the suspected fraud, waste and/or abuse you would like to report:

When did the event occur?

Year

Month

Day

Part 3 – Provider Information. Tell us about the provider(s) committing potential fraud, waste and/or abuse.

Name of the Provider:

Provider ID, if known:

Business address of the Provider:

City:

Zip code:

Telephone number:

Email address of the Provider, if known:

Name of Administrator/CEO/Owner, if known:

Part 4 - The Client affected by the suspected fraud/waste and/or abuse.

Name of the client involved, if known, enter First and Last Name:

Medicaid/Client ID number, if known:

Client street address:

Client telephone number:

Client email address, if known:

City:

Zip code:

READ THE STATEMENT BELOW BEFORE SUBMITTING THE REPORT!

By pressing the “Submit Now” button, I acknowledge that the information I am submitting is accurate and complete to the best of my knowledge.
Follow the instructions below and press the “Submit report now” button, if you agree with the statement.