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 Year20182019202020212022 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 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 Year20182019202020212022 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 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. Tweet
