Medicaid Provider Fraud Referral Form

Reporter Information

Do you wish to be contacted?

(Please provide a phone number if Yes)

Reporter Name

Reporter Relationship to Provider

Reporter Home Phone Number

(###)###-####

Reporter Work Phone Number

(###)###-####

Reporter Cell Phone Number

(###)###-####

Best Time to Call

Provider Information

Provider Name:

Provider Medicaid #

Provider NPI/Tax ID

Provider Address Line 1

Provider Address Line 2

Provider City

Provider State

Provider ZIP

Provider Other Identifying Information

Complaint Details

Complaint

Allegation Details

Complaint Start Date

Complaint End Date

Supporting DocumentationYou can upload a maximum of 5 files, each up to 8MB. Supported files include .doc, .dot, .docx, .dotx, .xls, .xlt, .xlsx, .xltx, .ppt, .pot, .pps, .pptx, .potx, .ppsx, .pdf, .tif, .tiff, .jpg, .jpeg, .png, .gif, .bmp, .txt.

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Medicaid Provider Fraud Referral Form

Reporter Information

Provider Information

Complaint Details

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