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.