Recipient Fraud Form

Recipient's Name

(First)

(Last)

Recipient's Gender

Male

Female

Medicaid Number

Recipient's Children - Names and Medicaid Numbers

(Please fill out this field if you are reporting fraud by a parent of Medicaid recipient(s))

Recipient's Telephone Number

(Please enter the phone number in XXX-XXX-XXXX format)

Recipient's Address

City

State

Zip Code

Suspected Fraud

You are able to report suspected fraud complaints anonymously. But, if you would like the Medicaid Fraud Complaints Unit to contact you, please complete the fields below.

Name

Telephone Number

E-Mail Address