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Bureau of Health Services Financing (Medicaid)
Beneficiary Fraud Form

Beneficiary Fraud Form

Beneficiary's Name

Beneficiary's Gender Male
Female

Medicaid Number

Beneficiary's Children - Names and Medicaid Numbers Please fill out this field if you are reporting fraud by a parent of a Medicaid beneficiary.

Beneficiary's Telephone Number Please enter the phone number in XXX-XXX-XXXX format

Beneficiary'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

Beneficiary Fraud Form

Surgeon General Ralph L. Abraham, M.D.

Secretary Bruce D. Greenstein