Provider Fraud Form

Provider's Name

(First)

(Last)

Provider's Gender

Male

Female

Provider's Business

Type of Business

Medicaid Number

Provider's Telephone Number

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

Provider'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

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