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The Fraud Allegation You Want To Report
Description of Your Allegation:
Client or Provider Name:
Client or Provider City/State:
 Zip
Your Contact Information (OPTIONAL)
Remain Anonymous:
 Yes
First Name:
 M. I. Last Name
Phone Number:
 Phone Ext
Email Address:
   

Once the report is sent out, the Coordinator has no further information regarding an investigation.

Law prohibits the Department from sharing the status or results of an investigation unless specifically exempted by statute.

Help and Hints
THE FRAUD ALLEGATION YOU WANT TO REPORT

Description of Your Allegation (required): Please provide as much information as possible specific to the allegation being made.
For client fraud referrals, useful information includes social security number, date of allegation, address, income sources, names of other individuals living in home, etc.
For provider fraud referrals, useful information includes date of incident, address, description of the improper billing activity, etc.

Client or Provider Name (required): Please provide the name of the client or provider you’re referring for fraud investigation.

YOUR CONTACT INFORMATION (OPTIONAL)

Remain Anonymous (optional): You may check this box to be assured that your contact information -- even if viewable on screen -- will NOT be saved.

First, M. I., Last Name (optional): You may enter your full name, so we can contact you about your comments and collect more information about this incident. You may leave these blank if you wish to remain anonymous.

Phone Number, Extension (optional): You may enter your phone number and phone extension (if applicable), so we can contact you about your comments and collect more information about this incident. You are allowed to leave these blanks empty.

Email Address (optional): You may enter your email address so we can contact you about your comments and collect more information about this incident. You are allowed to leave this empty.