If you suspect that someone is, or has committed any form of Medicaid fraud or abuse and would like to file a complaint, please fill out the form below. When completing the form, fill out as much information as possible, including name and contact information for follow up. Contact information is not mandatory so you may remain anonymous if you choose. If you have any further questions/concerns, please call toll free 1-855-MI-FRAUD. 

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• More information about  Medicaid Fraud and Abuse Reporting  
  
       

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  PERSON MAKING THE COMPLAINT      Choose One... Beneficiary Individual Pharmacy Provider  
  
  Contact Name:                            
  
  Contact Phone Number:              
  
  Email Address:                            
  
  Health Plan Name (if known):     
  
  

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  PROVIDER OR BENEFICIARY SUSPECTED OF MEDICAID FRAUD/ABUSE Choose One... Beneficiary Dentist Hospital Labs Medical Equipment/Supplies Nursing Home Pharmacy Physician Other  
  
  Individual Name (last, first):           
  
  Business Name:                             
  
  Address:                                         
  
  City, State:                                      
  
  Zip Code:                                                    
  
  Relationship to complainant:           
  
  
  

  If you suspect a provider, please provide the following information if known: Group Name/NPI #:     Individual NPI #:         NCPDP:

  If you suspect a beneficiary, please provide the following information if known:   Beneficiary ID #:       Case #:                        Health Plan Name:

  
  

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  BRIEF DESCRIPTION OF THE SUSPECTED FRAUD/ABUSE
  
  Date of Incident:                    Police Report Filed?:  No  Yes
  
  
  Nature of the Complaint 
   
  

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