Medicaid provider fraud complaint form

What kind of fraud? *

Falsifying time sheets
Billing fraud
Theft of patient funds
Falsifying medical records
Services not medically necessary
Other

Please describe. *

• Please give a detailed explanation of the Medicaid Provider Fraud being reported. *

Who is committing the fraud? *

Person
Business

Person's Details

Name of the Person Committing Fraud *

First Middle Last

Person's Employer

Address

Street Address Address Line 2 City State ZIP Code

Home Phone

Business Phone

Cell Phone *

Business Details

Business Name *

Doing Business As (DBA)

Names of People Involved

Address

Street Address Address Line 2 City State ZIP Code

Business Phone *

Cell Phone

Are you the victim of fraud, or are you reporting on behalf of someone else? *

I am the victim.
I am reporting on behalf of someone else.

Your Contact Information

Your Name *

First Middle Last

Your Date of Birth

Your Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Your Home Phone

Your Business Phone

Your Cell Phone *

Your Email *

Please Identify the Victim

Victim's Name *

First Middle Last

Victim's Employer

Victim's Alias/Nickname

Victim's Title

Victim's Date of Birth

Victim's Sex

Male
Female

Victim's Address

Street Address Address Line 2 City State ZIP Code

Victim's Home Phone

Victim's Business Phone

Victim's Cell Phone

File Upload

If you have any files to upload please upload here.

Drop files here or

Max. file size: 2 MB.

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Thank you for your participation in preventing Healthcare Fraud in NC.

Please review information on the importance of reporting healthcare fraud and abuse, signs of Medicaid fraud, and protection for those who report healthcare fraud or abuse.

Medicaid provider fraud complaint form