Patient abuse complaint form

Patient Abuse Complaint Form

Please give a detailed explanation of the abuse being reported. * Required
Who is committing the patient abuse? * Required
- Person
- Facility
Person's Details
Name of the Person Committing Fraud * Required
First Middle Last
Person's Employer
Address
Street Address Address Line 2 City State ZIP Code
Home Phone
Business Phone
Cell Phone * Required
Facility Details
Facility Name * Required
Doing Business As (DBA)
Names of People Involved
Address
Street Address Address Line 2 City State ZIP Code
Business Phone * Required
Cell Phone
If allegations indicate specific event(s), when did this happen? * Required
Where did this happen? * Required
How long has this been going on? * Required
When did you last see the patient? * Required
Has this situation caused harm or injury to the patient? If yes, explain. * Required
How has the patient’s physical/mental health and functioning declined or changed? * Required
Has the patient been involved with DSS before? If yes, explain.
Do you know if other reports have been made about the patient? If yes, give details. * Required
Do you know if law enforcement has been involved? If yes, give details. * Required
Does someone help the patient with the decision-making? If yes, who and describe role (i.e. POA, Legal Guardian, etc.).
Are you the victim of patient abuse, or are you reporting on behalf of someone else? * Required
- I am the victim.
- I am reporting on behalf of someone else.
Your Contact Information
Your Name * Required
First Middle Last
Your Date of Birth
MM slash DD slash YYYY
Your Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Please provide address if different than residence address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Your Home Phone
Your Business Phone
Your Cell Phone * Required
Your Email * Required
Please Identify the Victim
Victim's Name * Required
First Middle Last
Victim's Employer
Victim's Alias/Nickname
Victim's Title
Victim's Date of Birth
MM slash DD slash YYYY
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
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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.

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Patient abuse complaint form

Patient Abuse Complaint Form

Person's Details

Facility Details

Your Contact Information

Please Identify the Victim

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