Medicaid Fraud Allegation Online Form

After your allegation is received, the OMIG will evaluate it and take appropriate action. If you submit your name and contact information on the allegation, you will receive an acknowledgement from the OMIG.

Unless you have chosen to file your allegation anonymously, you may be contacted to verify details of the complaint or to provide additional information.

Your Contact Information

* Required fields are marked with an asterisk (*).

First Name:

Middle Initial:

Last Name:

Suffix:

Address Line 1:

Address Line 2:

City:

State:

Zip Code:

Phone Number:

Email Address:

Provider ID (if applicable):

Recipient CIN (if applicable):

Case Number (if applicable):

Nature of Allegation:

Allegation:

Select the Allegation Type

Please enter only a Provider Allegation or a Client Allegation. If you have a provider and a client allegation, please complete a separate allegation form for each.

Provider Allegation Client Allegation

Client Allegation

Client First Name:

Middle Initial:

Client Last Name:

Suffix:

Address Line 1:

Address Line 2:

City:

State:

Zip Code:

Phone Number:

Age/DOB:

CID #:

Case Number:

Provider Allegation

Provider or Facility:

Address Line 1:

Address Line 2:

City:

State:

Zip Code:

Phone Number:

Provider ID (if known):

Captcha

When you click the Submit button, a Confirmation Page will appear. Please print a copy of the Confirmation Page for your records.