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Benefits Administration

Report Fraud or Abuse of a State Sponsored Insurance Program

Please complete as much information as possible. If it is your desire, you can remain anonymous; however, if you wish to speak with someone regarding your complaint, please indicate below and provide contact information.

Please contact me regarding this complaint.

Daytime phone
E-mail
Are you reporting
   Doctor
   Health Care Professional
   Individual		  
Person you are reporting
  Name
  Other names used (if known)
  SSN (if known)
  Street address
  Apartment #
  City, State, Zip
  Other addresses used
  Home phone (include area code)
  Work phone (include area code)
  Employer's name
  Employer's address
  Employer's phone
What is your complaint? (In your own words, explain the problem)
What event led you to feel there was a problem?
Have you notified anyone of this problem? Yes    No
Who have you notified? (provide name and phone number, if known)
Have you notified anyone else? (provide name and phone number, if known)
Person Making Complaint (optional)