Medicaid Fraud and Abuse Complaint Form

Please complete this form to report patient or resident abuse, neglect, or exploitation, as well as attempts to commit fraud against the Kentucky Medicaid Program. Your report provides the Office of the Attorney General the information we need to investigate and, when appropriate, prosecute those who seek to harm our most vulnerable citizens. You may choose to make a complaint anonymously by selecting “Yes” to the question below regarding confidentiality. If you chose to do so, your name and contact information will ONLY be used by our staff if we require additional information to investigate your complaint.

Reporting Party

* First Name:

* Last Name:

Would you like your name to remain confidential?

Yes

Address:

City:

State:

Zip Code:

* Phone Number:

Type of Abuse

* Would you like to report patient abuse, Medicaid fraud, or both?

Patient Abuse

Medicaid Fraud

Patient Abuse AND Medicaid Fraud

Patient Abuse

Patient or Resident

* First Name:

* Last Name:

* Date of Birth:

Last four digits of Social Security Number:

Address:

City:

State:

Zip Code:

* Phone Number:

Facility

* Facility Name:

Address:

City:

State:

Zip Code:

* Phone Number:

Suspected Abuser

* First Name:

* Last Name:

Address:

City:

State:

Zip Code:

* Phone Number:

* Please describe the incident of neglect or abuse:

Medicaid Fraud

Healthcare Provider

* Facility Name:

Address:

City:

State:

Zip Code:

* Phone Number:

Facility

* Facility Name:

Address:

City:

State:

Zip Code:

* Phone Number:

* Please describe the incident/s of suspected Medicaid fraud or abuse:

Patient Abuse and Medicaid Fraud

Patient or Resident

* First Name:

* Last Name:

* Date of Birth:

Last four digits of Social Security Number:

Address:

City:

State:

Zip Code:

* Phone Number:

Facility

* Facility Name:

Address:

City:

State:

Zip Code:

* Phone Number:

Suspected Abuser

* First Name:

* Last Name:

Address:

City:

State:

Zip Code:

* Phone Number:

* Please describe the incident of neglect or abuse:

Healthcare Provider

* Provider Name:

Address:

City:

State:

Zip Code:

* Phone Number:

* Please describe the incident/s of suspected Medicaid fraud or patient abuse:

Verification

ATTORNEY GENERALDANIEL CAMERON

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