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Medicaid Fraud Complaint Form - Delaware Department of Justice - State of Delaware

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Delaware Department of Justice
Attorney General
Kathy Jennings

Medicaid Fraud Complaint Form

All fields are optional except "Description" under Details.

Your Information

Name

Address

Contact Phone

Fax

Please complete if reporting abuse, neglect, medication diversion, or financial exploitation

Victim Name

Victim / Facility Address

Victim Phone

Facility Name

Facility Phone

Suspect Name

Amount of Loss

Please complete if reporting Medicaid provider fraud

Provider Name

Provider Address

Provider Type

Provider Phone

Practice / Facility Name

Details

Description

Have you reported the complaint to another agency or police? Yes No

Agency Reported To

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