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PROVIDER
RECIPIENT
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REPORT FRAUD AND ABUSE
Fraud and Abuse Complaint Form
District Of Columbia Medicaid and Alliance Programs
Department of Health Care Finance
One Judiciary Square
441 4th Street, NW Suite 1000 S
Washington, D.C. 20001
Phone : 1-877-632-2873
My complaint is about: (check one)
A person receiving Medicaid or Alliance Services A person delivering Medicaid or Alliance Services
Type of Problem (select one or more)
Use of Another's Medicaid Card Provider Billing for Services Not Delivered
Quality of Care Kickback/Bribery
Provider Furnishing Services Not Medically Necessary Forged Prescriptions
Prescription Abuse / Doctor Shopping Person Receiving Services has Unreported Income / Assets
Person Receiving Services not living in Washington, D.C. Person Receiving Services has Private Insurance
Person Receiving Services has Unreported Spouse Person Receiving Services is Not Disabled
Person Receiving Services Over Reported Number of Household Members Other*
      * If other please specify: 
 Information about Person Providing Information (optional)
Last Name: First Name:
Employer/Agency/Company: Street Address:
City: State:
Zip Code: Email:
Telephone numbers must include the area code. Do not include dashes, spaces or parentheses.
Relationship to Recipient/Provider: Home Telephone:
Work Telephone: Extension:
May We Contact You? Yes No
 Information on the Person Receiving Services
(Please provide as much information as you have. We understand if you do not know all of this)
Their Last Name: Their First Name:
Medicaid Number:
(if known)
Date of birth (mm/dd/yyyy):
SSN: Address:
City: State:
Telephone numbers must include the area code. Do not include dashes, spaces or parentheses.
Zip Code: Telephone:
Gender: Race:
 Provider Information (provider name required if you are reporting a Medicaid provider)
Provider Name: Provider Number:
Address: City:
State: Zip Code:
Telephone numbers must include the area code. Do not include dashes, spaces or parentheses.
Office Telephone: Type Of Business:
 Other Agencies You Have Notified (optional)
Washington, D.C. Police: Department Of Health:
Other:*    
* If other please specify:    
Please provide detailed Information about your fraud and/or abuse concern below: REQUIRED
Describe the suspected fraudulent or abusive activities (include background, persons involved, events, dates and location).
Be sure to include who, what, when, where, why and how of the situation.
Please provide as much information as possible.
Description
(Max 1500 Characters)