Fraud and Abuse Complaint Form

Mississippi Division of Medicaid
Attn: Bureau of Program Integrity
Walter Sillers Building
550 High Street Suite 1000
Jackson Mississippi 39201-1111
Toll Free (800) 880-5920
Telephone (601) 576-4162
Email: fraud@medicaid.ms.gov

Upon completion, press the "Submit Complaint" button at the bottom of this form

Please check one:    (REQUIRED)

Type of Complaint (Required to select one or more)

  Use of Another's Medicaid Card   Provider Billing for Services Not Rendered
  Quality of Care   Kickback / Bribery
  Provider Furnishing Services Not Medically Necessary   Forged Prescriptions
  Prescription Abuse / Doctor Shopping   Beneficiary Has Unreported Income / Assets
  Beneficiary Living Out of State   Beneficiary Has Private Insurance
  Beneficiary Has Unreported Spouse   Beneficiary Is Not Disabled
  Beneficiary Over Reported Number of Household Members   Other*
*If other, please specify: 

Person Providing Information (optional)

Last Name: First Name:
Employer/Agency/Company:
Street Address:
City: State: Zip Code:
E-mail Address:
Relationship to Beneficiary/Provider:

Telephone numbers must include the area code. Do not include dashes, spaces, or parentheses.

Home Telephone: Work Telephone: Extension:
May We Contact You?

Beneficiary Information (first and last name required if you are reporting a person on Medicaid)

Beneficiary Last Name:   Beneficiary First Name:  
Medicaid Number:    Date of Birth:   SSN:  
Address:  
 
City:   State:   Zip Code:  
Telephone numbers must include the area code. Do not include dashes, spaces, or parentheses.
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)

                   City Police  County Sheriff
                   Department of Health  Department of Human Services
                   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, & location). Be sure to include who, what, when, where, why and how of the situation. Please provide as much information as possible.
(DESCRIPTION LENGTH LIMITED TO 1500 CHARACTERS.)