Medicaid Fraud and Patient Abuse Complaint Form

The Attorney General's Medicaid Fraud Division has three principal responsibilities: to investigate criminal fraud committed upon Georgia's Medicaid program; to investigate the abuse and neglect of residents in healthcare facilities receiving funding from the Medicaid program, as well as disabled adults and the elderly residing in community-based board and care facilities; and to enforce Georgia’s False Medicaid Claims Act in both state and federal court.

Please ensure your email address and phone number are listed accurately so we can reach you if we need additional information. If you wish to file an anonymous complaint, an email address is still necessary to submit your report and for follow-up replies.

If you have concerns regarding individuals who filed false applications to receive Medicaid benefits, please visit the following page: Report Fraud, Waste, and Abuse | Georgia Department of Community Health.

How are you submitting this complaint? (required)

What is your complaint about? (required)

Does this complaint involve allegations of elder abuse?

Yes

No

If yes, please explain.

Your First Name

Your Last Name

Your Phone Number

Your Email Address (required)

Confirm email (required)

What is the best way to contact you?

Phone

Email

Your Address

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

County of Address

Please explain your complaint. (required)

Date the Complaint Occurred (required)

Time the Complaint Occurred

Is the complaint ongoing?

Yes

No

Unsure

Where did the complaint occur?

Have you submitted this complaint to another agency?

Yes

No

If yes, please identify the agency.

Identify the party involved in the complaint you're reporting. (required)

Please state which businesses are involved in your complaint (required)

Include the type of organization, name of business, business address, and any other additional information that may be helpful.

Type "N/A" if none.

Please state which individuals are involved in your complaint. (required)

Please include the person's role in the complaint, the provider's NPI (if applicable), a physical description of the person, the person's employer, and the person's employer's address.

Type "N/A" if none.

Please attach any files you have to support your complaint.

Maximum 5 files.
10 MB limit.
Allowed types: gif, jpg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip.

Medicaid Fraud and Patient Abuse Complaint Form

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