**Andrew Bailey**
Missouri Attorney General

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MEDICAID/HEALTHCARE FRAUD COMPLAINT FORM

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Complete the form below to file a complaint with the Attorney General’s Medicaid Fraud Division.

Please understand that the Attorney General is not your private attorney, but enforces public safety laws. By submitting this form you agree to testify in court to the facts stated in this complaint. Please complete this complaint form in as much detail as possible.

A PDF version is available for printing and mailing.

Medicaid Fraud Complaints

YOUR CONTACT INFORMATION

Name(Required)

First Last

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Primary Phone Number(Required)

Email(Required)

County

Complaint Information

My complaint is against a (Check One):

Company

Agency

Individual

Name of Company/Agency/Individual(Required)

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

County

Phone

Website

Describe in detail the information you have relating to any allegation(s) of MO HealthNet Provider fraud. Please include names and contact information of individual(s) involved, dates of alleged occurrence(s), and an explanation of how the allegation relates to MO HealthNet Provider fraud.(Required)

File

Max. file size: 300 MB.

If you do not have material(s) relating to your allegation(s), but know that such material(s) exist(s), describe it and where it may be found, including who may have possession or control over it and how that person or entity may be reached.

Your Employer Information

Name of Company/Agency/Individual

Address

Street Address City State / Province / Region ZIP / Postal Code

County

Employer's Phone

Employer's Email

Employer's Website

Are you employed here now?

May we contact you at work?

The Medicaid Fraud Control Unit ("MFCU") of the Attorney General's Office has authority to investigate and prosecute allegations of fraud against Missouri's Medicaid program. Specifically, the MFCU investigates individuals and companies that provide health care services to MO HealthNet participants. If you wish to participate in the whistleblower program described in Section 191.907, RSMo, you must complete and return a Whistleblower Application. You will not be entitled to any proceeds of a recovery by this office if you do not do so. To request this application, please select the box below and a Whistleblower Application will be mailed to the address you provided on page one (1) of this Complaint Form.

I wish to receive a Whistleblower Application Form.

Name

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