OIG Fraud & Abuse Complaint

STATE OF KANSAS
Kansas Department of Health and Environment
Office of Inspector General
900 SW Jackson Street, Suite 900-N
Topeka, KS
Telephone: (785) 296 – 1076
Email: OIG@kdheks.gov
MEDICAID FRAUD AND ABUSE COMPLAINT FORM  

If you have witnessed incidents of Medicaid fraud, waste, and abuse, report to the OIG by completing as much information as you can using the form below. Every reported case will be reviewed and referrals to other agencies, including the Attorney General’s Medicaid Fraud and Abuse Division, may be made if necessary.
Contact Information of the Reporting Individual:

Please provide your contact information. We will keep it confidential and will not share it without your consent.
You may choose to remain anonymous and still submit your report – simply skip the information you do not wish to include.
 
First Name:
Last Name:
Street Address:
City:
State:
Zip code:
Email address:
Phone #(area code+):

Provider Information:

If a provider is involved, please include as much business information as you know about the provider:
 
Name of Provider:
Business Name:
Business Street Address:
City:
State:
Zip Code:
Medicaid Provider Id Number:
License Number:

Beneficiary Information:

Please provide any information you know about the Medicaid beneficiary (or member) involved in this case. This information will be kept confidential and will not be shared except with appropriate authorities in the resolution of this complaint:
 
Beneficiary First Name:
Beneficiary Middle Initial:
Beneficiary Last Name:
Beneficiary Street Address:
City:
State:
Zip Code:
Beneficiary ID Number:
Date of Birth (DOB):

Details of Complaint:

In the space below, please provide as much information as you can about your concern(s). Include what happened, when (dates and time if known), where (locations/places if known), how much money was involved, etc.
 


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