| |
|
| |
(Only New Complaints May Be Filed On-Line)
Please be aware of the following:
- When your complaint has been submitted, you will be informed of your
Web Complaint Number in your confirmation. Please make an accurate record of
this number or print the confirmation page.
- Complaints and inquiries become public records when they are submitted
to the Attorney General's office, and under the Michigan Freedom of Information
Act, copies may be subject to disclosure to anyone who asks for them.
- A copy of the complaint may be sent to other governmental agencies.
- Please be particularly cautious with information containing your
Social Security number, credit card account numbers, etc. for security purposes.
If you believe it is necessary to submit such information, you should mail that
information and the corresponding complaint instead of sending it electronically.
- Do not use punctuation when providing names and addresses.
NOTE: Fields labelled in
RED are required values.
|
| |
Complainant Information
|
| |
|
|
|
|
|
| |
|
|
| |
Your Medicaid ID No.:
|
*
|
Case No.:
|
*
|
|
| |
Your Last Name:
|
*
*
|
First Name:
|
*
*
|
M.I.:
*
|
| |
Your Street Address:
|
*
*
|
City:
|
*
*
|
|
| |
Your State:
|
*
|
Zip Code:
|
*
*
|
|
| |
Your County:
|
|
Your Home Phone:
|
*
|
|
| |
E-mail Address:
|
*
*
|
Your Work Phone:
|
*
|
*
Ext:
|
| |
Retype your E-mail:
|
*
|
Fax Number:
|
*
|
|
| |
|
| |
Fraud Information
|
|
| |
|
|
|
|
|
| |
Company or Person?
|
|
|
|
|
| |
Suspect Last Name:
|
*
*
|
Suspect First Name:
|
*
*
|
|
| |
Suspect Social Security No.:
|
*
|
Suspect Position/Title:
|
|
| |
Provider Company Name:
|
*
*
|
Provider Business ID:
|
*
|
|
| |
Street Address:
|
*
*
|
City:
|
*
*
|
|
| |
State:
|
*
|
Zip Code:
|
*
*
|
|
| |
County:
|
|
Phone:
|
*
|
|
| |
Fax Number:
|
*
|
E-mail Address:
|
*
|
|
| |
Web Site Address:
|
*
|
|
|
|
| |
|
| |
Other Information
|
| |
|
|
|
|
|
| |
Incident Date:
|
*
*
|
Incident Time:
|
:
|
| |
Incident Location:
|
*
|
| |
Are you willing to testify in court regarding this complaint?
|
|
| |
Did you complain directly to the provider?
|
|
If so, who?
|
*
|
| |
What was the response from the provider?
|
|
*
|
| |
If no complaint was given to the provider directly, why?
|
|
*
|
| |
Was this complaint filed with any other agencies?
(Including MDCH, Consumer Protection Division, Police, Insurance Bureau, B.C.B.S, Better Business Bureau, etc)
|
|
If so, who?
|
*
|
| |
|
| |
Fraud Detail
*
* Limited to 24000 characters
|
| |
Please provide any additional relevant information in chronological order, including
dates, names, addresses, telephone numbers, and account numbers where possible.
You have approximately 8-10 typed pages and you may paste text from
word processing documents.
|
| |
|
| |
|
|
|
|
|
| |
|
| |
|
| |
|
| |
|
| |
|
| |
*
|
| |
|
*
Read the Privacy Policy
|
| |
|
|
|
|
|
| |
|