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OIG Provider Fraud Complaint
OIG Provider Fraud Complaint
If you suspect a Medicaid provider (doctors, hospitals, nursing homes, personal assistants, etc.) is committing fraud, please provide the information below or call 1-844-ILFRAUD.
Provider Information
Provider First Name
*
Provider Last Name
*
Provider Entity Name (Business Name)
*
Provider ID
*
Provider Address
*
Provider City
*
Provider State
*
Provider Zip Code
*
Provider Office Phone Number
*
If complaint involves a Personal Assistant, please provide the following:
Personal Assistant SSN
*
Personal Assistant Birth Date
*
Is PA related to Recipient (Yes/No)
Yes
No
Complaint Information (Please describe your fraud complaint in as much detail as possible, including information on any involved parties and the nature of the misconduct. The more information you are able to provide, the more likely it is that investigators will be able to pursue the matter.)
Referral Details
*
*
Notified Others
Notified Others
No
Notified Others
Yes
Agency Notified
Aging, Department of
Agriculture, Department of
Attorney General, Office of the
Auditor General
Central Management Services, Department of
Children and Family Services, Department of
Comptroller, Office of the
Corrections, Department of
Employment Security, Department of
Environmental Protection Agency
Financial and Professional Regulation, Department of
Healthcare and Family Services, Department of
Human Rights, Department of
Human Services, Department of
Insurance, Department of
Labor, Department of
Military Affairs, Department of
Public Health, Department of
Revenue, Department of
Secretary of State, Office of the
State Fire Marshal
State Police, Illinois
State Treasurer, Office of the
State Treasurer, Office of the
Veterans Affairs, Department of
Other
Allegation Timeframe
Allegation Start Date
*
*
If the alleged conduct is ongoing leave blank, otherwise enter the Allegation End Date.
*
Recipient Information (If your complaint against a provider involved a particular recipient, please provide the recipient's information below.)
Recipient First Name
*
Recipient Last Name
*
RIN (9 numeric digits only)
*
Recipient SSN
*
Recipient Date of Birth
*
Recipient Address
*
Recipient City
*
Recipient State
*
Recipient Zip Code
*
Recipient Home Phone
*
Recipient Work Phone
*
Recipient Cell Phone
*
Recipient Email
*
Is recipient enrolled in Managed Care?
Yes
No
Recipient Plan
Aetna
Humana
Blue Cross Blue Shield
Molina
Meridian
CountyCare
Contact Information (If you are not the recipient described above or didn't complete that section, please provide your information below.)
Contact First Name
*
Contact Last Name
*
Contact Address
*
Contact City
*
Contact State
*
Contact Zip Code
*
Preferred Method of Contact
*
Contact Home Phone
*
Contact Work Phone
*
Contact Cell Phone
*
Contact Email
*
File Attachments (Please upload any documentation in support of your complaint.)
Attach a file
