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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
