Instructions
Please fully complete the following form to report possible Medicaid Fraud, waste, or abuse occurrences by any health care provider practicing in Nevada. All information received will be held in strict confidence. Thank you for taking the time to report your concerns. |
Section 1: Complaint Information
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| Your Name: |
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| Company (if any): |
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| Mailing Address: |
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| City, State, Zip: |
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| Telephone: |
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| E-Mail: |
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Section 2: Complaint Description
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| Name of Provider Individual: |
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| Name of Provider Company: |
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| Address of Provider: |
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| Telephone of Provider (if known): |
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Describe in Detail Your Complaint
Please include who, what, when, where, why and how.
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Section 3: Witness/Any Other Information
Please list additional witnesses along with any contact information for them you may have as well as any other information that you feel may be important.
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