Comments to the MFCU

Fighting Medicaid and Nursing Home Patient Abuse and Neglect
Office of New York State Attorney General

Please complete this form with as much information and in as detailed a manner as possible.

Your Name *

Email *

Daytime Phone *

County / Zip Code *

Type of Insurance Fraud / Complaint

Medicaid

Nursing Home Patient Abuse/Neglect/Mistreatment

Section I

What Type of Provider or Professional is Involved: (check all applicable)

Address of Provider/Professional:

Location of Fraudulent Activity (if different than provider’s address):

Date and Time of Fraud:

Insurance Policy and Claim Number

Names of Individuals Involved in Fraud:

In your own words, describe in as much detail as possible, what a person or business did to commit Medicaid or Insurance Fraud.

Section II

Name of the nursing home involved

Address of the nursing home involved

Name and job title of the alleged abuser

Name of resident involved

Date and time of incident:

Your relationship to the patient/resident

Injury to the patient/resident:

Medical treatment, if any, required (include the name of any hospital where treatment was rendered):

In your own words, describe the incident in as much detail as possible:

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