Please complete this form with as much information and in as detailed a manner as possible. Upon receipt, your complaint will be reviewed by a member of our staff. A representative from the Pennsylvania Office of Attorney General, Care-Dependent Neglect Team, Medicaid Fraud Control Section, may contact you if additional information is needed.
Complainant Information (Reporting Person)
- (There is space for a detailed narrative at the end of the form)
If you would like to attach any additional photos or documents to support this form, upload those document below. Acceptable file types are images and PDFs. Max file size is 4MB and max total upload size is 10MB.
Max. file size: 50 MB.
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