Wisconsin Department of Health Services

Report Fraud

»	Report Fraud

Office of the Inspector General

If you suspect that someone is committing or has committed any form of fraud or abuse of a Wisconsin Department of Health Services program and would like to file a complaint, please fill out the form below. Please fill out as much information as possible.

You may remain anonymous if you wish. However, if you choose not to provide your contact information, it may prevent us from investigating your complaint fully if questions arise during our review process.

Source Information

Do you wish to remain anonymous?	YesNo
First Name	First Name: Maximum characters required is (15).
Last Name	Last Name: Maximum characters required is (20).
Company(If Applicable)	Company(If Applicable): Maximum characters required is (50).
Street Address	Street Address: Maximum characters required is (40).
City	City: Maximum characters required is (30).
State/ZIP	Maximum characters required is (9).
Email	Email: Maximum characters required is (50).
Phone #	Phone #: Enter a valid value
Best way to reach you if needed	Phone
	Email
	Mail

If you suspect a provider, store, or agency is committing fraud or abuse, fill out this section:

Provider	Provider: Maximum characters required is (50).
First Name	First Name: Maximum characters required is (15).
Last Name	Last Name: Maximum characters required is (20).
Type of Service	Type of Service: Maximum characters required is (50).
Street Address	Street Address: Maximum characters required is (40).
City	City: Maximum characters required is (30).
State
Zip Code	Zip Code: Maximum characters required is (9).
Phone #	Phone #: Enter a valid value

If you suspect an individual is committing fraud or abuse, fill out this section:

First Name	First Name: Maximum characters required is (15).
Last Name	Last Name: Maximum characters required is (20).
Male/Female
Street Address	Street Address: Maximum characters required is (40).
City	City: Maximum characters required is (30).
State
Zip Code	Zip Code: Maximum characters required is (9).
Phone #	Phone #: Enter a valid value

Description of Allegation (required):

In the text box below explain the fraud, waste, and/or abuse you wish to report. Please include the following information, if known: Time frame of the activity. Date(s) of birth or approximate age(s) of those involved. Date(s) and names of other people or agencies that you have reported the activity to.

F-00577 (03/12)

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Wisconsin Department of Health Services

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