Wisconsin Department of Health Services
Report Fraud
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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?
Yes
No
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
WI
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WV
WY
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
WI
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WV
WY
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
Male
Female
Street Address
Street Address: Maximum characters required is (40).
City
City: Maximum characters required is (30).
State
WI
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WV
WY
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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