Medicaid Fraud and Abuse Division Allegation Form

I want to report suspected fraud or patient abuse committed by a caregiver, health care provider – doctor, nurse, physician assistant, dentist, psychologist, behavioral health, clinic, hospital, lab, pharmacy, or in a long-term care facility such as a skilled nursing home, assisted living, adult family home or supported living. I understand that the Washington State Office of the Attorney General can only process allegations involving events that occur inside the state of Washington and that the Attorney General does not represent private citizens seeking private remedies.

I submit my allegations for review to determine if law enforcement or statewide legal action is warranted. I understand that investigations are confidential, and I will not be informed of the status of the investigation and may not be informed of the outcome.

* Required fields

1 Contact Information

*Name:

*E-Mail Address: invalid

*Address:

*City:

*State:

*Zip: invalid

*Day Phone:

Evening Phone:

Preferred Method of Contact:

2 Person(s)/ Entity(ies) who are the Subject of the Allegation

*Name:

Address:

City:

State:

Zip:

Day Phone:

Evening Phone:

Are you a professional?

What is your profession?

Have you contacted your local law enforcement agency?

If yes, name of agency:

If this is related to a facility, have you complained to the facility?

If yes, have you filed a complaint about this facility or perpetrator with the Attorney General's Office before?

Have you contacted another state agency?

If yes, name of agency

Have you contacted an attorney?

If yes, name of attorney:

Is there a court action pending?

If yes, name of court:

Have you lost a lawsuit in this matter?

Please provide facts that clearly describe the date, place and nature of the incident or issue that you are reporting:

Briefly describe how you believe this office can be of assistance:

Please provide the names and contact information of any people who may have information about these allegations:

By submitting this form, I certify that I understand that the Attorney General does not represent private citizens seeking the return of money or other personal remedies.