Name:
Address:
City:
State: Select State Alabama Alaska Alberta Arizona Arkansas British Columbia California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitobia Maryland Massachusets Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada Brunswick New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Nova Scotia Ohio Oklahoma Oregon Pennsylvania Prince Edward Island Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip Code:
Email:
Phone:
Provider ID (if applicable):
Recipient CIN#(if applicable):
Case #(if applicable):
Nature of Complaint: Select Complaint Billing Issue Internal Affairs/OWIG Other Payment from Recipient Provider-RX Fraud Quality of Care Issue Recipient Eligibility Recipient Misuse Other Than RX Recipient Misuse RX Fraud Services Not Rendered Unlicensed Provider Unnecessary Services
Provider or Facility:
Client First Name:
Client Last Name:
DOB / Age:
CID#:
Case#:
