Form
for Reporting Fraud
Committed by a Provider or Vendor
Use this form to report online an individual or
entity that has committed fraud against the State of Connecticut, Department of Social
Services, Medical Assistance Program. This would include any provider or vendor operating
as an individual or business entity including their employees, owners, and/or officers.
If you want to report any other type of welfare fraud you
should do so by contacting the client fraud
unit.
If you suspect or have knowledge of fraud you can report welfare fraud by filling in
all portions of the following form. You may then either print the form and fax or mail it to
us, or you
may submit the form electronically. Our address, fax and phone numbers appear at the
bottom of this page.
Note: The printed
version of this form is in PDF format. If you do not have Adobe Acrobat Reader, you can download if FREE
by clicking on this icon.
Your name and phone number is optional but it would be helpful to us
in case we need to contact you for additional or clarifying information.
Note:
Fields in RED must be completed.
YOUR NAME:
YOUR ADDRESS:
YOUR E-MAIL ADDRESS:
YOUR AREA CODE +
PHONE
NUMBER
()--
PROVIDER
/ VENDOR
INFORMATION:
PROVIDER
/ VENDOR
NAME PROVIDER
/
VENDOR MAILING ADDRESS PROVIDER
/
VENDOR CITY PROVIDER
/
VENDOR STATE PROVIDER /
VENDOR ZIP
BUSINESS TYPE
Please enter ALL the information you haveregarding the allegation
or suspicion of how the above individual(s) or
Company(s) is defrauding the department:
How do you want to
report this?
I am willing to
identify myself. I wish to remain anonymous.
Please be advised that by
remaining anonymous you may become exempt from any future claim to a
financial incentive as stated in Connecticut Statue: 17b-102
Regulations providing a financial incentive for reporting vendor fraud.
The commissioner of social services shall adopt regulations in accordance
with the provisions of chapter 54 to provide a financial incentive for
reporting of vendor fraud in the medical assistance program by offering a
person up to fifteen percent of any amounts recovered by the state as a
result of such person's report.
If You prefer you can report fraud by mail,
fax or
phone at the address or phone numbers below:
State of Connecticut Department of Social Services
Medical Audits Division
25 Sigourney Street
Hartford, Connecticut 06106-5033
Phone: 1-800-842-2155 or 860-424-5923
Fax: (860) 424-5900
