Medicaid fraud complaint form

Please complete this form with as much information and in as detailed a manner as possible.

Fields with an asterisk * are required. To learn how we safeguard your personal information, please read our privacy policy.

Type of complaint

I am a:

Family member reporting an incident of patient abuse, neglect or mistreatment

Healthcare worker reporting patient abuse or neglect, infection control violations, or inadequate PPE

Your information

Full name

Street address

City/town

State

Zip code

Email

Phone number

Facility information

Type of facility

Assisted living

Hospital

Nursing home

Other

(please specify)

Type of facility (other)

Full name of facility

Street address

City/town

State

Zip code

Patient/resident information

Full name of patient/resident

Your relationship to the patient/resident

Are you the resident's health care proxy?

Yes

No

Name of health care proxy

Is the resident deceased?

Yes

No

Date and location of death

Date of death

Location of death

Is the resident still at the facility?

Yes

No

Date and location of transfer

Date of transfer

Location of transfer

Incident/issue details

Are you reporting a specific incident?

Yes

No, I have general concerns about a facility

Please describe your issue or concern about a facility

Date of incident

Description of incident

Was there any known injury to resident from this incident?

Yes

No

Medical treatment required, if any. (Include the name of any hospital where treatment was rendered)

Supporting documentation

Please upload supporting files as available, including records of communications, signed documents, images, or other relevant materials.

Maximum 4 files.
5 MB limit.
Allowed types: gif, jpg, jpeg, png, bmp, txt, pdf, doc, docx, xls, xlsx.

In filing this complaint, I understand that:

The Attorney General is not my private lawyer. The Attorney General is a public servant who protects the public from illegal or misleading practices. This complaint does not mean that the Attorney General will start a lawsuit for me.

The Attorney General cannot give me legal advice or represent me in court. If I have any questions about my legal rights or responsibilities, I should contact a private lawyer.

The Attorney General may send a copy of my complaint, and any documents I provide, to the person or organization I mention in my complaint. I give that person or organization permission to provide information about my complaint to the Attorney General.

The Attorney General works with other government agencies at the state, local, and federal levels to investigate complaints and work with the police. The Attorney General may share my complaint with these agencies.

I affirm this 7th day of December, 2025, under the penalties of perjury under the laws of New York, which may include a fine or imprisonment, that:

the foregoing is true, except as to matters alleged on information and belief and as those matters I believe it to be true, and
I understand that this document may be filed in an action or proceeding in a court of law.

Signature