Medicaid Fraud Report Form

Vermont Office of Attorney General
109 State Street
Montpelier, VT 05609-1001

If you suspect someone is being or has been neglected or abused, contact local law enforcement immediately.

This online form requests the necessary information for investigating and potentially prosecuting your allegation. We need as much information as you can provide regarding the "who, what, when, where, and how" of the related incident. Please tell us as much as you know.
Any compliant form or associated documents may become public record when submitted to this office.

Your Information (fields with an asterisk * are required.) We must be able to contact you in case we need more information.

First Name

Last Name

Email Address

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Phone Number

Provider or Person Committing Fraud or Abuse Information

Provider or Person Committing Fraud or Abuse Information

The Medicaid Fraud Unit does not investigate individuals who receive services from Medicaid. For more information, contact the Economic Services Division of the Agency of Human Health.

Provider Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Provider Relationship to Victim

Other Information

Victim Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Occurrence Dates

*Specific Details of Your Report - Nature of harm or fraud, additional victim/provider details, locations, etc.

Do you have additional documents or information

Yes

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Medicaid Fraud Report Form

Vermont Office of Attorney General 109 State Street Montpelier, VT 05609-1001

Your Information (fields with an asterisk * are required.) We must be able to contact you in case we need more information.

Provider or Person Committing Fraud or Abuse Information

Other Information

Vermont Office of Attorney General
109 State Street
Montpelier, VT 05609-1001