NYS Office of the Medicaid Inspector General

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Provider Complaint

Client Complaint

Name:

Address:

City:

State:

Zip Code:

Email:

Phone:

Provider ID (if applicable):

Recipient CIN#(if applicable):

Case #(if applicable):

Nature of Allegation:

Allegation:

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Provider Complaint

Client Complaint

Provider or Facility:

Address:

City:

State:

Zip Code:

Phone:

Provider ID (if applicable):

Provider Complaint

Client Complaint

Client First Name:

Client Last Name:

Address:

City:

State:

Zip Code:

Phone:

DOB / Age:

CID#:

Case#:

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