1. Identify The PROVIDER Involved In The Wrongdoing? (Please provide as much information as possible)

Name of Provider:                                            

Name of Medical Group or Organization:                                                

Address: (Street Address, City, State, Zip Code)

Provider Type                             

  Select Provider Pharmacy Hospital Inpatient Podiatry Vision Care Contract Clinics Home Care Hospital Outpatient Durable Medical Equipment Physical Therapists HMOs Physician Dental Long Term Care Facilities Other      

Specialty:                               Medicaid Provider Number (ex., 555-555-5555)

2. What is the complaint: (Please provide a detailed description of the wrongdoing)

3. Dates of Occurrence(s): (ex., mm/dd/yr)

4. HAVE YOU FILED THIS COMPLAINT WITH ANY OTHER PERSON OR ORGANIZATION?  IF YES, WHO AND WHEN?

5. IF YOU ARE AWARE OF ANY WITNESSES TO THE WRONGDOING, PLEASE PROVIDE THEIR NAMES AND CONTACT INFORMATION.

6. IF YOU HAVE DOCUMENTATION SUPPORTING THIS COMPLAINT, PLEASE PROVIDE VIA FAX OR MAIL.

Department of Health & Mental Hygiene

Office of the Inspector General

201 W. Preston Street

Baltimore, Maryland 21201

FAX:  410/333-7194

7. Person Making This Complaint:  (optional)

Full Name: (Print)

Home Address: (Street Address, City, State, Zip Code)

Home Telephone: (ex., 555-555-5555)     Office Telephone: (ex., 555-555-5555)

DISCLAIMER: You may file this complaint anonymously.  However, despite efforts on behalf of the Office of the Inspector General to maintain your anonymity, you should know that your identity may eventually become known as a result of the investigation.