Medicaid Recipient Information

First Name                                     Last Name

Address

City                                         State                                   Zip Code

Phone Number

(Ex., 555-555-5555)

Date of Birth                          Age                       Social Security Number

(ex., 00/00/00)                                                      (00-00-0000)

Provide detailed description of wrongdoing:

Information on Person Filing Complaint

First Name                                     Last Name

Address

City                                       State                                    Zip Code

Email Address  

How would you like to be contacted?

Telephone

  Mail

  Email