Complaint Form - Central Ca Alliance for Health



Complaint Form

Bureau of Medi-Cal Fraud & Elder Abuse

California Department of Justice

To report suspected Medi-Cal fraud or elder abuse, consider these options:

Send A Written Complaint By Mail

California Department of Justice Bureau of Medi-Cal Fraud Elder Abuse P.O. Box 944255 Sacramento, CA 94244-2550

Call the Hotline

Phone Toll-free: (800) 722-0432 Attorney General's Bureau of Medi-Cal Fraud & Elder Abuse

Phone Toll-free: (800) 822-6222 Department of Health Services

Or Email Your Complaint Using This On-line Form

I want to report suspected Medi-Cal fraud or elder abuse. I understand that the Attorney General does not represent private citizens seeking private remedies. I submit my allegations for review to determine if law enforcement or statewide legal action is warranted.

[pic]Indicates Required Fields

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[pic][pic][pic][pic][pic][pic]Complaining Party

• Name: [pic]

• Address: [pic]

• City: [pic]

• State: [pic]

• Zip: [pic]

• Home Phone Number: [pic]



• Work Phone Number: [pic]

• Email Address: [pic]

• Preferred Method of Contact: [pic]Home [pic]Work [pic]Email

Complaint Against

• Company Name: [pic]

• Company Address: [pic]

• Company City: [pic]

• Company State: [pic]

• Company Zip: [pic]

• Have you contacted your local law enforcement agency?   [pic]Yes    [pic]No

• If yes, name of agency [pic]

• Have you contacted another state agency?   [pic]Yes    [pic]No

• If yes, name of agency [pic]

• Have you contacted an attorney?   [pic]Yes    [pic]No

• If yes, name of attorney [pic]

• Is there a court action pending?   [pic]Yes    [pic]No

• If yes, name of court [pic]

• Have you lost a lawsuit in this matter?   [pic]Yes    [pic]No



• Please provide a factual statement that clearly describes the date, place and nature of the incident or issue that you are reporting.

• [pic]

• Briefly describe how you believe this office can be of assistance.

• [pic]

• I will sign a sworn statement if requested.   [pic]Yes    [pic]No

• By submitting this form, I certify that I understand that the Attorney General does not represent private citizens seeking the return of money or other personal remedies.

Please click only once. Multiple clicks will delay processing.

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