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
Top of Form
[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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