REPORTING FRAUD IS EASY, SAFE AND SECURE
Note: Because of confidentiality laws we are NOT able to inform or respond to you as to the outcome or specifics of a case.
Use this form to submit online or follow this link to print this form and fax or mail it,
Note: The printed version of this form is in PDF format. If you do not have Adobe Acrobat Reader, you can download if FREE by clicking on this icon.
Providing your personal information is optional but is helpful in case we need to contact you for additional or clarifying information. Reports can be made anonymously, and all reports are kept confidential.
Note:
Fields in RED must be completed.
PROVIDER / VENDOR NAME
PROVIDER / VENDOR MAILING ADDRESS
PROVIDER / VENDOR CITY
PROVIDER / VENDOR STATE
PROVIDER / VENDOR ZIP
BUSINESS TYPE
Please enter ALL the information you have regarding the allegation or suspicion of how the above
individual(s) or Company(s) is defrauding the department:
How do you want to report this?
I am willing to identify myself. I wish to remain anonymous.
Please be advised that by remaining anonymous you may become exempt from any future claim to a financial incentive as stated in Connecticut Statue: 17b-102 Regulations providing a financial incentive for reporting vendor fraud. The commissioner of social services shall adopt regulations in accordance with the provisions of chapter 54 to provide a financial incentive for reporting of vendor fraud in the medical assistance program by offering a person up to fifteen percent of any amounts recovered by the state as a result of such person's report.
YOUR PERSONAL INFORMATION:
YOUR NAME:
YOUR ADDRESS:
YOUR E-MAIL ADDRESS:
YOUR AREA CODE + PHONE NUMBER
()--
If you prefer, you can report fraud by mail, fax or
phone at the address or phone numbers below:State of Connecticut Department of Social Services
Investigations Division
55 Farmington Avenue
Hartford, Connecticut 06105-3730
Phone: 1-800-842-2155
Fax: (860) 424-5900Email: providerfraud.dss@ct.gov
