If you suspect that someone is committing or has committed any form of fraud or abuse of a Wisconsin Department of Health Services program and would like to file a complaint, please fill out the form below. Please fill out as much information as possible.

If you have document(s) that will support the allegation, you will have an opportunity to add them before submitting this form.

You may remain anonymous if you wish. However, if you choose not to provide your contact information, it may prevent us from investigating your complaint fully if questions arise during our review process.

Source Information Do you wish to remain anonymous? YesNo First Name  First Name: Maximum characters required is (15). Last Name  Last Name: Maximum characters required is (20). Company (If Applicable)  Company (If Applicable): Maximum characters required is (50). Street Address  Street Address: Maximum characters required is (40). City  City: Maximum characters required is (30). State WI AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WV WY ZIP Code  ZIP Code: Maximum characters required is (9). Email  Email: Maximum characters required is (50). Phone Number  Phone Number: Enter a valid value Best way to reach you if needed Phone Email Mail

If you suspect a provider, store, or agency is committing fraud or abuse, fill out this section: Provider  Provider: Maximum characters required is (50). First Name  First Name: Maximum characters required is (15). Last Name  Last Name: Maximum characters required is (20). Type of Service  Type of Service: Maximum characters required is (50). Street Address  Street Address: Maximum characters required is (40). City  City: Maximum characters required is (30). State WI AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WV WY Zip Code  Zip Code: Maximum characters required is (9). Phone Number  Phone Number: Enter a valid value

If you suspect an individual is committing fraud or abuse, fill out this section: First Name  First Name: Maximum characters required is (15). Last Name  Last Name: Maximum characters required is (20). Male/Female Male Female Subject Date of Birth or Approximate Age  Subject Date of Birth or Approximate Age: Maximum characters required is (50). Street Address  Street Address: Maximum characters required is (40). City  City: Maximum characters required is (30). State WI AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WV WY Zip Code  Zip Code: Maximum characters required is (9). Phone Number  Phone Number: Enter a valid value

Description of Allegation (required):    In the text box below, explain the fraud, waste, and/or abuse you wish to report. Please include    the following information if known: Time frame of the activity. Date(s) of birth or approximate age(s) of those involved. Date(s) and names of other people or agencies to whom you have reported the activity. Any additional details that may assist in the investigation.