Nassau County Department of Social Services

Office of Investigations

Medicaid & Public Assistance Fraud Form

60 Charles Lindbergh Blvd. Uniondale, NY 11553-3656
Toll Free Hotline: (877) 711-TIPS (8477)

1 Your Information

Check here to remain anonymous

First Name: *

Last Name:

Address 1:

Address 2:

City:

State:

Zip Code:

Phone Number: *

Alt Phone Number:

Email Address:

2 Fraud Information

Fraud Type: *

Medicaid

Public Assistance

Day Care

SNAP (f/k/a Food Stamps)

HEAP - Home Energy Assistance Program

Other

Other Fraud: *

Please use this form to report any suspected fraud in Medicaid, SNAP, Child Care, HEAP, and Public Assistance programs. In the space provided below, kindly furnish specific details of the alleged fraud, including dates, locations, and the nature of the fraudulent activity. This form should not be used for allegations related to child abuse, elder abuse, or other issues not pertaining to these programs. For such matters, please contact Social Services directly to obtain the appropriate department or agency contact information: *

3 Recipient of Benefits

Check here if unknown or to remain anonymous

First Name: *

Last Name: *

Address 1: *

Address 2:

City: *

State: *

Zip Code: *

Phone Number: *

Date of Birth:

Age:

4 Provider of Services

Check here if unknown or to remain anonymous

Provider's Name: *

Provider's ID Number:

Address 1: *

Address 2:

City: *

State: *

Zip Code: *

Phone Number: *

Location of Fraudulent Activity: If different from provider's address

Insurance Claim Number: