Nassau County, NY

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: *

Description of the suspected fraudulant activity or misuse of public funds: * Give a statement that clearly describes the persons involved, dates, locations and nature of the incident or issues that you are reporting. The more specific the information you provide us, the better we will be able to follow-up on your complaint.

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: