DMFEA Fraud and Abuse Complaint Form

Are you the victim? *

Yes

No

Is the victim a Medi-Cal recipient? *

Yes

No

Unknown

If Yes, Enter the Victim’s Medi-Cal Number (if known)

Victim's First Name *

Victim's Middle Name (if any)

Victim's Last Name *

Is the victims physical address known?

Yes

No

Victim's Phone Number

Victim's Phone Extension

Victim's E-mail Address

Victim Date of Birth (if known)

Month

Day

Year

Is the victim receiving services from In-Home Supportive Services (IHSS?)

Yes

No

Unknown

Is the victim living in a facility? (assisted living, nursing home etc. )

Yes

No

Unknown