Fillable Intake Form Attorney General of the State of (New Mexico Attorey General's Office)

Fill Online, Printable, Fillable, Blank Intake Form Attorney General of the State of (New Mexico Attorey General's Office) Form

Use Fill to complete blank online NEW MEXICO ATTOREY GENERAL'S OFFICE (NM) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Intake Form Attorney General of the State of (New Mexico Attorey General's Office)

On average this form takes 16 minutes to complete

The Intake Form Attorney General of the State of (New Mexico Attorey General's Office) form is 4 pages long and contains:

  • 0 signatures
  • 17 check-boxes
  • 58 other fields

Country of origin: US
File type: PDF

U.S.A. forms for New Mexico Attorey General's Office

BROWSE NEW MEXICO ATTOREY GENERAL'S OFFICE (NM) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Attorney General of the State of New Mexico
Medicaid Fraud Control Division (MFCD)
Confidential Investigation Report
Intake Form
The following information is necessary for us to begin our investigation. Please make every attempt to provide as
much information as possible.
Reporting Party
____ I would like my identity to remain confidential
Note on Anonymous complaints: Failure to provide name or contact information may result in no action being taken as to this matter. While
anonymous complaints will be thoroughly investigated to the best of our abilities, most investigations require follow up questions to be
answered by the complainant. Without follow up information from the complainant, in some instances, we may not be able to proceed with
an investigation. Please be advised that your name will need to be disclosed if this allegation results in civil or criminal action.
Last Name First Name Middle Initial
Address
City State Zip
EMAIL
Home Phone Work Phone Mobile Phone
PREFERRED CONTACT METHOD
Phone E-mail
Text Instant Message
Other
PREFERRED TIME TO BE CONTACTED
TYPE OF INCIDENT
Abuse/Neglect of facility resident
Fraud committed by Medicaid provider
Fraud committed by Medicaid member/recipient (the MFEAD lacks authority over issues of recipient fraud, these
matters may be forwarded to an outside agency for investigation)
Exploitation of facility resident
Victim/Patient/Medicaid recipient
Last Name First Name Middle Initial
Address
City State Zip
Home Phone Work Phone Mobile Phone
SSN Medicaid Number Date of Birth
Facility/Provider
Name of Organization/Facility/Provider/Company Provider ID
Provider
NPI
Street Address
City State Zip
EMAIL Phone
OTHER PARTIES INVOLVED/WITNESS
Name
Street Address
City State Zip
Home Phone Work Phone Mobile Phone
INCIDENT INFORMATION
Date of Incident Time of Incident Location of Incident
Have you previously filed a complaint with the facility or any agency involved?
YES NO
What was the response from the facility?
Has a complaint been filed with any other agency?
YES NO
If yes, please name the agency.
Have you contacted an attorney?
YES NO
If yes, please name the attorney.
Is there a court action pending in this matter or has there previously been a lawsuit related to this matter?
YES NO
Please provide a factual statement that clearly describes the incident or issue that you are reporting. Attach additional
pages if necessary.
Do not send original documents.
Please retain a copy for your records and send us photocopies or an electronic scan of any
documentation you think may be helpful in reviewing your complaint.
Consulting with a private attorney
The Office of the Attorney General represents the public interest. The office cannot give you legal
advice and is not able to act as your private attorney. If you have any questions concerning your
individual legal rights or responsibilities, you should contact a private attorney.
For Office Use Only
NMAG Staff
Date of Intake
Investigator Assigned
Attorney Assigned
Closed. Refer to:
Director Signature
Date Assigned
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Intake Form Attorney General of the State of (New Mexico Attorey General's Office)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 21 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document