Report Suspected Fraud or Abuse of the Program

The Office of Inspector General (OIG) provides a way for individuals, plans, and providers to report all forms of abuse including, suspected fraud or abuse of the program. Everyone (members/beneficiaries, caregivers, health plans, and the public) can report suspected fraud or abuse of the program with this online form.

You may also submit attachments and/or additional information email to AHCCCSFraud@azahcccs.gov.

Please Enter Your Contact Information

NOTE: You may choose to remain anonymous and still submit a referral. AHCCCS does not receive any information about you, except for what you are willing to provide in the fields listed below.

Your First Name:

Your Last Name:

Your Title (if applicable):

Your Company's Name (if applicable):

Your Address:

City:

State:

ZIP Code: (xxxxx-xxxx, last four optional) Please enter a valid ZIP Code.

Your E-Mail Address: Please enter a valid e-mail address.

Your Phone Number: Please enter a valid phone number. Ex: 000-000-0000

Return Call Requested:

Yes

Please Enter Suspected Provider/Company or Recipient/Member Fraud Information

* required fields

Name of Provider/Company Allegedly Involved (if applicable):

Provider Address (if known):

AHCCCS Provider ID (if known):

Provider Phone Number (if known): Please enter a valid phone number. Ex: 000-000-0000

Title XIX or Non-Title XIX (if known):

Title XIX

Non-Title XIX

Name of AHCCCS Recipient/Member Allegedly Involved (if applicable):

Member Date of Birth (if known): (dd/mm/yyyy)

Member Address (if known):

Case Number (if known):

Member AHCCCS ID Number (if known):

Member Phone Number (if known):
Please enter a valid phone number.

Estimated Dollar Loss to AHCCCS (if known):

*Please Describe Suspected Fraud, Waste, or Abuse: Please describe the suspected fraud, waste, or abuse that you want to report.

Upload Attachment 1:

Upload Attachment 2:

Upload Attachment 3:

Upload Attachment 4:

Upload Attachment 5:

Note: Additional attachments must be submitted on an additional referral.

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