Program Integrity Referral
Submit a Referral:
Eastpointe would like to hear from you regarding any Program Integrity Referrals that you may have.
Please complete the information below and a Program Integrity representative will contact you regarding your referral.
If you would like to report anonymously please put the word unknown in the name and e-mail fields.
Name reporting referral:
I want to remain anonymous
Email Address of person submitting Referral:
Referral is about:
Phone Number of person submitting Referral:
Name of person completing this form:
Name of Medicaid Client:
Client’s Medicaid Card Number
(if you have access to this information)
Name of doctor, hospital, or other healthcare provider:
Date of Service From:
Date of Service To:
Program Integrity Concern
(Please provide a description of the acts that you suspect involve fraud, waste, and/or abuse)
Attach a file
This form is intended for the use of the person or entity to which it is addressed and may contain information that is privileged
and confidential, the disclosure of which is governed by applicable law. If the reader is not the intended recipient, or the
employee or agent responsible to deliver it to the intended recipient, you are hereby notified that any dissemination,
distribution, or copying of this information is
. If you have received this message in error, please
notify the original sender immediately by return email, along with this form from any electronic device. Thank you.
= Input is required
This form was created at