Confidential Investigation Report Intake Form - Attorney General Of The State Of New Mexico
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4Attorney General of the State of New Mexico
Medicaid Fraud and Elder Abuse Division (MFEAD)
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
PREFERRED TIME TO BE CONTACTED
Phone
E-mail
Text
Instant Message
Other
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Parent category: Legal