Fraud Waste & Abuse Form

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First Name(Required)

Last Name(Required)

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Does the Consumer currently have Medicaid?

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Would you like to apply for New York State Medicaid? We can assist.

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Does the Consumer currently receive home care services?

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Consumer’s Medicaid CIN Number(Required)

Name of Personal Assistant(Required)

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70-20 Austin St.,
Suite 135
Forest Hills, NY 11375