Fraud and Abuse Reporting Form

Suspected cases of fraud and abuse should be reported to the Maryland VFC program. Upon receipt of a complaint, an investigation of all suspected or reported case(s) of fraud and abuse will be initiated.

PLEASE COMPLETE THIS FORM FOR SUSPECTED CASES OF FRAUD AND/OR ABUSE.
Date*
MM slash DD slash YYYY
VFC PIN and Office*
VFC PIN Office Name
Medicaid ID (if known)
Medicaid ID
Date incident occurred*
MM slash DD slash YYYY
Address where the incident occurred*
Value of vaccine involved
(for internal use only)
Description of suspected misconduct and/or specific VFC requirement(s) violated.*
Action Taken
(for internal use only)
Please attach all applicable files here:
Drop files here or

Max. file size: 20 MB, Max. files: 10.
Name of person completing this report
First Last Title
Email
Phone*

About Us

The Maryland Vaccines For Children (VFC) program helps ensure that all children have a chance of getting their recommended vaccinations on schedule.

Vaccinating on time means healthier children, families, and communities. Contact the VFC program for more information.

Contact Us

Email:
MDH.IZinfo@maryland.gov

Address:
201 W Preston Street. Baltimore, MD 21201

VFC Contact Center:
410-274-6240
Baltimore, Baltimore City, Harford, Howard

410-299-5647
Frederick, Montgomery, Prince George’s

410-404-4128
All Other Counties

Maryland Vaccines for Children Program

Fraud and Abuse Reporting Form