Report a Healthcare Crime

Name: (required)

Address:

City/Town: (required)

State: (required)

Zip Code: (required)

Phone number: (required)

E-mail address:

• May we contact you if we need additional information? (required) YesNo
• Preferred time and method of contact: Method: Select one E-Mail Phone Time: Select one Morning Afternoon Evening No Preference

Victim's name: (required)

Name of residential care facility: (required)

Address of residential care facility: (required)

City/Town: (required)

State: (required)

Zip Code: (required)

County of residential care facility:

Approximate date of alleged abuse and/or neglect:

Description of alleged abuse and/or neglect (please be as thorough as possible): (required)

Have you reported the alleged abuse and neglect to either of the following state government agencies?

• Maine DHHS: YesNo
• Adult Protective Services: YesNo
• Local Law Enforcement: YesNo
• Did you file a report with the facility: YesNo