Medicaid Fraud Control Unit
Resident Death Reporting Form
Proceed to the On-line Reporting Form by entering your Vendor Number below.
Vendor numbers will look like: 00XXXX, 01xxxx , 05xxxx or 10xxxx.
You must include any leading zeros.
You must include any leading zeros.
If you would like to have a blank copy of the form for data gathering purposes only, you may print this form (PDF). However, please use the on-line form above to sumbit your information.
