WRINKLE CITY

Name *

First Name

Last Name

Phone

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Your Experience - Abuse

Check any type of abuse you have experienced personally or witnessed.

Physical Abuse

Emotional Abuse

Verbal Abuse and Threats

Lack of Hygiene

Neglect

Mismedication

Your Experience - Financial

Check any type of financial abuse you have experienced personally or witnessed.

Theft or Extortion

Misbilling

Insurance Fraud

Medicaid or Medicare Fraud

CDPAP Fraud

Pay Issues

Your Experience - Administrative

Check any type of administrative abuse you have experienced personally or witnessed.

Is the facility or agency unlicensed?

Is the facility or agency uninsured?

Does the facility or agency lack state or federal required permits or certificates?

Does the facility or agency have open violations?

Does the facility or agency hire undocumented workers?

Does the facility or agency have the required registered nurse to provide oversight of operations?

Does the facility or agency direct care providers to claim that they are licensed or certified, when when they aren't?

Does the home health care company force to to claim more hours than you actually worked or used the services?