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Get Dads Referral Form Texas

Date Fraud Referral Sent to HHSC OIG Fraud Referral Log Data Entry Completed By CRS Fraud Referral Log No. OIG Fraud Referral No. Contact Information for DADS Staff Submitting Referral Name of Staff Title or Position DADS Area State Office Region No. A&I RS CFO DADS Office Street Address COS SSLC Other (specify) City Mail Code State ZIP Code TX Area Code and Telephone No. Email Address Ext. Contact Information for Witness With Information About Suspected Fraudulent Activi.

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