Medical Payment Law Complaint Form
[Revised Statutes 23: 634 & 23:897]
To Look up the Louisiana Medical Payment Law go to - http://www.legis.la.gov/Legis/Law.aspx?d=84006

If you would like to report someone who you think may be committing a Louisiana Medical Payment Law Violation, complete the information below and press the Submit button. You may choose to submit this information anonymously, however, this may limit the scope of the investigation.

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(*) Entry Required

1. * Name of Complainant.
   
   
2. * Phone # of Complainant.
   
   
3. * Complainant E-Mail Address:
   
   
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4. * Name of the company or person you are reporting.
   
5. Address, city and state of the company or person.
   
   Character Count: (Max 200, remaining 200.)
6. * Contact Name/Owner at Company.
   
7. * Phone # of Company.
   
8. Type of Work Done / Occupation / Title
   
   Character Count: (Max 100, remaining 100.)
9. ALLEGED VIOLATIONS – check all that apply
   

   Did you pay for Drug Testing?
   Did you pay for Background check?
   Did you pay for Medical Exam?
   Another Reason?

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10. Additional comments
    
    Character Count: (Max 400, remaining 400.)

By submission of this form the complainant affirms and certifies that all information provided and the statements made herein are true, correct to the best of their knowledge, information and belief.

If you have any other questions, please email laborprograms@la.gov or call toll-free 1-225-219-2989.