Medicaid Entities/Providers are required to prepare and maintain contemporaneous records demonstrating their right to receive payment under the medical assistance program and furnish the records, upon request.
If a provider becomes aware that their records have been damaged, lost or destroyed they are required to report that information to the Self-Disclosure Program as soon as practicable, but no later than thirty (30) calendar days after discovery.
Please see Self-Disclosure Guidance for information about damaged, lost or destroyed records.
How to self-report Lost, Damaged or Destroyed Records
Click on the form links below and save them to your computer. Once they are complete, navigate back to this page and use the Secure Submission Link below to submit them, along with any additional supplemental documentation, to OMIG’s Self-Disclosure Program. The Secure Submission Link will bring you to a page where you can upload your self-disclosure form and documents along with an optional message, and then send them securely to OMIG.
What You Need
- Statement of Damaged, Lost or Destroyed Records
- Certification Form
- Additional documentation you may need (as applicable)
- Police reports
- Photographs
- Insurance claim documentation
Secure Submission Link
Submit your Statement of Damaged, Lost or Destroyed Records at: Secure Submission Link