Form CMS-10287 Medicare Quality of Care Complaint Form

INSTRUCTIONS FOR THE MEDICARE QUALITY OF CARE COMPLAINT FORM

Medicare contracts with Quality Improvement Organizations (QIOs) to review complaints from people with Medicare about the quality of health care services. Follow the instructions below to describe your complaint.

If you need help with this form or if you need help with your complaint call your QIO. Their phone number is ________________________________. If your complaint isn’t about the quality of care you got, the QIO will refer your complaint to the right organization.

Follow the directions below and complete each line of the form. If your personal information is already included on the form, please make sure it’s correct.

Line 1. Print the name of the person with Medicare who got the services related to the complaint.

Line 2. Include this person’s Medicare (HICN) number, if known.

Line 3. Check the box next to this person’s sex. Write this person’s age in the blank space.

Line 4. Check the box or boxes that show this person’s race or ethnicity. Please note that this information is strictly voluntary and won’t impact your complaint.

Line 5. If the person with Medicare won’t be the primary contact during the complaint process, print the name of the person’s authorized representative.

Line 6. Print the contact information for the person who will be the primary contact during the complaint process – either the person with Medicare or the authorized representative.

Line 7. Check the box indicating whether you would like the doctor or provider who was involved in your complaint to know your name. If you check “No,” the QIO won’t reveal your name.

Line 8. Describe what happened. Include any information you believe would help the reviewer, including dates and times; names and addresses of doctors, staff and providers; information from witnesses, if available. If you need more space, you can attach additional sheets of paper. You can also include any documents you believe support your complaint.

Line 9. By signing the form, you are authorizing the QIO to review your complaint and give you a formal decision. The QIO may need to request your medical records related to the complaint.

Once you’ve finished the form, do the following:

• Keep these instructions (page 1) for your information.

• Make a copy of the form (page 2). Keep a copy for yourself and mail a copy to the QIO.

The QIO will send you a decision on your complaint within ___ days of getting the signed complaint form.

MEDICARE QUALITY OF CARE COMPLAINT FORM

1. Name:
2. Medicare Number (HICN):
3. Sex: Male Female Date of Birth: __________
4. Race/Ethnicity (This section is voluntary): A. Are you Hispanic or Latino? Yes No B. How would you describe your race? Please mark one or more boxes. American Indian or Alaska Native Native Hawaiian or Other Pacific Islander White Asian Black or African American
5. Authorized Representative’s Name (if primary contact for the complaint):
6. Contact Information for primary contact: Street/Apt.
City:	State:	Zip:
Phone:	Alternate Phone:
7. During the review of your complaint, do you want the doctor or provider staff involved in the complaint to know your name? Yes No
8. Briefly Describe the incident or your concerns: Include names, addresses, dates, and times involved. You can attach additional sheets of paper or other documents.
9. By signing this form, I am requesting that the QIO review my complaint. _____________________________________ ____________________ Signature of Beneficiary or Representative Date

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is ________. The time required to prepare and distribute this collection is 10 minutes per notice, including the time to select the preprinted form, complete it and deliver it to the beneficiary. If you have comments concerning the accuracy of the time estimates or suggestions for improving this form, please write to CMS, PRA Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850