Crosswalk

Revisions to Form CMS-10287: Medicare Quality of Care Complaint Form

OMB-0938-1102

APPLICATION/UPDATE FORM

Issue #	Page #	Section	Action to be performed	Changes to the Application	Reason for the Change
	2	Page 2 of the Medicare Quality of Care Complaint Form	Original Text: 10. By signing this form, I am requesting that the QIO review my complaint and ensure a satisfaction survey is sent to me concerning my complaint.	Replace: 10. By signing this form, I am requesting that the QIO review my complaint.	The current language as stated may allow for misinterpretation of whether a beneficiary would like to receive the satisfaction survey if he/she were to select “no” on question #9

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