Information Collection

Medicare Quality of Care Complaint Form

IC 191138 under ICR 201402-0938-005 · OMB 0938-1102.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1102 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10287 Medicare Quality of Care Complaint Form	Form and Instruction
CMS-10287 Medicare QUALITY OF CARE COMPLAINT FORM Complaint Form (clean).docx	Form and Instruction
Crosswalk CMS 0938 1102 (revision).doc Crosswalk	IC Document

IC Title:

Medicare Quality of Care Complaint Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10287	Medicare QUALITY OF CARE COMPLAINT FORM	Complaint Form (clean).docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,500

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	3,500	3,500
Annual IC Time Burden (Hours)	583	583
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk	Crosswalk CMS 0938 1102 (revision).doc	02/10/2014

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.