Medicare Quality of Care Complaint Form

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.