Form CMS-10287 Medicare QUALITY OF CARE COMPLAINT FORM

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

MEDICARE QUALITY OF CARE COMPLAINT FORM

INFORMATION TO HELP YOU FILL OUT THE “QUALITY OF CARE COMPLAINT” FORM
The Medicare Program works to ensure that beneficiaries get the best care possible. We take your
concerns seriously and would like to get more information to help us review your request. Use of
this form will ensure that we process your concerns in an efficient manner. Quality Improvement
Organizations (QIOs), under contract with Medicare, are required to conduct reviews of all written
complaints from beneficiaries about the quality of services not meeting professionally recognized
standards of health care. You may contact the QIO for assistance in completing this form or for general
assistance regarding your complaint.
Please use this step-by-step instruction sheet when completing your “Quality of Care Complaint” Form.
Be sure to complete all sections of the form. In addition, if your personal information has been included
in the form based on contact you have had with the QIO for your state, please review the information to
confirm its accuracy.
1. Print the name of the Medicare beneficiary who has a complaint about the quality of health care he/
she received.
2. Include the Beneficiary’s Medicare Beneficiary Identifier (MBI) number if known.
3. Check the appropriate box designating the sex of the individual listed in number 1. In addition,
please indicate the age of the beneficiary in the blank space provided, if known.
4. Check the appropriate box or boxes indicating the race/ethnicity of the individual listed in
number 1. Please note that this information is strictly voluntary and has no impact on the processing
of the complaint.
5. Print the name of the beneficiary’s authorized representative if someone other than the beneficiary
will be the contact for the processing of the complaint.
6. Print the contact information for the beneficiary or for the beneficiary’s authorized representative
someone other than the beneficiary will be the contact for the processing of the complaint.
7. Provide a brief description of the incident or concern. The description should include any information
you believe is relevant to the review of your complaint, including:
•

dates and times,

•

physicians and provider staff involved,

•

information from witnesses if available, and

•

a description of what happened. If you require more space to describe your complaint, you
may attach additional sheets of paper. In addition, you may provide any documents you believe
support your complaint.

8. When the QIO reviews your complaint as a general quality of care review, after you answered NO to item 8, you
may not receive report of the review.
9. If you leave item 9 question blank, a surveyor may contact you about your satisfaction
10. By signing the form, you are authorizing the QIO to review your complaint and render a formal determination
Please note:
The processing of your complaint may require the requesting of pertinent medical records.

PLEASE keep this page for your information. Only mail the second page (Medicare Quality of Care Complaint
Form) to the QIO.
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MEDICARE QUALITY OF CARE COMPLAINT FORM

1. BENEFICIARY NAME:
2. MEDICARE BENEFICIARY IDENTIFIER (MBI) NUMBER:

3. SEX:

MALE

DATE OF BIRTH:

FEMALE

4. RACE/ETHNICITY (Completion of this section is voluntary) How would you describe your race? Please mark one or more boxes.
How would you describe your race? Please mark one or more boxes.

American Indian or Alaska Native

White

Black or African American

Native Hawaiian or Other Pacific Islander

Asian

Hispanic or Latino

5. BENEFICIARY’S AUTHORIZED REPRESENTATIVE’S NAME (IF APPLICABLE):

6. CONTACT INFORMATION FOR PRIMARY CONTACT:
STREET/APT.
CITY

STATE

PHONE

ALTERNATE PHONE

ZIP

7. Briefly Describe the incident or your concerns: Include dates and times, persons involved, and description of what
happened. Include attachments, if appropriate.

8. May we reveal your identity during the review of your complaint?
YES
NO
If you check “no” we cannot review your complaint as a written beneficiary complaint. However, based on the
circumstances of your complaint, we may choose to review your complaint as a general quality of care review.

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9. Check “yes” here if you authorize the QIO to forward your address or other contact information to the entity that conducts

beneficiary satisfaction surveys. If you check “yes” or leave this question blank, you may be contacted to conduct a brief survey about
your satisfaction with the service you received from the QIO. YES
NO
FOR YOUR INFORMATION: If you have any questions about your complaint, please call _____________________________.
You will be contacted within ___ days upon the QIO’s receipt of the signed complaint form. The QIO will utilize a
physician who practices in the same or similar clinical area as the physician who provided your care in completing its
review. You may provide any information you believe is relevant to your complaint, including copies of documentation,
names of witnesses, etc. A decision will be made on your complaint within ___ days of receiving the signed complaint
form. If your complaint includes concerns not within the scope of the QIO’s authority, the concerns will be referred to
the appropriate entity.
10. 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 0938-1102 (Expires XX/XX/XXXX). This
is a voluntary information collection. The time required to complete this information collection is estimated to be 10 minutes per
response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review
the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this
form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland
21244-1850.
*****CMS Disclaimer*****Please do not send applications, claims, payments, medical records or any documents containing
sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the
information collection burden approved under the associated OMB control number listed on this form will not be reviewed,
forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact the
QIO concern email at: [email protected].

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