Medicare Quality of Care Complaint Form

Medicare Quality of Care Complaint Form (CMS-10287)

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 CMS 10287_Medicare Quality of Care Complaint Form_04-20-20.pdf Form and Instruction
CMS-10287 Medicare QUALITY OF CARE COMPLAINT FORM CMS 10287_Medicare Quality of Care Complaint Form_04-20-20.pdf Form and Instruction
Revised Form CMS-10287 Changes Table 03262020.pdf Crosswalk IC Document
Revised Form CMS-10287 Changes Table 03262020.pdf Crosswalk IC Document

Information Collection (IC) Details

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	CMS 10287_Medicare Quality of Care Complaint Form_04-20-20.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 4,350	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	4,350	4,350
Annual IC Time Burden (Hours)	725	725
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk	Revised Form CMS-10287 Changes Table 03262020.pdf	07/28/2020

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