Information Collection

Medicare Quality of Care Complaint Form

IC 191138 under ICR 202007-0938-009 · 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⚠️ Notice: This information collection may be referencing outdated material.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 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

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	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 %

table that charts list of burden
	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

table that charts IC Documents
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.