Information Collection

Medicare Quality of Care Complaint Form

IC 191138 under ICR 202602-0938-021 · OMB 0938-1102.

Documents and Forms

Document Name Document Type
Form CMS-10287 Medicare QUALITY OF CARE COMPLAINT FORM Medicare Quality of Care Complaint Form Form and Instruction
CMS-10287 Medicare QUALITY OF CARE COMPLAINT FORM CMS-10287-updated 05012025final.pdf Form and Instruction
Revised Form CMS-10287 Changes Table 04292025_ 508.pdf 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	CMS-10287-updated 05012025final.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,369	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	3,369	-981	4,350
Annual IC Time Burden (Hours)	562	-163	725
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk	Revised Form CMS-10287 Changes Table 04292025_ 508.pdf	03/02/2026

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

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