OMB control number
Medicare Quality of Care Complaint Form (CMS-10287)
OMB 0938-1102 ยท HHS/CMS.
OMB 0938-1102
In accordance with Section 1154(a)(14) of the Social Security Act, QIOs are required to conduct appropriate reviews of all written complaints submitted by beneficiaries concerning the quality of care received. This form will establish a standard form for all beneficiaries to utilize and ensure pertinent information is obtained by QIOs to effectively process these complaints.
The latest form for Medicare Quality of Care Complaint Form (CMS-10287) expires 2029-10-31 and is listed under ICR 202602-0938-021.
Latest Forms, Documents, and Supporting Material
| Document | Type |
|---|---|
 Form CMS-10287 Medicare QUALITY OF CARE COMPLAINT FORM | Form and Instruction |
 CMS-10287 Supporting Statement- clean 4-30-25.docx | Supporting Statement A |
 Medicare Quality of Care Complaint Form |
Form and Instruction |
| Medicare Quality of Care Complaint Form |
Form and Instruction |
All Historical Document Collections
| Reference | Filing | Received | Concluded | Action |
|---|---|---|---|---|
| 202602-0938-021 | Reinstatement with change of a previously approved collection | 2026-03-02 | ||
| 202007-0938-009 | Reinstatement with change of a previously approved collection | 2020-08-03 | ||
| 201611-0938-013 | Extension without change of a currently approved collection | 2016-11-23 | Approved with change | |
| 201402-0938-005 | No material or nonsubstantive change to a currently approved collection | 2014-02-10 | Approved without change | |
| 201307-0938-023 | Revision of a currently approved collection | 2013-07-30 | Approved with change | |
| 200910-0938-012 | New collection (Request for a new OMB Control Number) | 2009-10-27 | Approved with change |