OMB control number
Medicare Quality of Care Complaint Form (CMS-10287)
OMB 0938-1102 ยท HHS/CMS.
OMB 0938-1102
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All Historical Document Collections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 |