Form Cms-10287 - Medicare Quality Of Care Complaint
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3DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
MEDICARE QUALITY OF CARE COMPLAINT FORM
INFORMATION TO HELP YOU FILL OUT THE “QUALITY OF CARE COMPLAINT” FORM
The Medicare Program works to ensure that beneficiaries get the best care possible. We take your
concerns seriously and would like to get more information to help us review your request. Use of
this form will ensure that we process your concerns in an efficient manner. Quality Improvement
Organizations (QIOs), under contract with Medicare, are required to conduct reviews of all written
complaints from beneficiaries about the quality of services not meeting professionally recognized
standards of health care. You may contact the QIO for assistance in completing this form or for general
assistance regarding your complaint.
Please use this step-by-step instruction sheet when completing your “Quality of Care Complaint” Form.
Be sure to complete all sections of the form. In addition, if your personal information has been included
in the form based on contact you have had with the QIO for your state, please review the information to
confirm its accuracy.
1. Print the name of the Medicare beneficiary who has a complaint about the quality of health care he/
she received.
2. Include the Beneficiary’s Medicare (HICN) number if known.
3. Check the appropriate box designating the sex of the individual listed in number 1. In addition,
please indicate the age of the beneficiary in the blank space provided, if known.
4. Check the appropriate box or boxes indicating the race/ethnicity of the individual listed in
number 1. Please note that this information is strictly voluntary and has no impact on the processing
of the complaint.
5. Print the name of the beneficiary’s authorized representative if someone other than the beneficiary
will be the contact for the processing of the complaint.
6. Print the contact information for the beneficiary or for the beneficiary’s authorized representative
someone other than the beneficiary will be the contact for the processing of the complaint.
7. Provide a brief description of the incident or concern. The description should include any information
you believe is relevant to the review of your complaint, including:
•
dates and times,
•
physicians and provider staff involved,
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information from witnesses if available, and
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a description of what happened. If you require more space to describe your complaint, you
may attach additional sheets of paper. In addition, you may provide any documents you believe
support your complaint.
Please note: If you raise concerns that are not quality of care concerns within the scope of the QIO’s
authority, your complaint will be referred to the appropriate entity.
1. By signing the form, you are authorizing the QIO to review your complaint and render a formal
determination. The processing of your complaint may require the requesting of pertinent medical
records.
2. PLEASE keep this page for your information. Only mail the second page (Medicare Quality of Care
Complaint Form) to the QIO. The phone number of your QIO is ______________. A decision on your
complaint will be made within ___ days of receiving the signed complaint form.
Form CMS-10287 (11/15)
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Parent category: Medical