Form Cms-10287 - Medicare Quality Of Care Complaint Page 2

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MEDICARE QUALITY OF CARE COMPLAINT FORM
1. BENEFICIARY NAME:
2. MEDICARE NUMBER (HICN):
DATE OF BIRTH:
3. SEX:
MALE
FEMALE
4. RACE/ETHNICITY
(Completion of this section is voluntary)
How would you describe your race? Please mark one or more boxes.
American Indian or Alaska Native
White
Black or African American
Native Hawaiian or Other Pacific Islander
Asian
Hispanic or Latino
5. BENEFICIARY’S AUTHORIZED REPRESENTATIVE’S NAME (IF APPLICABLE):
6. CONTACT INFORMATION FOR PRIMARY CONTACT:
STREET/APT.
CITY
STATE
ZIP
PHONE
ALTERNATE PHONE
7. Briefly Describe the incident or your concerns: Include dates and times, persons involved, and description of what
happened. Include attachments, if appropriate.
8. May we reveal your identity during the review of your complaint?
YES
NO
If you check “no” we cannot review your complaint as a written beneficiary complaint. However, based on the
circumstances of your complaint, we may choose to review your complaint as a general quality of care review.
Form CMS-10287 (11/15)
2

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