Form Cms-10287 - Medicare Quality Of Care Complaint Page 3

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9. Check “yes” here if you authorize the QIO to forward your address or other contact information to the entity that

conducts beneficiary satisfaction surveys. If you check “yes”, you will be contacted by telephone or postal mail to

conduct a brief survey about your satisfaction with the service you received from the QIO. If you leave this question

blank, a surveyor will contact you about your satisfaction.

YES

FOR YOUR INFORMATION: If you have any questions about your complaint, please call _____________________________.

You will be contacted within ___ days upon the QIO’s receipt of the signed complaint form. The QIO will utilize a

physician who practices in the same or similar clinical area as the physician who provided your care in completing its

review. You may provide any information you believe is relevant to your complaint, including copies of documentation,

names of witnesses, etc. A decision will be made on your complaint within ___ days of receiving the signed complaint

form. If your complaint includes concerns not within the scope of the QIO’s authority, the concerns will be referred to

the appropriate entity.

10. By signing this form, I am requesting that the QIO review my complaint.

SIGNATURE OF BENEFICIARY OR REPRESENTATIVE

DATE

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid

OMB control number. The valid OMB control number for this information collection is 0938-1102. The time required to prepare and distribute

this collection is 10 minutes per notice, including the time to select the preprinted form, complete it and deliver it to the beneficiary. If you have

comments concerning the accuracy of the time estimates or suggestions for improving this form, please write to CMS, PRA Clearance Officer,

7500 Security Boulevard, Baltimore, Maryland 21244-1850

Form CMS-10287 (11/15)