CMS-10287 Medicare Quality of Care Complaint Form

Medicare Form Summary

You’ll need the CMS-10287 form if you wish to file a complaint about care you received from a Medicare provider, physician, or a physician’s staff.

What you’ll need:
• A description of the complaint, including date, time, who was involved, and exactly what happened
Other important information:
• You can contact your Quality Improvement Organization (QIO) for assistance in filling out this form.

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