Form Cms 10287 PDF Details

Understanding the critical pathway for addressing concerns about the quality of care received under Medicare, it's pivotal to grasp the complexities and the structured approach facilitated by the CMS 10287 form. The Centers for Medicare & Medicaid Services (CMS) have designed this form as a streamlined process to lodge complaints about healthcare services quality by those covered by Medicare. This initiative underscores the role of Quality Improvement Organizations (QIOs) in reviewing these complaints, ensuring that the concerns of Medicare beneficiaries are heard and addressed aptly. The form itself is meticulously structured, requiring detailed information about the complainant, the services in question, and the specifics of the grievance, ranging from personal identification and event description to the option of anonymity during the review process. Furthermore, it emphasizes the importance of informed consent, as indicated by the necessity of a signature before any action can be taken on the complaint. As a comprehensive tool, the CMS 10287 form not only empowers individuals to take action against unsatisfactory healthcare services but also plays a significant role in maintaining the standards of healthcare rendered to Medicare beneficiaries, guided by the principles of accountability and quality assurance.

QuestionAnswer
Form NameForm Cms 10287
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesowthedirec, Checkth, ouneedhel, CMS10287

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DEPAR TMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

INSTRUCTIONS FOR THE MEDICARE QUALITY OF CARE COMPLAINT FORM

Medicare contracts with Quality Improvement Organizations (QIOs) to review complaints from people with Medicare about the quality of health care services. Follow the instructions below to describe your complaint.

If you need help with this form, or if you need help with your complaint, call your QIO. Their phone num ber is 1‐ 88 8‐ 354‐ 9100. If your complaint isn’t about the quality of care you got, the QIO will refer your complaint to the right organization.

Follow the directions below and complete each line of the form. If your personal information is already included on the form, please make sure it’s correct.

Line 1: Print the name of the person with Medicare who got the services related to the complaint.

Line 2: Include this person’s Medicare (HICN) number, if known.

Line 3: Check the box next to this person’s sex. Write this person’s age in the blank space.

Line 4: Check the box or boxes that show this person’s race or ethnicity. Please note that this information is strictly voluntary and won’t impact your complaint.

Line 5: If the person with Medicare won’t be the primary contact during the complaint process, print the nam e of the person’s authorized representative.

Line 6: Print the contact information for the person who will be the primary contact during the complaint process – either the person with Medicare or the authorized representative.

Line 7: Check the box indicating whether you would like the doctor or provider who was involved in your complaint to know your name. If you check “No,” the QIO won’t reveal your name.

Line 8: Describe what happened. Include any information you believe would help the reviewer, including dates and times; names and addresses of doctors, staff and providers; information from witnesses, if available. If you need more space, you can attach additional sheets of paper. You can also include any documents you believe support your complaint.

Line 9: By signing the form, you are authorizing the QIO to review your complaint and give you a formal decision. The QIO may need to request your medical records related to the complaint.

Once you’ve finished the form, do the following:

•Keep these instructions (page 1) for your information.

•Make a copy of the form (page 2). Keep a copy for yourself and mail a copy to the QIO.

The QIO will send you a decision on your complaint once the review is c ompleted.

Form CMS‐10287 (09/10)

1

Mailing Address: AFMC, PO Box 180001, Fort Smith, AR 72918‐0001

MEDICARE QUALITY OF CARE COMPLAINT FORM

1.NAME

2.MEDICARE NUMBER (HICN)

3. SEX

 

DATE OF BIRTH

Male

Female

 

4.RACE/ETHNICITY (This section is voluntary):

A. Are you Hispanic or Latino?

Yes

No

B. How would you describe your race? Please mark one or more boxes.

American Indian or Alaska Native

 

Native Hawaiian or Other Pacific Islander

White

 

Asian

Black or African American

 

 

 

 

 

5.AUTHORIZED REPRESENTATIVE’S NAME (if primary contact for the complaint)

6.CONTACT INFORMATION FOR PRIMARY CONTACT:

STREET/APT.

CITY

STATE

ZIP

PHONE

ALTERNATE PHONE

7. During the review of your complaint, do you want the doctor or provider staff involved in the complaint to

know your name?

Yes

No

8.Briefly describe the incident or your concerns: Include names, addresses, dates, and times involved. You can attach additional sheets of paper or other documents.

9. 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 21244-1849.

Form CMS‐10287 (09/10)

2

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Step # 1 in filling in FormC

2. After performing this step, go on to the subsequent part and enter all required particulars in all these blank fields - BENEFICIARY NAME, MEDICARE NUMBER HICN, SEX MALE, FEMALE, DATE OF BIRTH, RACEETHNICITY Completion of this, American Indian or Alaska Native, Native Hawaiian or Other Pacific, White, Asian, Black or African American, Hispanic or Latino, BENEFICIARYS AUTHORIZED, CONTACT INFORMATION FOR PRIMARY, and STREETAPT.

The right way to prepare FormC step 2

3. This third segment should also be quite uncomplicated, PHONE, ALTERNATE PHONE, and Briefly Describe the incident or - each one of these form fields needs to be filled out here.

FormC conclusion process detailed (stage 3)

Always be really mindful when filling in Briefly Describe the incident or and ALTERNATE PHONE, as this is where most users make a few mistakes.

4. This fourth paragraph comes next with the next few blank fields to enter your details in: May we reveal your identity, YES, and Form CMS.

Best ways to prepare FormC step 4

5. To wrap up your form, this last part requires a couple of extra fields. Filling out Check yes here if you authorize, YES, FOR YOUR INFORMATION If you have, By signing this form I am, SIGNATURE OF BENEFICIARY OR, DATE, and According to the Paperwork is going to finalize everything and you'll be done in the blink of an eye!

Filling out section 5 of FormC

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