Items 1 to 3: Beneficiary
The beneficiary's name, Medicare number (HICN) if known, sex and date of birth.
CMS-10287
Medicare Quality of Care Complaint Form
- Agency
- CMS
- Revision
- 11/15
- Fillable fields
- 29
- Pages
- 3
- Official source
- CMS form page
- Checked
- October 20, 2026
Form CMS-10287: Medicare Quality of Care Complaint Form
Form CMS-10287 is the Medicare Quality of Care Complaint Form from the Centers for Medicare & Medicaid Services, part of the U.S. Department of Health and Human Services. The form says Quality Improvement Organizations (QIOs), under contract with Medicare, review written complaints from beneficiaries about the quality of services not meeting professionally recognized standards of health care. The CMS page lists the form as OMB Exempt.
The first page is an instruction sheet to keep. The complaint form asks for the beneficiary's name, Medicare number, sex and date of birth, a voluntary race and ethnicity section, an authorized representative if there is one, contact details and a description of the incident. It ends with two yes or no questions and a signature.
The form says to mail only the complaint form to the QIO, and the CMS page points to a QIO Contact Information document with each QIO's name, address, phone number and email address. You can fill it out free in your browser on this page and download the result without an account.
What's on Form CMS-10287
Item 4: Race and ethnicity
One or more boxes from six choices. The form says this section is voluntary, and the instructions say it has no impact on the processing of the complaint.
Items 5 and 6: Representative and contact
The authorized representative's name if applicable, then the primary contact's street and apartment, city, state, ZIP code, phone and alternate phone.
Item 7: Description of the concern
A brief description of the incident with dates and times, persons involved and what happened. The instructions say extra sheets and supporting documents can be attached.
Items 8 and 9: Identity and survey
Whether the QIO may reveal your identity during the review, and whether it may forward your contact information to the entity that conducts beneficiary satisfaction surveys.
Item 10: Signature
The signature of the beneficiary or representative and the date. The form says signing requests that the QIO review the complaint.
The instructions ask that all sections be completed.
How to fill out Form CMS-10287
- 1
Find your QIO
The CMS page points to its QIO Contact Information document for each QIO's name, address, phone number and email. The instructions say the QIO can help with completing the form.
- 2
Enter the beneficiary and contact details
Fill in items 1 to 6: the beneficiary, the optional race and ethnicity boxes, any authorized representative and the primary contact's address and phone.
- 3
Describe what happened
The instructions ask for dates and times, physicians and provider staff involved, information from witnesses if available, and a description of what happened.
- 4
Answer items 8 and 9
Check yes or no on revealing your identity and on sharing contact information for a satisfaction survey.
- 5
Sign and date
The beneficiary or representative signs and dates item 10.
- 6
Mail it to the QIO
The instructions say to keep the instruction page and mail only the complaint form to the QIO.
Why fill Form CMS-10287 on indox
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
- Fill the form right in your browser, no software to install
- Free to fill and free to download, with no account
- The official blank straight from the CMS, not a copy someone retyped
- Works on a phone, tablet or computer
Where it goes and what happens next
Where to send it
To the QIO, according to the form. The CMS page lists each QIO's name, address, phone number and email in its QIO Contact Information document. The CMS address on page 3 is for comments on the time estimate only.
Review and medical records
The form says signing authorizes the QIO to review the complaint and render a formal determination, and that processing may require requesting pertinent medical records.
Who reviews it
The form says the QIO uses a physician who practices in the same or similar clinical area as the physician who provided the care.
Timing
The form leaves blanks for the QIO's phone number and for the number of days to contact you and to decide. It does not print a number of days.
Time to complete
The form's Paperwork Reduction Act statement estimates 10 minutes per notice.
Related forms
Who uses Form CMS-10287?
The form is written for Medicare beneficiaries and their authorized representatives.
Official sources and the blank
Do it all with indox
No tool matches that search.
Questions about Form CMS-10287
Where do I send Form CMS-10287?
The form says to keep the instruction page and mail only the complaint form to the QIO. The CMS page points to a QIO Contact Information document with each QIO's name, address, phone number and email address.
Is the race and ethnicity section required?
No. Item 4 says completion is voluntary, and the instructions say the information has no impact on the processing of the complaint.
What happens if I check No on item 8?
The form says the complaint then cannot be reviewed as a written beneficiary complaint. Based on the circumstances, the QIO may choose to review it as a general quality of care review.
Can someone file the complaint for the beneficiary?
Item 5 asks for the beneficiary's authorized representative if someone other than the beneficiary will be the contact, and item 10 can be signed by the beneficiary or the representative.
Can I attach documents?
Yes. The instructions say extra sheets can be attached if more space is needed, along with any documents that support the complaint.
How long does a decision take?
The form leaves a blank for the number of days, so it does not state a time. It says a decision is made within that number of days of the QIO receiving the signed form.
What if my concern is not about quality of care?
The form says concerns outside the scope of the QIO's authority are referred to the appropriate entity.