QUALITY OF CARE COMPLAINT – Innosoft

MEDICARE QUALITY OF CARE COMPLAINT

Department Of Health And Human Services Centers For Medicare & Medicaid Service

COMPLAINT FORM

The Medicare Program works to ensure that beneficiaries get the best care possible. We take your concerns seriously and would like to get more information to help us review your request.

Use of this form will ensure that we process your concerns in an efficient manner. Quality Improvement Organizations (QIOs), under contract with Medicare, are required to conduct reviews of all written complaints from beneficiaries about the quality of services not meeting professionally recognized standards of health care.

You may contact the QIO for assistance in completing this form or for general assistance regarding your complaint.

Beneficiary Full Name:

Medicare Number (HICN):

Gender:

Date of Birth:

Race/Ethnicity:

(Completion of this section is voluntary)

Beneficiary's Authorized Representative:

(If Applicable)

Street/Apt:

City:

State:

Zipcode:

Phone Number:

Alternative Number:

Briefly Describe the incident or your concerns:

Include dates and times, persons involved, and description of what happened. Include attachments, if appropriate.

May we reveal your identity during the review of your complaint?

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.

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.