How to Fill Out the Medicare Quality of Care Complaint Form

Kepro is the Beneficiary and Family Centered Care Quality Improvement Organization (also known as a BFCC-QIO) for 29 states. Kepro helps people with Medicare file complaints about quality of healthcare services and make requests to appeal a hospital discharge or stopping of skilled services such as physical therapy. We also offer Immediate Advocacy services when issues need to be taken care of right away.
This video goes over how to fill out a quality of care complaint form.
Quality of care complaint form: www.cms.gov/Medicare/CMS-Form... (PDF)
Any person you choose, such as a family member or friend, may help you file a quality of care concern. You must first fill out this form to appoint a representative: www.cms.gov/Medicare/CMS-Form... (PDF)
If you signed the form digitally, email the completed form to Kepro: [e-mail].
If you printed the form out and signed it, please use the mailing address for the state where the patient received medical care. You can find mailing addresses on our contact page: keproqio.com/aboutus/contacts.
Get details about the process and what to expect when a complaint is filed: keproqio.com/media/1392/qoc-p... (PDF)
Visit www.keproqio.com/services to learn about Kepro’s free services for people who have Medicare.
Publication No. R146810-231-2/2022. This material was prepared by Kepro, a Medicare Quality Improvement Organization under contract number 75FCMC19D0069 with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.