English and Spanish Mailing Material

WAVE: PRENOTIFICATION POSTCARD 2006
PROTOCOL: BASELINE
MAILING MATERIALS TRACKING NUMBER: 1
[CMS Logo]

Dear Medicare Beneficiary:
The Centers for Medicare & Medicaid Services (CMS), the Federal agency that runs Medicare, is
conducting a survey to find out more about the care that is provided to people with Medicare. This survey
is called the “Medicare Health Outcomes Survey.” Your name was selected at random from your health
plan. In a few days, you will receive a questionnaire in the mail. We would greatly appreciate your taking
the time to complete the form.
Please look for the Medicare Health Outcomes Survey in the mail in a few days. Thank you for helping
with this important survey.
Sincerely,

Walter Stone
CMS Privacy Officer

En un esfuerzo por enterarnos más sobre la calidad de la asistencia que se brinda a los beneficiarios
del programa Medicare, la CMS está llevando a cabo una encuesta de los beneficiarios. Si desea
recibir la Encuesta de Medicare Sobre la Salud en español sírvase llamar gratuitamente al (800) …….

WAVE: LETTER FOR FIRST QUESTIONNAIRE MAILING – SIDE A 2006
PROTOCOL: BASELINE
MAILING MATERIALS TRACKING NUMBER: 2
[CMS Letterhead]
Dear Medicare Beneficiary:
The Centers for Medicare & Medicaid Services (CMS) is the Federal agency that administers the
Medicare program. Our responsibility is to make sure that you get high quality care. One of the ways we
can fulfill that responsibility is to find out directly from you about how the care you are currently
receiving under the Medicare program affects your health.
CMS is conducting a survey of people with Medicare called the Medicare Health Outcomes Survey. Your
name was selected at random by CMS from among the people in your health plan with Medicare. We
would greatly appreciate your taking the time to fill out this questionnaire. A postage-paid return
envelope is enclosed.
Your answers to the survey will provide information about the state of your health. You will be contacted
two years from now and asked to complete the survey again. Your answers to the two surveys will be
compared to determine if the care you receive is keeping you as healthy as possible. After the study is
completed, your responses will be shared with your health plan. Your plan will use this information to
improve the quality of care.
Learning about the state of your health is very important to us. While your participation is voluntary, we
hope that you will take the time to answer the questionnaire. Your answers will have no effect on your
Medicare benefits.
[SURVEY VENDOR NAME] is a survey research organization working with us to carry out this survey.
If you have any problems completing the survey or have other questions about it, please don’t hesitate to
call [SURVEY VENDOR NAME toll free at 1-800-Number] or e-mail [SURVEY VENDOR NAME at
…].
Thank you for your help with this important survey.
Sincerely,

Walter Stone
CMS Privacy Officer

Enclosures
ESPANOL AL OTRO LADO

WAVE: LETTER FOR FIRST QUESTIONNAIRE MAILING – SIDE B 2006
PROTOCOL: BASELINE
MAILING MATERIALS TRACKING NUMBER: 3
[CMS Letterhead]
Estimado beneficiario del programa Medicare:
Los Centros de Servicios de Medicare y Medicaid (CMS por sus siglas en inglés) es la agencia federal
que administra el programa Medicare. Nuestra responsabilidad es garantizar que usted reciba cuidado
médico de alta calidad. Una de las maneras en que podemos cumplir con esa responsabilidad es
enterarnos directamente por usted cómo afecta su salud el cuidado médico que está recibiendo
actualmente en el programa Medicare.
Los CMS están realizando una encuesta a las personas con Medicare llamada Encuesta de Medicare
Sobre la Salud. Su nombre ha sido seleccionado al azar por CMS, de entre las personas con Medicare en
su plan de salud. Le agradeceríamos que dedique unos minutos para completar este cuestionario. Para su
comodidad le adjuntamos un sobre con franqueo pagado.
Sus respuestas a la encuesta proporcionarán información sobre el estado de su salud. Dentro de dos años
nos pondremos en contacto con usted para pedirle que complete la encuesta nuevamente. Sus respuestas a
las dos encuestas se compararán para determinar si el cuidado médico que usted recibe lo mantiene tan
sano como sea posible. Después de que se termine el estudio, sus respuestas serán compartidas con su
plan de salud. Su plan usará esta información para mejorar la calidad de los servicios que ofrece.
Es muy importante para nosotros enterarnos sobre su salud. Aunque su participación es voluntaria,
esperamos que no deje pasar la ocasión de responder al cuestionario. Sus respuestas no afectarán los
beneficios que recibe de Medicare.
[SURVEY VENDOR NAME] es una companía de investigación que trabaja con Medicare para llevar a
cabo esta encuesta. Si tiene algún problema para completar el cuestionario o tiene preguntas sobre el
mismo, por favor llamar gratuitamente al [SURVEY VENDOR NAME a 1-800-Number] o escribir por
correo electrónico a [ SURVEY VENDOR NAME] a [e-mail address].
Muchísimas gracias por su participación en esta encuesta importante.
Atentamente,

Walter Stone
CMS Privacy Officer
Anexos
ENGLISH ON THE OTHER SIDE

WAVE: LETTER FOR SECOND QUESTIONNAIRE MAILING 2006
PROTOCOL: BASELINE
MAILING MATERIALS TRACKING NUMBER: 4
[CMS Letterhead]
Dear Medicare Beneficiary:
The Centers for Medicare & Medicaid Services (CMS) is conducting a survey of people with Medicare in
managed care plans to learn if the care you receive is keeping you as healthy as possible. Your name was
randomly selected from your health plan.
Recently, we mailed the Medicare Health Outcomes Survey to you but have not received your response.
We are enclosing another copy and would greatly appreciate your taking the time to complete the survey.
Please return it in the enclosed postage-paid envelope.
Learning about the state of your health is very important to us. While your participation is voluntary, we
hope you will help us by completing the questionnaire. Your answers will have no effect on your
Medicare benefits.
You will be contacted again two years from now and asked to complete the survey again. Your answers to
the two surveys will be compared to determine if the care you receive is keeping you as healthy as
possible. After the study is completed, your responses will be shared with your health plan. Your plan
will use this information to improve the quality of care.
[SURVEY VENDOR NAME] is a survey research organization working with us to carry out this survey.
If you have any problems completing the survey or have other questions about the survey, please don’t
hesitate to call [SURVEY VENDOR NAME toll free at 1-800-Number] or e-mail [SURVEY VENDOR
NAME at …].
Thank you for your help with this important survey.
Sincerely,

Walter Stone
CMS Privacy Officer
Enclosures

WAVE: REMINDER/THANK-YOU POSTCARD 2006
PROTOCOL: BASELINE, FOLLOW-UP—NO PROXY AT BASELINE, FOLLOW-UP—
PROXY AT BASELINE
MAILING MATERIALS TRACKING NUMBER: 5
[CMS Logo]
MEDICARE HEALTH OUTCOMES SURVEY
Hello!
About a week ago you received the Medicare Health Outcomes Survey in the mail.
This is a reminder that we would like you to fill out the questionnaire and mail it back in the postagepaid envelope that came with it. We need your answers. This is your chance to help your health plan serve
you better.
If you have returned the completed questionnaire, thank you!
If you did not get the questionnaire or have misplaced it, please call [SURVEY VENDOR NAME at 1800-Number] or e-mail [SURVEY VENDOR NAME at …] and we will mail a questionnaire to you.
THANK YOU!

[SURVEY VENDOR NAME]

WAVE: PRENOTIFICATION POSTCARD 2006
PROTOCOL: SPANISH
MAILING MATERIALS TRACKING NUMBER: 6
[CMS Logo]
Estimado beneficiario del programa Medicare:
En un esfuerzo por enterarnos más sobre la calidad de la asistencia que se brinda a los beneficiarios del
programa Medicare, los Centros de Servicios de Medicare y Medicaid (cuya sigla en inglés es CMS) está
llevando a cabo una encuesta de los beneficiarios. Esta encuesta se llama Encuesta de Medicare Sobre la
Salud. La CMS ha seleccionado su nombre al azar de entre todos los miembros inscritos en su plan de
cuidado médico. En pocos días recibirá usted un cuestionario por correo. Le agradeceremos mucho que,
en cuanto lo reciba, le dedique su valioso tiempo a llenar esta encuesta.

Atentamente,

Walter Stone
CMS Privacy Officer

WAVE: LETTER FOR FIRST QUESTIONNAIRE MAILING 2006
PROTOCOL: SPANISH
MAILING MATERIALS TRACKING NUMBER: 7
[CMS Letterhead]
Estimado beneficiario del programa Medicare:
Los Centros de Servicios de Medicare y Medicaid (CMS por sus siglas en inglés) es la agencia federal
que administra el programa Medicare. Nuestra responsabilidad es garantizar que usted reciba cuidado
médico de alta calidad. Una de las maneras en que podemos cumplir con esa responsabilidad es
enterarnos directamente por usted cómo afecta su salud el cuidado médico que está recibiendo
actualmente en el programa Medicare.
Los CMS están realizando una encuesta a las personas con Medicare llamada Encuesta de Medicare
Sobre la Salud. Su nombre ha sido seleccionado al azar por CMS, de entre las personas con Medicare en
su plan de salud. Le agradeceríamos que dedique unos minutos para completar este cuestionario. Para su
comodidad le adjuntamos un sobre con franqueo pagado.
Sus respuestas a la encuesta proporcionarán información sobre el estado de su salud. Dentro de dos años
nos pondremos en contacto con usted para pedirle que complete la encuesta nuevamente. Sus respuestas a
las dos encuestas se compararán para determinar si el cuidado médico que usted recibe lo mantiene tan
sano como sea posible. Después de que se termine el estudio, sus respuestas serán compartidas con su
plan de salud. Su plan usará esta información para mejorar la calidad de los servicios que ofrece.
Es muy importante para nosotros enterarnos sobre su salud. Aunque su participación es voluntaria,
esperamos que no deje pasar la ocasión de responder al cuestionario. Sus respuestas no afectarán los
beneficios que recibe de Medicare.
[SURVEY VENDOR NAME] es una companía de investigación que trabaja con Medicare para llevar a
cabo esta encuesta. Si tiene algún problema para completar el cuestionario o tiene preguntas sobre el
mismo, por favor llamar gratuitamente al [VENDOR NAME at 1-800-Number] o escribir por correo
electrónico a [SURVEY VENDOR NAME] a [e-mail address].
Muchísimas gracias por su participación en esta encuesta importante.
Atentamente,

Walter Stone
CMS Privacy Officer

Anexos

WAVE: LETTER FOR REPLACEMENT QUESTIONNAIRE MAILING 2006
PROTOCOL: SPANISH
MAILING MATERIALS TRACKING NUMBER: 8
[CMS Letterhead]

Estimado beneficiario del programa Medicare:
Los Centros de Servicios de Medicare y Medicaid (CMS por sus siglas en inglés) está llevando a cabo una
encuesta de personas con Medicare inscritas en planes de salud administrados. Esta encuesta tiene el
propósito de averiguar si el cuidado médico que usted recibe lo mantiene tan sano como sea posible. Su
nombre ha sido seleccionado al azar de entre todos los miembros inscritos en su plan de cuidado médico.
Recientemente le enviamos por correo la Encuesta de Medicare Sobre la Salud, pero no hemos recibido
su respuesta. Adjunto le enviamos otra copia y le agradeceremos mucho que dedique unos minutos para
completarla. Luego que termine, enviar la encuesta en el sobre con franqueo pagado que se adjunta.
Es muy importante para nosotros enterarnos sobre su salud. Aunque su participación es voluntaria,
esperamos que no deje pasar la ocasión de responder al cuestionario. Sus respuestas no afectarán los
beneficios que recibe de Medicare.
Dentro de dos años nos pondremos en contacto con usted para pedirle que complete la encuesta
nuevamente. Sus respuestas a las dos encuestas se compararán para determinar si el cuidado médico que
usted recibe lo mantiene tan sano como sea posible. Después de que se termine el estudio, sus respuestas
serán compartidas con su plan de salud. Su plan usará esta información para mejorar la calidad del
cuidado que ofrece.
[VENDOR NAME] es una companía de investigación que trabaja con Medicare para llevar a cabo esta
encuesta. Si tiene algún problema para completar el cuestionario o tiene otras preguntas sobre el mismo,
por favor llamar gratuitamente al [VENDOR NAME at 1-800-Number] o escribir por correo electrónico a
[VENDOR NAME] a la dirección [e-mail address].
Muchísimas gracias por su participación en esta encuesta importante.
Atentamente,

Walter Stone
CMS Privacy Officer

Anexos

WAVE: REMINDER/THANK YOU POSTCARD 2006
PROTOCOL: SPANISH
MAILING MATERIALS TRACKING NUMBER: 9
[CMS Logo]

ENCUESTA DE MEDICARE SOBRE LA SALUD
¡Hola!
Hace aproximadamente una semana, usted recibió la Encuesta de Medicare Sobre la Salud por correo.
Esta nota es para recordarle que le agradeceríamos se tome la molestia de responder a la encuesta y
enviarla en el sobre con franqueo pagado adjunto al cuestionario. Necesitamos sus respuestas. Esta es su
oportunidad de ayudar a que su plan de salud le sirva mejor.
Si ya ha devuelto el cuestionario, le quedamos agradecidos.
Si no ha recibido el cuestionario o se le ha perdido, llame gratis [SURVEY VENDOR NAME al 1-800Number] o escriba por correo electrónico a [e-mail address] y se lo enviaremos por correo.
¡MUCHAS GRACIAS!

[SURVEY VENDOR NAME]

WAVE: PRENOTIFICATION POSTCARD 2006
PROTOCOL: FOLLOW-UP—NO PROXY AT BASELINE, FOLLOW-UP—PROXY AT
BASELINE
MAILING MATERIALS TRACKING NUMBER: 10
[CMS Logo]
Dear Medicare Beneficiary:
Two years ago you completed the Medicare Health Outcomes Survey. At that time, we said that we
would like you to complete the survey again in the year 2006. In a few days, you will receive a
questionnaire in the mail. We would greatly appreciate your taking the time to complete the form.
The Centers for Medicare & Medicaid Services conducts this survey to find out more about the care that
is provided to people with Medicare. Your answers can help your health plan to improve the quality of
care.
Please look for the Medicare Health Outcomes Survey in the mail in a few days. Thank you for your
continued help in this important study.
Sincerely,

Walter Stone
CMS Privacy Officer

WAVE: LETTER FOR FIRST QUESTIONNAIRE MAILING 2006
PROTOCOL: FOLLOW-UP—NO-PROXY AT BASELINE
MAILING MATERIALS TRACKING NUMBER: 11
[CMS Letterhead]
Dear Medicare Beneficiary:
Two years ago you completed the Medicare Health Outcomes Survey. At that time, we said that we
would like you to complete the survey again in the year 2006. Therefore, we are writing to ask for your
continued help. We would greatly appreciate your taking the time to fill out the enclosed questionnaire. A
postage-paid return envelope is enclosed.
After the study is completed, your responses will be shared with your health plan. Your plan will use this
information to improve the quality of care. Your responses to this follow-up survey will also help the
Centers for Medicare & Medicaid Services to determine if the care you receive is keeping you as healthy
as possible.
[SURVEY VENDOR NAME] is a survey research organization working with us to carry out this survey.
If you have any problems completing the survey or have other questions about it, please don’t hesitate to
call [SURVEY VENDOR NAME toll free at 1-800-Number] or e-mail [SURVEY VENDOR NAME at
…].
Thank you for your help with this important survey.
Sincerely,

Walter Stone
CMS Privacy Officer

Enclosures

WAVE: LETTER FOR REPLACEMENT QUESTIONNAIRE MAILING 2006
PROTOCOL: FOLLOW-UP—NO-PROXY AT BASELINE
MAILING MATERIALS TRACKING NUMBER: 12
[CMS Letterhead]
Dear Medicare Beneficiary:
Two years ago you completed the Medicare Health Outcomes Survey. At that time, we said that we
would like you to complete the survey again in the year 2006. Recently we wrote to ask for your
continued help but have not received your response. We would greatly appreciate your taking the time to
fill out the enclosed questionnaire. A postage-paid return envelope is enclosed.
After the study is completed, your responses will be shared with your health plan. Your plan will use this
information to improve the quality of care. Your responses to this follow-up survey will also help the
Centers for Medicare & Medicaid Services to determine if the care you receive is keeping you as healthy
as possible.
[SURVEY VENDOR NAME] is a survey research organization working with us to carry out this survey.
If you have any problems completing the survey or have other questions about it, please don’t hesitate to
call [SURVEY VENDOR NAME toll free at 1-800-Number] or e-mail [SURVEY VENDOR NAME at
…].
Thank you for your help with this important survey.
Sincerely,

Walter Stone
CMS Privacy Officer

Enclosures

WAVE: LETTER FOR FIRST QUESTIONNAIRE MAILING 2006
PROTOCOL: FOLLOW-UP—PROXY AT BASELINE
MAILING MATERIALS TRACKING NUMBER: 13
[CMS Letterhead]
Dear Medicare Beneficiary:
Two years ago you completed the Medicare Health Outcomes Survey. At that time, we said we would
like you to complete the survey again in the year 2006. Therefore, we are writing to ask for your
continued help. We would greatly appreciate your taking the time to fill out the enclosed questionnaire. A
postage-paid return envelope is enclosed.
Two years ago someone completed this survey for you. This person’s name is printed [VENDOR
INSERTS APPROPRIATE INFORMATION]. If you are unable to complete the survey at this
time, please ask the same person to complete the survey about you again. If that person is not able
to help you, please ask another person who knows about your health to complete the survey about
you.
After the study is completed, your responses will be shared with your health plan. Your plan will use this
information to improve the quality of care. Your responses to this follow-up survey will also help the
Centers for Medicare & Medicaid Services to determine if the care you receive is keeping you as healthy
as possible.
[SURVEY VENDOR NAME] is a survey research organization working with us to carry out this survey.
If you have any problems completing the survey or have other questions about it, please don’t hesitate to
call [SURVEY VENDOR NAME toll free at 1-800-Number] or e-mail [SURVEY VENDOR NAME at
…].
Thank you for your help with this important survey.
Sincerely,

Walter Stone
CMS Privacy Officer

Enclosures

WAVE: LETTER FOR REPLACEMENT QUESTIONNAIRE MAILING 2006
PROTOCOL: FOLLOW-UP—PROXY AT BASELINE
MAILING MATERIALS TRACKING NUMBER: 14
[CMS Letterhead]
Dear Medicare Beneficiary:
Two years ago you completed the Medicare Health Outcomes Survey. At that time, we said that we
would like you to complete the survey again in the year 2006. Recently we wrote to ask for your
continued help but have not received your response. We would greatly appreciate your taking the time to
fill out the enclosed questionnaire. A postage-paid return envelope is enclosed.
Two years ago someone completed this survey for you. This person’s name is printed [VENDOR
INSERTS APPROPRIATE INFORMATION]. If you are unable to complete the survey at this
time, please ask the same person to complete the survey about you again. If that person is not able
to help you, please ask another person who knows about your health to complete the survey about
you.
After the study is completed, your responses will be shared with your health plan. Your plan will use this
information to improve the quality of care. Your responses to this follow-up survey will also help the
Centers for Medicare & Medicaid Services to determine if the care you receive is keeping you as healthy
as possible.
[SURVEY VENDOR NAME] is a survey research organization working with us to carry out this survey.
If you have any problems completing the survey or have other questions about it, please don’t hesitate to
call [SURVEY VENDOR NAME toll free at 1-800-Number] or e-mail [SURVEY VENDOR NAME at
…].
Thank you for your help with this important survey.
Sincerely,

Walter Stone
CMS Privacy Officer

Enclosures

WAVE: PRENOTIFICATION POSTCARD 2006
PROTOCOL: SPANISH-MODIFIED (IF APPLICABLE)
MAILING MATERIALS TRACKING NUMBER: 15

[CMS Logo]
Estimado beneficiario del programa Medicare:
En un esfuerzo por enterarnos más sobre la calidad de la asistencia que se brinda a los beneficiarios del
programa Medicare, los Centros de Servicios de Medicare y Medicaid (cuya sigla en inglés es CMS) está
llevando a cabo una encuesta de los beneficiarios. Esta encuesta se llama Encuesta de Medicare Sobre la
Salud. La CMS ha seleccionado su nombre al azar de entre todos los miembros inscritos en su plan de
cuidado médico. En pocos días recibirá usted un cuestionario por correo. Le agradeceremos mucho que,
en cuanto lo reciba, le dedique su valioso tiempo a llenar esta encuesta.

Atentamente,

Walter Stone
CMS Privacy Officer

The Centers for Medicare & Medicaid Services (CMS), the Federal agency that runs Medicare, is
conducting a survey to find out more about the care that is provided to people with Medicare. This
survey is called the “Medicare Health Outcomes Survey.” If you would like to receive an English
copy of the survey please call toll free at (800)…..