CMS-10080.Appendix A

Appendix A.

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services

7500 Security Boulevard

Baltimore, Maryland 21244

Dear Medicare Beneficiary:

The Centers for Medicare & Medicare Services (CMS) administers the Medicare program. CMS is cooperating with _____ and the _______ by providing them with a list of potential participants for a study which involves Medicare beneficiaries. This study will help the researchers learn more about health care preference and experiences of people 65 years old and older across the USA.

You are one of approximately 45 million Americans with health insurance under the Medicare program. Your name was selected at random to participate in this study. In a few weeks, you will be contacted by a representative of the _________, at _______, to determine if you are willing to participate in a telephone interview. That person will want to ask you questions about your health. The interview will be conducted on the telephone and should take about 15 minutes of your time.

You do not have to participate in this study. Your decisions to participate or not participate will have no effect on your Medicare benefits. All information you and the other participants provide is protected by the Privacy Act.

If you have questions about this letter, please contact 1-800-MEDICARE (1-800-633-4227). This toll-free helpline is available 24 hours a day, seven days a week to answer your questions. You can speak to a Customer Service Representative in English or Spanish. TTY users should call 1-877-486-2048.

If you have any questions about the study, please feel free to call _______ at the ______, at this number XXX-XXX-XXXX. Thank you for your cooperation.

Sincerely,

Walter Stone

CMS Privacy Officer