CMS-10197 AppendixD-InfConsentFormsScript

APPENDIX D:
Nonstatistical Informed Consent Forms and Scripts

Informed Consent Form: Referral Agent Focus Group
Abt Associates Inc. has been hired by the Centers for Medicare & Medicaid Services (CMS) to
conduct an evaluation of the durable medical equipment, prosthetics, orthotics & suppliers
(DMEPOS) competitive bidding program. As part of that evaluation Abt Associates is
conducting focus groups to learn about the perceptions and experiences of referral agents with
durable medical equipment and the competitive bidding program in the area. These focus groups
will help CMS understand the affect of the program on referral agents, suppliers and Medicare
beneficiaries.
You are being asked to participate in a focus group because you are a referral agent for Medicare
beneficiaries and their durable medical equipment. A total of 6 focus groups with both suppliers
and referral agents are being held as part of the study and each focus group will have up to 10
participants and two moderators. Abt Associates will conduct the focus groups and other forms
of data collection, analysis, and reporting. Andrea Hassol is the Principal Investigator at Abt
Associates.
You are being asked to sign a consent form to participate in the focus group.
PROCEDURES
You will be asked to join with other referral agents in a 1.5-hour discussion about the Medicare
competitive bidding program for DMEPOS. A researcher will facilitate the group in discussing
your experiences with the Medicare competitive bidding program. The focus group will not be
audio or video taped.
The discussion will be confidential. You can refuse to take part in this focus group if you wish
without losing any rights or benefits related to your professional relationship with CMS. You can
also refuse to answer a question during the focus group, without affecting your continued
participation in the group or your relationship with CMS.
RISKS OF TAKING PART IN THE STUDY
The researchers do not foresee any possible risks to you from participating in this focus group,
other than the minimal risk that your confidentiality might not be preserved. One of the risks to
confidentiality is that other focus group participants may repeat what they hear during the group.
The researchers will do everything allowable by law to assure that your privacy is protected and
will ask all participants at the beginning of the focus group not to repeat the focus group
discussion outside of the group.
Additionally, the focus group discussion notes will be labeled with a study code, not your or
another participant’s name. Notes and reports from the discussion will be stored in a secure
location (i.e. locked office file cabinet) and electronic materials will be stored in a passwordprotected computer. Your comments, and those of others in the focus group, will be presented in
reports to the government in summary form. Your name will not be included in any reports.

Abt Associates Inc.

Informed Consent Form: Referral Agent Focus Group

1

COSTS AND FINANCIAL RISKS
There will be no costs charged to you for participating in the focus group.
POSSIBLE BENEFITS OF TAKING PART IN THE STUDY
There may not be any direct benefit to you from joining the focus group, although you may
benefit from the opportunity to hear about others’ experiences with the competitive bidding
program.
COMPENSATION
You will receive $75 for participating in the focus group today, after the discussion is held. You
will also receive dinner at the focus group facility.
VOLUNTARY PARTICIPATION AND WITHDRAWAL STATEMENT
It is up to you to decide whether to participate in the focus group. If you decide not to participate
in the focus group, you will not be penalized and your relationship with the Centers for Medicare
& Medicaid Services will not be affected. Even if you agree to participate, you are not required
to answer all the questions you are asked.
QUESTIONS
You understand that you may phone Andrea Hassol of Abt Associates (617 349-2488) to have
my questions answered. You can also phone Ann Meadow at CMS (410 786-6022). You can
mail a letter to Ms. Hassol at:
Andrea Hassol
Abt Associates Inc.
55 Wheeler Street
Cambridge, MA 02138
You may also phone Teresa Doksum, the chairperson of Abt Associates’ Institutional Review
Board (617 349-2896) if you have other questions about your rights as a focus group participant.
All of these numbers are toll calls.
STATEMENT BY FOCUS GROUP MODERATOR IN THIS RESEARCH STUDY
I have explained the purpose of this research, the study procedures, identifying the potential risks
and benefits. I have answered any questions regarding the research study to the best of my
ability.
Moderator’s Name

Abt Associates Inc.

Moderator’s Signature

Date

Informed Consent Form: Referral Agent Focus Group

2

STATEMENT BY PERSON AGREEING TO PARTICIPATE IN THIS RESEARCH
STUDY
I have read and understand this information. I have had all my questions answered fully and I
freely and voluntarily choose to participate in the focus group. I have been given a copy of this
consent form.
Volunteer’s Name

Abt Associates Inc.

Volunteer’s Signature

Date

Informed Consent Form: Referral Agent Focus Group

3

Informed Consent Form: Supplier Focus Group
Abt Associates Inc. has been hired by the Centers for Medicare & Medicaid Services (CMS) to
conduct an evaluation of the durable medical equipment, prosthetics, orthotics & suppliers
(DMEPOS) competitive bidding program. As part of that evaluation Abt Associates is
conducting focus groups to learn about the perceptions and experiences of referral agents with
durable medical equipment and the competitive bidding program in the area. These focus groups
will help CMS understand the affect of the program on referral agents, suppliers and Medicare
beneficiaries.
You are being asked to participate in a focus group because you are a DMEPOS supplier who
provides these supplies to Medicare beneficiaries
A total of 6 focus groups with both suppliers and referral agents are being held as part of the
study and each focus group will have up to 10 participants and two moderators. Abt Associates
will conduct the focus groups and other forms of data collection, analysis, and reporting. Andrea
Hassol is the Principal Investigator at Abt Associates.
You are being asked to sign a consent form to participate in the focus group.
PROCEDURES
You will be asked to join with other suppliers in a 1.5-hour discussion about the Medicare
competitive bidding program for DMEPOS. A researcher will facilitate the group in discussing
your experiences with the competitive bidding program. The focus group will not be audio or
video taped.
The discussion will be confidential. You can refuse to take part in this focus group if you wish
without losing any rights or benefits related to youtr professional relationship with CMS. You
can also refuse to answer a question during the focus group, without affecting your continued
participation in the group or your relationship with CMS.
RISKS OF TAKING PART IN THE STUDY
The researchers do not foresee any possible risks to you from participating in this focus group,
other than the minimal risk that your confidentiality might not be preserved. One of the risks to
confidentiality is that other focus group participants may repeat what they hear during the group.
The researchers will do everything allowable by law to assure that your privacy is protected and
will ask all participants at the beginning of the focus group not to repeat the focus group
discussion outside of the group.
Additionally, the focus group discussion notes will be labeled with a study code, not your or
another participant’s name. Notes and reports from the discussion will be stored in a secure
location (i.e. locked office file cabinet) and electronic materials will be stored in a passwordprotected computer. Your comments, and those of others in the focus group, will be presented in
reports to the government in summary form. Your name will not be included in any reports.

Abt Associates Inc.

Informed Consent Form: Supplier Focus Group

1

COSTS AND FINANCIAL RISKS
There will be no costs charged to you for participating in the focus group.
POSSIBLE BENEFITS OF TAKING PART IN THE STUDY
There may not be any direct benefit to you from joining the focus group, although you may
benefit from the opportunity to hear about others’ experiences with the competitive bidding
program.
COMPENSATION
You will receive $75 for participating in the focus group today, after the discussion is held. You
will also receive dinner at the focus group facility.
VOLUNTARY PARTICIPATION AND WITHDRAWAL STATEMENT
It is up to you to decide whether to participate in the focus group. If you decide not to participate
in the focus group, you will not be penalized and your relationship with the Centers for Medicare
& Medicaid Services will not be affected. Even if you agree to participate, you are not required
to answer all the questions you are asked.
QUESTIONS
You understand that you may phone Andrea Hassol of Abt Associates (617 349-2488) to have
my questions answered. You can also phone Ann Meadow at CMS (410 786-6022). You can
mail a letter to Ms. Hassol at:
Andrea Hassol
Abt Associates Inc.
55 Wheeler Street
Cambridge, MA 02138
You may also phone Teresa Doksum, the chairperson of Abt Associates’ Institutional Review
Board (617 349-2896) if you have other questions about your rights as a focus group participant.
All of these numbers are toll calls.
STATEMENT BY FOCUS GROUP MODERATOR IN THIS RESEARCH STUDY
I have explained the purpose of this research, the study procedures, identifying the potential risks
and benefits. I have answered any questions regarding the research study to the best of my
ability.
Moderator’s Name

Abt Associates Inc.

Moderator’s Signature

Date

Informed Consent Form: Supplier Focus Group

2

STATEMENT BY PERSON AGREEING TO PARTICIPATE IN THIS RESEARCH
STUDY
I have read and understand this information. I have had all my questions answered fully and I
freely and voluntarily choose to participate in the focus group. I have been given a copy of this
consent form.
Volunteer’s Name

Abt Associates Inc.

Volunteer’s Signature

Date

Informed Consent Form: Supplier Focus Group

3

Informed Consent Form: Key Informant Discussion—Beneficiary
Group/Advocate
Abt Associates Inc. has been hired by the Centers for Medicare & Medicaid Services (CMS) to
conduct an evaluation of the durable medical equipment, prosthetics, orthotics & suppliers
(DMEPOS) competitive bidding program. As part of that evaluation Abt Associates is
conducting discussions to learn about the perceptions and experiences of beneficiary groups and
advocates. These discussions will help CMS understand the affect of the program on referral
agents, suppliers and Medicare beneficiaries.
You are being asked to participate in a discussion because you are with a beneficiary group or
are an advocate for Medicare beneficiaries and their durable medical equipment.
A total of 12 discussions with different groups are being held as part of the study. Abt Associates
will conduct the discussions and other forms of data collection, analysis, and reporting. Andrea
Hassol is the Principal Investigator at Abt Associates.
PROCEDURES
You will be asked to discuss the durable medical equipment and the Medicare competitive
bidding program in this discussion that will last approximately 45 minutes.
The discussion will be confidential. You can refuse to take part if you wish without losing any
rights or benefits related to your professional relationship with CMS. You can also refuse to
answer any particular question during the discussion, without affecting your continued
participation in the discussion or your relationship with CMS.
RISKS OF TAKING PART IN THE STUDY
The researcher does not foresee any possible risks to you from participating in this discussion,
other than the minimal risk that your confidentiality might not be preserved.
The discussion notes will be labeled with a study code, not your name. Notes and reports from
the discussion will be stored in a secure location (i.e. locked office file cabinet) and electronic
materials will be stored in a password-protected computer. Your comments will be presented in
reports to the government in summary form. Your name will not be included in any reports.
COSTS AND FINANCIAL RISKS
There will be no costs charged to you for participating in the interview.
POSSIBLE BENEFITS OF TAKING PART IN THE STUDY
There may not be any direct benefit to you from being interviewed, although you may benefit
from the opportunity to share your experiences.

Abt Associates Inc.

Informed Consent Form: Key Informant Discussion—Beneficiary Group/Advocate

1

COMPENSATION
You will not receive compensation.
VOLUNTARY PARTICIPATION AND WITHDRAWAL STATEMENT
It is up to you to decide whether to be interviewed. If you decide not to participate in the
discussion, you will not be penalized and your relationship with the Centers for Medicare &
Medicaid Services will not be affected. Even if you agree to participate, you are not required to
answer all the questions you are asked.
QUESTIONS
You understand that you may phone Andrea Hassol of Abt Associates (617 349-2488) to have
my questions answered. You can also phone Ann Meadow at CMS (410 786-6022). You can
mail a letter to Ms. Hassol at:
Andrea Hassol
Abt Associates Inc.
55 Wheeler Street
Cambridge, MA 02138
You may also phone Teresa Doksum, the chairperson of Abt Associates’ Institutional Review
Board (617 349-2896) if you have other questions about your rights as a focus group participant.
All of these numbers are toll calls.
STATEMENT BY INTERVIEWER IN THIS RESEARCH STUDY
I have explained the purpose of this research, the study procedures, identifying the potential risks
and benefits. I have answered any questions regarding the research study to the best of my
ability.
Interviewer’s Name

Interviewer’s Signature

Date

STATEMENT BY PERSON AGREEING TO PARTICIPATE IN THIS DISCUSSION
I have read and understand this information. I have had all my questions answered fully and I
freely and voluntarily choose to participate in the focus group. I have been given a copy of this
consent form.
Volunteer’s Name

Abt Associates Inc.

Volunteer’s Signature

Date

Informed Consent Form: Key Informant Discussion—Beneficiary Group/Advocate

2

Informed Consent Form: Key Informant Discussion—CMS Officials/
Bidding Program Managers
Abt Associates Inc. has been hired by the Centers for Medicare & Medicaid Services (CMS) to
conduct an evaluation of the durable medical equipment, prosthetics, orthotics & suppliers
(DMEPOS) competitive bidding program. As part of that evaluation Abt Associates is
conducting discussions to learn about the perceptions and experiences of CMS officials and
bidding program managers. These discussions will help CMS understand the affect of the
program on referral agents, suppliers and Medicare beneficiaries.
You are being asked to participate in a discussion because you are a CMS official/bidding
program manager who works with Medicare beneficiaries to receive durable medical equipment.
A total of 12 discussions with different groups are being held as part of the study. Abt Associates
will conduct the focus groups and other forms of data collection, analysis, and reporting. Andrea
Hassol is the Principal Investigator at Abt Associates.
PROCEDURES
You will be asked to discuss the Medicare competitive bidding program in this discussion that
will last approximately 45 minutes.
The discussion will be confidential. You can refuse to take part in this discussion if you wish
without losing any rights or benefits related to my professional relationship with CMS. You can
also refuse to answer any particular question during the discussion, without affecting your
continued participation in the discussion or your relationship with CMS.
RISKS OF TAKING PART IN THE STUDY
The researcher does not foresee any possible risks to you from participating in this discussion,
other than the minimal risk that your confidentiality might not be preserved.
The discussion notes will be labeled with a study code, not your name. Notes and reports from
the discussion will be stored in a secure location (i.e. locked office file cabinet) and electronic
materials will be stored in a password-protected computer. Your comments will be presented in
reports to the government in summary form. Your name will not be included in any reports.
COSTS AND FINANCIAL RISKS
There will be no costs charged to you for participating in the discussion.
POSSIBLE BENEFITS OF TAKING PART IN THE STUDY
There may not be any direct benefit to you from being interviewed, although you may benefit
from the opportunity to share your experiences.

Abt Associates Inc. Informed Consent Form: Key Informant Discussion—CMS Officials/Bidding Program Managers

1

COMPENSATION
You will not receive compensation.
VOLUNTARY PARTICIPATION AND WITHDRAWAL STATEMENT
It is up to you to decide whether to be interviewed. If you decide not to participate in the
interview, you will not be penalized and your relationship with the Centers for Medicare &
Medicaid Services will not be affected. Even if you agree to participate, you are not required to
answer all the questions you are asked.
QUESTIONS
You understand that you may phone Andrea Hassol of Abt Associates (617 349-2488) to have
my questions answered. You can also phone Ann Meadow at CMS (410 786-6022). You can
mail a letter to Ms. Hassol at:
Andrea Hassol
Abt Associates Inc.
55 Wheeler Street
Cambridge, MA 02138
You may also phone Teresa Doksum, the chairperson of Abt Associates’ Institutional Review
Board (617 349-2896) if you have other questions about your rights as a focus group participant.
All of these numbers are toll calls.
STATEMENT BY INTERVIEWER IN THIS RESEARCH STUDY
I have explained the purpose of this research, the study procedures, identifying the potential risks
and benefits. I have answered any questions regarding the research study to the best of my
ability.
Interviewer’s Name

Interviewer’s Signature

Date

STATEMENT BY PERSON AGREEING TO PARTICIPATE IN THIS DISCUSSION
I have read and understand this information. I have had all my questions answered fully and I
freely and voluntarily choose to participate in the focus group. I have been given a copy of this
consent form.
Volunteer’s Name

Volunteer’s Signature

Date

Abt Associates Inc. Informed Consent Form: Key Informant Discussion—CMS Officials/Bidding Program Managers

2

Informed Consent Form: Key Informant Discussion—Referral Agent
Abt Associates Inc. has been hired by the Centers for Medicare & Medicaid Services (CMS) to
conduct an evaluation of the durable medical equipment, prosthetics, orthotics & suppliers
(DMEPOS) competitive bidding program. As part of that evaluation Abt Associates is
conducting discussions to learn about the perceptions and experiences of referral agents. These
discussions will help CMS understand the affect of the program on referral agents, suppliers and
Medicare beneficiaries.
You are being asked to participate in a discussion because you are a referral agent who works
with Medicare beneficiaries to receive durable medical equipment.
A total of 12 discussions with different groups are being held as part of the study. Abt Associates
will conduct the discussions and other forms of data collection, analysis, and reporting. Andrea
Hassol is the Principal Investigator at Abt Associates.
PROCEDURES
You will be asked to discuss the Medicare competitive bidding program in this discussion that
will last approximately 45 minutes.
The discussion will be confidential. You can refuse to take part in this discussion if you wish
without losing any rights or benefits related to your professional relationship with CMS. You can
also refuse to answer any particular question during the discussion, without affecting your
continued participation in the discussion or your relationship with CMS.
RISKS OF TAKING PART IN THE STUDY
The researcher does not foresee any possible risks to you from participating in this discussion,
other than the minimal risk that your confidentiality might not be preserved.
The discussion notes will be labeled with a study code, not your name. Notes and reports from
the discussion will be stored in a secure location (i.e. locked office file cabinet) and electronic
materials will be stored in a password-protected computer. Your comments will be presented in
reports to the government in summary form. Your name will not be included in any reports.
COSTS AND FINANCIAL RISKS
There will be no costs charged to you for participating in the discussion.
POSSIBLE BENEFITS OF TAKING PART IN THE STUDY
There may not be any direct benefit to you from being interviewed, although you may benefit
from the opportunity to share your experiences.
COMPENSATION
You will not receive compensation.

Abt Associates Inc.

Informed Consent Form: Key Informant Discussion—Referral Agent

1

VOLUNTARY PARTICIPATION AND WITHDRAWAL STATEMENT
It is up to you to decide whether to be interviewed. If you decide not to participate in the
discussion, you will not be penalized and your relationship with the Centers for Medicare &
Medicaid Services will not be affected. Even if you agree to participate, you are not required to
answer all the questions you are asked.
QUESTIONS
You understand that you may phone Andrea Hassol of Abt Associates (617 349-2488) to have
my questions answered. You can also phone Ann Meadow at CMS (410 786-6022). You can
mail a letter to Ms. Hassol at:
Andrea Hassol
Abt Associates Inc.
55 Wheeler Street
Cambridge, MA 02138
You may also phone Teresa Doksum, the chairperson of Abt Associates’ Institutional Review
Board (617 349-2896) if you have other questions about your rights as a focus group participant.
All of these numbers are toll calls.
STATEMENT BY INTERVIEWER IN THIS RESEARCH STUDY
I have explained the purpose of this research, the study procedures, identifying the potential risks
and benefits. I have answered any questions regarding the research study to the best of my
ability.
Interviewer’s Name

Interviewer’s Signature

Date

STATEMENT BY PERSON AGREEING TO PARTICIPATE IN THIS DISCUSSION
I have read and understand this information. I have had all my questions answered fully and I
freely and voluntarily choose to participate in the focus group. I have been given a copy of this
consent form.
Volunteer’s Name

Abt Associates Inc.

Volunteer’s Signature

Date

Informed Consent Form: Key Informant Discussion—Referral Agent

2

Informed Consent Form: Key Informant Discussion—Supplier
Abt Associates Inc. has been hired by the Centers for Medicare & Medicaid Services (CMS) to
conduct an evaluation of the durable medical equipment, prosthetics, orthotics & suppliers
(DMEPOS) competitive bidding program. As part of that evaluation Abt Associates is
conducting discussions to learn about the perceptions and experiences of suppliers of durable
medical equipment. These discussions will help CMS understand the affect of the program on
referral agents, suppliers and Medicare beneficiaries. You are being asked to participate in a
discussion because you are a DMEPOS supplier who provides durable medical equipment to
Medicare beneficiaries.
A total of 12 discussions with different groups are being held as part of the study. Abt Associates
will conduct the discussions and other forms of data collection, analysis, and reporting. Andrea
Hassol is the Principal Investigator at Abt Associates.
PROCEDURES
You will be asked to discuss the Medicare competitive bidding program in this discussion that
will last approximately 45 minutes.
The discussion will be confidential. You can refuse to take part in this discussion if you wish
without losing any rights or benefits related to your professional relationship with CMS. You can
also refuse to answer any particular question during the discussion, without affecting your
continued participation in the discussion or your relationship with CMS.
RISKS OF TAKING PART IN THE STUDY
The researcher does not foresee any possible risks to you from participating in this discussion,
other than the minimal risk that your confidentiality might not be preserved.
COSTS AND FINANCIAL RISKS
There will be no costs charged to you for participating in the discussion.
POSSIBLE BENEFITS OF TAKING PART IN THE STUDY
There may not be any direct benefit to you from being interviewed, although you may benefit
from the opportunity to share your experiences.
COMPENSATION
You will not receive compensation.
VOLUNTARY PARTICIPATION AND WITHDRAWAL STATEMENT
It is up to you to decide whether to be interviewed. If you decide not to participate in the
discussion, you will not be penalized and your relationship with the Centers for Medicare &

Abt Associates Inc.

Informed Consent Form: Key Informant Discussion—Supplier

1

Medicaid Services will not be affected. Even if you agree to participate, you are not required to
answer all the questions you are asked.
QUESTIONS
You understand that you may phone Andrea Hassol of Abt Associates (617 349-2488) to have
my questions answered. You can also phone Ann Meadow at CMS (410 786-6022). You can
mail a letter to Ms. Hassol at:
Andrea Hassol
Abt Associates Inc.
55 Wheeler Street
Cambridge, MA 02138
You may also phone Teresa Doksum, the chairperson of Abt Associates’ Institutional Review
Board (617 349-2896) if you have other questions about your rights as a focus group participant.
All of these numbers are toll calls.
STATEMENT BY INTERVIEWER IN THIS RESEARCH STUDY
I have explained the purpose of this research, the study procedures, identifying the potential risks
and benefits. I have answered any questions regarding the research study to the best of my
ability.
Interviewer’s Name

Interviewer’s Signature

Date

STATEMENT BY PERSON AGREEING TO PARTICIPATE IN THIS DISCUSSION
I have read and understand this information. I have had all my questions answered fully and I
freely and voluntarily choose to participate in the focus group. I have been given a copy of this
consent form.
Volunteer’s Name

Abt Associates Inc.

Volunteer’s Signature

Date

Informed Consent Form: Key Informant Discussion—Supplier

2

INFORMED CONSENT SCRIPT: Comparison Area Key Informant
Discussion: Beneficiary Group/Advocate
Hello/Good morning/Good afternoon…May I speak with…(if not available, leave a message)
My name is [Interviewer name]. I am calling from Abt Associates Inc. You are scheduled to
conduct an interview on the evaluation of the Centers for Medicare and Medicaid Services’
Durable Medical Equipment, Prosthetic, Orthotic Supplies’ competitive bidding program. Is this
still a good time to do the interview?
[If no] May I reschedule the interview at a time that is convenient for you?
[If yes] Before we begin, I need to review a few details about the study with you.
As you may or may not know, Medicare is implementing a new fee schedule for durable medical
equipment, prosthetic, and orthotic supplies (DMEPOS) in various areas of the United States.
The purpose of our study is to evaluate the affect of the competitive bidding program on
suppliers, beneficiaries and referral agents. The study is being conducted by Abt Associates on
behalf of the Centers for Medicare and Medicaid Services (CMS).
You were chosen to participate as a member of a beneficiary group or an advocate to provide an
understanding of the current environment for Medicare beneficiaries and their durable medical
equipment in your area, as a comparison. [If relevant] You were also recommended by [name
referral].
Our interview today should last about 45 minutes. Please understand that your participation in
this study is voluntary and that if you choose not to participate you will not be penalized in any
way. You can refuse to answer any question I ask and may even ask to stop the interview at any
time. This interview will not be tape-recorded. Instead I will take notes. These notes will be used
to create summaries, which will not include your personal information, and will be used to write
a report to CMS on the education and outreach program for the new Medicare drug benefit. Do
you have any questions?
If you have any questions that I may not be able to answer at this time, or at any time after this
interview, you may contact __________, at the Centers for Medicare and Medicare Services
(___) ___-____and she will be happy to assist you. Note, this is a toll call.
Given the information that I have just reviewed with you, do you still wish to participate in this
study/interview?
If Yes, _______________ [Interviewer’s Initials}. Great. Let me begin with the first question.
If No, _______________ [Interviewer’s Initials}. Great. That is fine. We appreciate your time.
Thank you.

Abt Associates Inc.

Informed Consent Script: Comparison Area Key Informant Discussion—Beneficiary Group/Advocate

3

INFORMED CONSENT SCRIPT: Comparison Areas Key Informant
Discussion—Referral Agent
Hello/Good morning/Good afternoon…May I speak with…(if not available, leave a message)
My name is [Interviewer name]. I am calling from Abt Associates Inc. You are scheduled to
conduct an interview on the evaluation of the Centers for Medicare and Medicaid Services’
Durable Medical Equipment, Prosthetic, Orthotic Supplies’ competitive bidding program. Is this
still a good time to do the interview?
[If no] May I reschedule the interview at a time that is convenient for you?
[If yes] Before we begin, I need to review a few details about the study with you.
As you may or may not know, Medicare is implementing a new fee schedule for durable medical
equipment, prosthetic, and orthotic supplies (DMEPOS) in various areas of the United States.
The purpose of our study is to evaluate the affect of the competitive bidding program on
suppliers, beneficiaries and referral agents. The study is being conducted by Abt Associates on
behalf of the Centers for Medicare and Medicaid Services (CMS).
You were chosen to participate as a referral agent to provide an understanding of the current
environment for Medicare beneficiaries and their durable medical equipment in your area, as a
comparison. [If relevant] You were also recommended by [name referral].
Our interview today should last about 45 minutes. Please understand that your participation in
this study is voluntary and that if you choose not to participate you will not be penalized in any
way. You can refuse to answer any question I ask and may even ask to stop the interview at any
time. This interview will not be tape-recorded. Instead I will take notes. These notes will be used
to create summaries, which will not include your personal information, and will be used to write
a report to CMS on the education and outreach program for the new Medicare drug benefit. Do
you have any questions?
If you have any questions that I may not be able to answer at this time, or at any time after this
interview, you may contact Ann Meadows, at the Centers for Medicare and Medicare Services
(___) ___-____and she will be happy to assist you. Note, this is a toll call.
Given the information that I have just reviewed with you, do you still wish to participate in this
study/interview?
If Yes, _______________ [Interviewer’s Initials}. Great. Let me begin with the first question.
If No, ______________ [Interviewer’s Initials]. That is fine. We appreciate your time. Thank
you.

Abt Associates Inc.

Informed Consent Script: Comparison Area Key Informant Discussion—Referral Agent

1

Informed Consent Script: Comparison Areas Key Informant
Discussion—Supplier
Hello/Good morning/Good afternoon…May I speak with…(if not available, leave a message)
My name is [Interviewer name]. I am calling from Abt Associates Inc. You are scheduled to
conduct an interview on the evaluation of the Centers for Medicare and Medicaid Services’
Durable Medical Equipment, Prosthetic, Orthotic Supplies’ competitive bidding program. Is this
still a good time to do the interview?
[If no] May I reschedule the interview at a time that is convenient for you?
[If yes] Before we begin, I need to review a few details about the study with you.
As you may or may not know, Medicare is implementing a new fee schedule for durable medical
equipment, prosthetic, and orthotic supplies (DMEPOS) in various areas of the United States.
The purpose of our study is to evaluate the affect of the competitive bidding program on
suppliers, beneficiaries and referral agents. The study is being conducted by Abt Associates on
behalf of the Centers for Medicare and Medicaid Services (CMS).
You were chosen to participate as supplier to provide an understanding of the current
environment for Medicare beneficiaries and their durable medical equipment in your area, as a
comparison. [If relevant] You were also recommended by [name referral].
Our interview today should last about 45 minutes. Please understand that your participation in
this study is voluntary and that if you choose not to participate you will not be penalized in any
way. You can refuse to answer any question I ask and may even ask to stop the interview at any
time. This interview will not be tape-recorded. Instead I will take notes. These notes will be used
to create summaries, which will not include your personal information, and will be used to write
a report to CMS on the education and outreach program for the new Medicare drug benefit. Do
you have any questions?
If you have any questions that I may not be able to answer at this time, or at any time after this
interview, you may contact Ann Meadows, at the Centers for Medicare and Medicare Services
(___) ___-____and she will be happy to assist you. Note, this is a toll call.
Given the information that I have just reviewed with you, do you still wish to participate in this
study/interview?
If Yes, _______________ [Interviewer’s Initials}. Great. Let me begin with the first question.
If No, ______________ [Interviewer’s Initials]. That is fine. We appreciate your time. Thank
you.

Abt Associates Inc.

Informed Consent Script: Comparison Area Key Informant Discussion—Supplier

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