Attachment7a

WAVE: PRENOTIFICATION POSTCARD 2010-HOS-M
PROTOCOL: ENGLISH
MAILING MATERIALS TRACKING NUMBER: 1
[CMS Logo]
MEDICARE HEALTH OUTCOMES SURVEY - MODIFIED

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 SurveyModified.” 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 you taking the time
to complete the form.
Please look for the Medicare Health Outcomes Survey—Modified in the mail in a few
days. Thank you for helping with this important survey.

Sincerely,

Walter Stone
CMS Privacy Officer

WAVE: LETTER FOR FIRST QUESTIONNAIRE MAILING - 2010-HOS-M
PROTOCOL: ENGLISH
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-Modified. 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 and
help 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 [1-800Number] or e-mail [SURVEY VENDOR NAME] at [email address].
Thank you for your help with this important survey.
Sincerely,

Walter Stone
CMS Privacy Officer
P.S. If you have trouble completing the survey, a relative, friend, or caregiver, who
knows about your health, can fill out the survey for you.

WAVE: LETTER FOR SECOND QUESTIONNAIRE MAILING 2010-HOS-M
PROTOCOL: ENGLISH
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-Modified to you but have
not received your responses. 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.
Your answers to the survey will provide information about the state of your health and
help 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 [email address].
Thank you for your help with this important survey.
Sincerely,

Walter Stone
CMS Privacy Officer
P.S. If you have trouble completing the survey, a relative, friend, or caregiver, who
knows about your health, can fill out the survey for you.

WAVE: REMINDER/THANK YOU POSTCARD 2010-HOS-M
PROTOCOL: ENGLISH
MAILING MATERIALS TRACKING NUMBER: 3
[CMS Logo]
MEDICARE HEALTH OUTCOMES SURVEY- MODIFIED
Hello!
About a week ago you received the Medicare Health Outcomes Survey-Modified in the
mail. This is a reminder that we would like you to fill out the questionnaire and mail it
back in the postage-paid 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] toll free at [1-800-Number] or e-mail [SURVEY VENDOR NAME]
at [email address] and we will mail a questionnaire to you.
THANK YOU!

[SURVEY VENDOR NAME]