Form CMS-10068 Beneficiary Customer Service Feedback Survey

OMB approved form number: 0938-XXXX

Medicare Ombudsman CUSTOMER SERVICE FEEDBACK SURVEY

Dear Medicare Customer:

The Centers for Medicare & Medicaid Services (CMS) strives to provide excellent customer service. Our primary customer service goal is to provide accurate, timely, and relevant information to our customers. Recently, you contacted CMS to ask for help. Enclosed is the Office of the Medicare Ombudsman’s response to your request. After you read our reply, please tell us how satisfied you are with the information we provided you. Please take a few minutes to answer the questions on the back of this letter, and then mail it back in the enclosed self-addressed, postage-paid envelope.

Your feedback is voluntary, and your decision to participate in this survey won’t affect your Medicare benefits or those of the individuals you represent. Your answers to the survey questions will be used to help us improve the way the Office of the Medicare Ombudsman responds to the public. We sincerely hope you will share your opinions with us. All personal information will be kept confidential by CMS.

If you have any questions about this survey, you may contact Nancy Conn of the Office of the Medicare Ombudsman toll-free at 1-877-267-2323 ext. 68374. However, if you have a question about Medicare benefits, you should call 1-800-MEDICARE

(1-800-633-4227); TTY users should call 1-877-486-2048.

Thank you for taking the time to help us improve the Office of the Medicare Ombudsman’s service. We look forward to hearing from you soon.

Sincerely,

Walter Stone

Privacy Officer

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-XXXX. The time required to complete this information collection is estimated to average ( XX hours) or (XX minutes) per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850

Thinking about how the Office of the Medicare Ombudsman responded to your request, please tell us how satisfied you are by answering a few questions. Based on a scale where 5 means you are very satisfied and 1 means you are very dissatisfied, please circle one number for each question that best describes your experience.

			Very …………………………………………..Very Dissatisfied Satisfied  
Overall, how satisfied are you with the way the Office of the Medicare Ombudsman responded to your question? How satisfied are you that the information we gave you is clear and understandable? How satisfied are you that the information we gave you responded to your question? How satisfied are you with the time it took us to respond to your question?		2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5

Please tell us how the Office of the Medicare Ombudsman can better respond to your future questions: ______________________________________

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Thank you for taking the time to answer our survey. Please send us your completed survey in the enclosed postage paid envelope as soon as possible.

CMS-00068 (00/10)