MCBSConfidentialityAgreement

MCBS Confidentiality Agreement/Service Receipt

MEDICARE CURRENT BENEFICIARY SURVEY
Confidentiality Agreement/Service Receipt

(Non-Westat Employee’s)

CASE ID(S):

Escort/Interpreter

(Please Print)
acknowledge the receipt of payment from (interviewer name)
for the following services:
Escort:

Translator/Interpreter: Other (specify):

Number of hours:

Total Amount:

Assurance of Confidentiality
In accordance with Section 1875 of the Social Security Act (42 U.S.C. 139511), the contractor assures all
respondents that the confidentiality of their responses to this information request will be maintained by
the contractor and the Center for Medicare and Medicaid Services, and that no information obtained in the
course of this activity will be disclosed in a manner in which the individual or establishment is
identifiable, unless the individual or establishment has consented to such disclosure, to anyone other than
those involved in this research, except for very limited circumstances as prescribed by the Privacy Act of
1974.
I have carefully read and understood the assurance which pertains to the confidential nature of all
records to be handled in regard to this survey. I understand that I am prohibited by law from disclosing
any such confidential information which has been obtained under the terms of this contract to anyone
other than those involved in the research. I understand that any willful and knowing disclosure in
violation of the Privacy Act of 1974 is a misdemeanor and would subject the violator to a fine up to
$5,000.
(Signature)

(Date)
WHITE: FIELD PAYROLL

CANARY: FIELD DIRECTOR

PINK: RECIPIENT