Hospice Experience of Care Survey

Attachment D HOSPICE SURVEY LETTER
DRAFT 1
5/30/13
RAND LETTERHEAD

DATE

Dear [NAME]:
[HOSPICE NAME] is working with Medicare and the RAND Corporation to improve
hospice care. Together, we are conducting a survey about the hospice services that
patients and their families receive. The information from this survey will be used to help
ensure that all Americans get the highest quality hospice care. Medicare, administered
by the Centers for Medicare & Medicaid Services, pays for most hospice care in the
United States
You were selected for this survey because you were identified as the caregiver of
[PATIENT NAME]. We realize this may be a difficult time for you, but we hope that you
will help us learn about the quality of care that you and your loved one received from the
hospice. The survey should take you less than 20 minutes to complete. We encourage
you to answer only the questions that you are comfortable responding to. The accuracy
of the results depends on getting answers from you and other people selected for this
survey.
We will hold your identifying information and all information you provide in confidence,
and your information is protected by U.S. federal law under the Privacy Act of 1974. We
will not share your information with anyone other than authorized persons at the Centers
for Medicare & Medicaid Services, except as required by law. We will not share your
individual survey with any hospice. Your help is voluntary, however we hope you will
choose to help us because your knowledge and experience will help improve hospice
care for others.
We hope that you will take this opportunity to help the Centers for Medicare & Medicaid
Services learn about the quality of care your family member or friend received. Please
return the survey in the enclosed postage-paid envelope. If you have any questions
about the survey, please call RAND’s survey line toll-free at XXX-XXX-XXXX, any time
from 9:00 am to 9:00 pm Pacific time, Monday through Saturday.
Thank you in advance for your participation, and please accept our sincere condolences
on the loss of your loved one.
Sincerely,

[Project Director]
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 XXXXXXX. The time required to complete this information collection is estimated to average 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.