Beneficiary survey mail cover letter

Attachment 6.b. Survey Cover Letter
DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
7500 Security Boulevard, Mail Stop S1-13-05
Baltimore, Maryland 21244-1850
Month 2014
NAME
ADDRESS
CITY, STATE ZIP
Dear NAME:
About a week ago, we sent you a letter about a survey that the Centers for Medicare & Medicaid
Services (CMS) is doing called the Program Participant Survey. That survey is included with
this letter.
Your name was chosen at random from a list of people who were in the (Program Name or
Specific Program Name) program. The survey has questions about your experiences with the
(Program Name or Specific Program Name) program. Please take a few minutes to answer the
survey. Please return the survey in the envelope included with this letter.
It is your choice whether or not to do the survey. Your decision will not affect your
Medicaid benefits. Your answers will be kept confidential and are protected by the Privacy Act.
We will not share your answers with (Program Name or Specific Program Name). We hope
that you will do the survey. Your answers will help us to make programs like this better.
Everyone who returns a survey can enter into a drawing for the chance to win a $50 gift card. If
you want to enter into the drawing, please complete and mail the enclosed postcard. On the
postcard, please write the name and address where you want the gift card sent (it is OK to use a
fake name or your initials). To protect your privacy, please mail the postcard separately from the
survey.
If you have any questions, please call NAME toll-free at 1-877-XXX-XXXX. Si desea recibir la
versión de la encuesta en español, por favor llame al 1-877- XXX-XXXX.
Thank you for your help with this survey.
Sincerely,

NAME
CMS TITLE

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