CMS-1500 Telephone Interview Script for the Outpatient and Ambula

ATTACHMENT C:

INTRODUCTORY SCRIPT FOR TELEPHONE CONTACT

Telephone Interview Script

for the Outpatient and Ambulatory Surgery Experience of Care Survey

INTRO1 Hello, may I please speak to [SAMPLE MEMBER’S NAME]?

1. YES Go to INTRO 2 once Sample Member is on phone

2. NO, NOT AVAILABLE RIGHT NOW [SET CALLBACK]

3. NO [REFUSAL] Go to TERMINATE Screen

4. MENTALLY/PHYSICALLY INCAPABLE [CODE AS INCAPABLE]

IF ASKED WHO IS CALLING:

This is [INTERVIEWER NAME] calling from RTI International on behalf of the US Department of Health and Human Services (DHHS). I’d like to speak to [SAMPLE MEMBER’S NAME] about a health care survey.

INTRO2 Hello, this is [INTERVIEWER NAME] calling on behalf of the US Department of Health and Human Services (DHHS). [HOSD/ASC facility name] is participating in a survey about patients’ experiences with outpatient surgeries and procedures. The results will be used to help DHHS understand patient experiences in outpatient or ambulatory surgery facilities.

Your participation in this survey is completely voluntary and will not affect any health care or benefits you receive. All information you provide is confidential and is protected by the Privacy Act. Your information will not be shared with anyone other than authorized persons who are working on this project at DHHS and RTI. The interview will take about 10 minutes to complete. This call may be monitored or recorded for quality improvement purposes.

[ADDRESS ANY QUESTIONS/CONCERNS THEN CONTINUE.]

INTRO3 This survey asks about your experience at [FACILITY NAME]. For this survey, we use the term “procedure” for diagnostic, surgical or other procedures. We refer to “facility” as the place where you had your procedure. Please answer these questions only for the procedure you had on [DATE]. Do not include any other procedures in your answers.

[QUESTIONS FROM PAPER SURVEY (ATTACHMENT 1) IMPLEMENTED IN CATI.]