Beneficiary survey pre-notification letter

Attachment 6.a. Pre-Notification 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:
The Centers for Medicare & Medicaid Services (CMS), a federal government agency, is doing a survey
with people who took part in special programs just for people with Medicaid. This survey is called the
Program Participant Survey. Your name was chosen at random from a list of people who were in one
of these special programs. In the next few days you will get a survey in the mail asking about your
experiences with the (Program Name or Specific Program Name) program.
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]. We hope that you will do the survey. Your answers will help us to
make programs like this better.
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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