Form CMS-10068 Medicare OMBudsman Customer Service Feedback Survey

Dear Medicare Customer:
The Centers for Medicare & Medicaid Services (CMS) strives to provide excellent
customer service. Our primary customer service goal is to provide accurate, timely, and
relevant information to our customers. Recently, you contacted CMS to ask for help.
Enclosed is the Office of the Medicare Ombudsman’s response to your request.
The Office of the Medicare Ombudsman provides beneficiary assistance with complaints,
grievances, and requests for Medicare related information. Feedback we receive from
beneficiaries is used to identify trends, evaluate issues, and make recommendations for
improving the Medicare Program.
After you read our reply, please tell us how satisfied you are with the information the
Office of the Medicare Ombudsman provided you. Please take a few minutes to answer
the questions on the back of this letter, and then mail it back in the enclosed selfaddressed, postage-paid envelope.
Your feedback is voluntary, and your decision to participate in this survey won’t affect
your Medicare benefits or those of the individuals you represent. Your answers to the
survey questions will be used to help us improve the way the Office of the Medicare
Ombudsman responds to the public. We sincerely hope you will share your opinions
with us. All personal information will be kept confidential by CMS.
If you have any questions about this survey, you may contact Nancy Conn of the Office
of the Medicare Ombudsman toll-free at 1-877-267-2323 ext. 68374. However, if you
have a question about Medicare benefits, you should call 1-800-MEDICARE
(1-800-633-4227); TTY users should call 1-877-486-2048.
Thank you for taking the time to help us improve the Office of the Medicare
Ombudsman’s service. We look forward to hearing from you soon.
Sincerely,

Walter Stone
Privacy Officer
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 0938-0894. The time
required to complete this information collection is estimated to average 06 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

over

OMB approved form number: 0938-0894

MEDICARE OMBUDSMAN CUSTOMER SERVICE FEEDBACK SURVEY
This survey is to measure your satisfaction with the customer service ________________
provided from the Office of the Medicare Ombudsman only (not Social Security,
1-800-MEDICARE or any other agency or department, please).
Based on a scale where 5 means you are very satisfied  and 1 means you are very
dissatisfied , please circle one number for each question that best describes your
experience.
Very …………………………………………..Very
Satisfied
Dissatisfied


1. Are you satisfied the information
I provided answered your
question(s)?
2. Are you satisfied the information
I provided is clear?
3. Are you satisfied with the length
of time it took me to respond to
you?
4. Are you satisfied with the
method of response
(letter, telephone, or e-mail)?
5. Are you satisfied I responded in
a courteous manner?
6. Overall, are you satisfied with
the customer service I provided?

5


4

3

2


5


4

3

2


5

4

3

2

4

3

2

4

3

2

1


4

3

2



We welcome any suggestions to improve customer service provided by the Office of the
Medicare Ombudsman: __________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Thank you for taking the time to answer our survey. Please return your completed survey
in the enclosed postage paid envelope.
CMS-00068 (01/11)

1




5

1




5

1




5

1

1

