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 response to your request from a Medicare Ombudsman Representative within the Medicare Ombudsman Group.

The Medicare Ombudsman Representatives provide 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 their reply, please tell us how satisfied you are with the information the Medicare Ombudsman Representative 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 self-addressed, postage-paid envelope.

Your feedback is voluntary, and your decision to participate in this survey will not 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 Medicare Ombudsman Representatives respond 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 Cara Vriezen toll-free at

1-877-267-2323 ext. 65695. 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 Medicare Ombudsman Representative’s service. We look forward to hearing from you soon.

Sincerely,

Walter Stone

Privacy Officer

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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

OMB approved form number: 0938-0894

Medicare Ombudsman Representative Customer Service Feedback Survey

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

We welcome any suggestions to improve customer service provided by the Medicare Ombudsman Representative:

Thank you for taking the time to answer our survey. Please return your completed survey in the enclosed postage paid envelope.

CMS-10068 (11/14)