Attachment 7 - Consent Forms

MEDICARE CURRENT BENEFICIARY SURVEY
RESIDENT CONSENT FORM

You have been selected to participate in the Medicare Current Beneficiary Survey (MCBS). The
purpose of this survey is to collect information about the use of health services and costs
associated with those services, health status, and insurance coverage of sample members who are
or were receiving Medicare benefits. The survey is sponsored by Centers for Medicare and
Medicaid Services (CMS), an agency within the U.S. Department of Health and Human Services
that oversees the Medicare Program.
The information collected for MCBS will be held in strict confidence by Westat, the contractor
collecting the data, and by CMS. It will be used only for the purposes stated for this study, and
will not be disclosed or released to anyone except those involved in research without the consent
of the individual or the establishment in accordance with the Privacy Act of 1974 (Public Law 93579).
Data will be collected from your medical records and through interviews with designated
"responsible persons." Participation in the study is voluntary. Refusal to participate or continue
participation will involve no penalty or loss of benefits to which you are otherwise entitled.
Your participation is very important for assuring that survey information is complete and
accurate, and we hope you will agree to participate.
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I have read the above statement and have had my questions answered to my satisfaction. I agree
to participate in the Medicare Current Beneficiary Survey.

Name (Please Print)

Signature

Date

FOR OFFICE USE ONLY

SP ID:

FACILITY ID:

MEDICARE CURRENT BENEFICIARY SURVEY
NEXT OF KIN CONSENT FORM
________________________________ has been selected to participate in the Medicare Current
Name of Sampled Person
Beneficiary Survey (MCBS). The purpose of this survey is to collect information about the use
of health services and costs associated with those services, health status, and insurance coverage
of sample members who are or were receiving Medicare benefits. The survey is sponsored by the
Centers for Medicare and Medicaid Services (CMS), an agency within the U.S. Department of
Health and Human Services that oversees the Medicare Program.
Information collected for the MCBS will be held in strict confidence by Westat, the contractor
collecting the data, and by CMS. It will be used only for the purposes stated for this study, and
will not be disclosed or released to anyone except those involved in research without the consent
of the individual or the establishment in accordance with the Privacy Act of 1974 (Public Law 93579).
Data will be collected from medical records and through interviews with relatives or designated
"responsible persons." Participation in the study is voluntary. Refusal to participate or continue
participation will involve no penalty or loss of benefits to which
Sampled Person
is otherwise entitled.
Your participation is very important for assuring that survey information is complete and
accurate, and we hope you will agree to participate.
******************************************************************************
I have read the above statement and have had my questions answered to my satisfaction. I give
my consent for participation in the Medicare Current Beneficiary Survey.

Name (Please Print)

Signature

Relationship to Sampled Person

Date
FOR OFFICE USE ONLY
SP ID: