Attachment 7 Resident Consent Form

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 NORC at the
University of Chicago, 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 93-579).
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 ensuring 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.

FOR INTERVIEWER USE ONLY

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Name (Please Print)

RESPONDENT ID:
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Signature

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Date

OMB No. 0938-0568 | Expires 7/31/2017