[SURVEY VENDOR LOGO] and/or [QHP ISSUER LOGO ONLY NO ADDRESS]
[SURVEY VENDOR ADDRESS]
OMB No. 0938-1221: Approval Expires XX/XX/20XX
[FIRST AND LAST NAME]
[LINE
ONE OF ADDRESS]
[LINE TWO OF ADDRESS (IF ANY)]
[CITY, STATE
ZIP]
Dear [ENROLLEE FIRST AND LAST NAME],
You will soon receive a survey about the care you received through [QHP ISSUER NAME] in the last 6 months. This is your chance to help your health plan serve you better. This survey is part of a national ongoing effort to understand the experiences enrollees have with their health plan. The results will help consumers like you make important choices about their health care and will help health plans improve the care they provide. You have been chosen as part of a random sample of enrollees in your health plan. Your answers are important and we cannot replace you with anyone else. The survey will take about 15 minutes to complete.
Your answers will be part of a pool of information from others who are enrolled in your health plan. The information you provide will only be shared with authorized persons. Your health plan will not see your responses. You may choose to fill out this survey or not. If you choose not to, this will not affect the benefits you receive. However, your knowledge and experiences will help other people like you choose a health plan, so we hope you will help us.
To save time and paper, you can complete this survey online right now by visiting [SURVEY URL]. On this website you will be asked for this private [LOGIN CREDENTIAL(S)].
Respond now at [SURVEY URL]
[LOGIN CREDENTIAL(S)]
[QHP ISSUER NAME] contracted with [SURVEY VENDOR NAME] to conduct this survey. If you have any questions about the survey, call [SURVEY VENDOR NAME] toll free at (XXX) [XXX-XXXX] between [XX:XX] a.m. and [XX:XX] p.m. [SURVEY VENDOR LOCAL TIME], Monday through Friday (excluding federal holidays), or e-mail [SURVEY VENDOR E-MAIL].
Si prefiere la encuesta en español, por favor llame al (XXX) [XXX-XXXX].
[IF OFFERING CHINESE] 如果你想要中文問卷，請致電 (XXX) [XXX-XXXX].
Sincerely,
[SIGNATURE]
[NAME & TITLE OF SENIOR EXECUTIVE FROM SURVEY VENDOR or QHP ISSUER]
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid Office of Management and Budget (OMB) control number. The valid OMB control number for this information collection is 0938-1221. The time required to complete this information collection is estimated to average 15 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.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | 2017 QHP Survey Prenotification Letter - English |
| Subject | 2017 Qualified Health Plan Enrollee Experience Survey |
| Author | Centers for Medicare & Medicaid Services |
| File Modified | 0000-00-00 |
| File Created | 2021-01-13 |