In-Center Hemodialysis CAHPS Survey: National Implementation

FOR OFFICIAL ICH CAHPS
USE ONLY:
CMS LOGO INSERTED HERE

Centers for Medicare & Medicaid Services
7500 Security Boulevard, Mail Stop C1-25-05
Baltimore, Maryland 21244-1850

[DATE]
[FIRST NAME] [LAST NAME]
[ADDRESS]
[CITY, STATE AND ZIP]
PLEASE TELL US ABOUT YOUR DIALYSIS CARE
Dear [FIRST NAME] [LAST NAME]:
This is an important survey from Medicare for people who get dialysis. We hope you will take the time to share
your experiences about [FACILITY NAME]. Your feedback helps Medicare improve the overall quality of
dialysis care that you and others like you receive, and also helps others choose a dialysis center that is
right for them.
You can learn more about the survey and see ratings of dialysis centers and staff online at
www.medicare.gov/care-compare under the provider type “Dialysis Facilities.” For common questions and
answers about the survey, you can also visit https://ichcahps.org and click on the “DIALYSIS PATIENTS
Click Here” button.
Your voice matters. Participation is voluntary, and your information is kept private by law. No one can
connect your name to your answers.
Please do not ask anyone from [FACILITY NAME] for help with this survey. We are interested in your own
opinions about your dialysis care. Please return the survey in the enclosed pre-paid envelope.
For additional questions about the survey, please call [VENDOR NAME], toll-free at [VENDOR 800
NUMBER], [DAYS], between [HOURS AND TIME ZONE]. (Si usted tiene preguntas acerca de esta encuesta
o desea recibirla en español, por favor llame al administrador de encuestas al [VENDOR 800 NUMBER].)
Thank you for helping to improve dialysis care.
Sincerely,
FOR OFFICIAL ICH CAHPS
USE ONLY:
CMS STAFF SIGNATURE
INSERTED HERE

Amy Larrick Chavez-Valdez
Director
Medicare Drug Benefit and C & D Data Group

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 0938-0926. The time required
to complete this information collection is estimated to average 16 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 any comments
concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, Attn: PRA Reports
Clearance Officer, 7500 Security Boulevard, Mail Stop C1-25-05, Baltimore, Maryland 21244-1850.