CMS-10275 Consent to Share Question #35 (English)

CAHPS Home Health Care Survey (CMS-10275)

HHCAHPS_Q35_EnglishText

OMB: 0938-1066

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Your home health care agency may want to review your answers so that they can decide how to
address any concerns that you have. We will not share your answers to this survey linked to your
name unless you give your permission for this information to be shared with your home health
agency.
Q35. Do you give your permission to provide your answers to this survey linked to your name to
your home health agency?
1

2

Yes, I give my permission to share my name and survey responses with my home
health care agency.
No, I do not give permission to share my name and survey responses with my home
health care agency.


File Typeapplication/pdf
File TitleConsent_share identifying HHCAHPS data
Subjectpermission to share identifiable data, Private health information, HHCAHPS PHI, HHCAHPS PII
AuthorCMS_HHCAHPS Coordination Team
File Modified2013-01-07
File Created2010-03-17

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