Form CMS-10731. (GenIC# CMS-10731. (GenIC# CMS-10731 (GenIC#1). Was This Page Helfpul Survey

Campaign Feedback Survey

* denotes a response is required 

Q1*. Was this page helpful?

• Yes

• No

{Note: If ‘Yes’ is selected show Q2-yes, if ‘No’ is selected show Q2-no}

Q2-yes*. I found this page helpful because the content on the page (select all that apply):

• Answers my question(s)

• Is up-to-date

• Is trustworthy

• Is clearly written

• Other [open text box]*

Q2-no* I didn’t find this page helpful because the content on the page (select all that apply)

• Isn’t enough information

• Is too much information

• Is confusing

• Is out-of-date

• Other [open text box]*

Q3. What can we do to improve this page?

[Open text box]

Q4*. What was the primary purpose of your visit to this webpage today?

• Get payment rates

• Get coding information

• Get coverage information

• Learn about roster billing

• Become a centralized biller

• Learn about eligibility requirements

• Learn about reporting data

• Get coverage information

• Get payment information

• Learn about certification requirements

• Learn about reporting requirements

• Get regulation & guidance information

• Get enrollment information

• Get billing information

• Get payment rates

• Get coding information

• Get claims information

• Learn about billing

• Get Ground Ambulance Data Collection System (GADCS) webinar information or references

• Something else [open text box]*

Q5*. Were you able to {pull answer selection from Q4} today?

• Yes

• No

{Note:

If ‘Something else’ is selected for Q4, this question will ask “Were you able to accomplish your task?”}

Q6*. Which best describes you?

• Provider of medical services

• Supplier of medical equipment or supplies

• Staff of a provider of medical services

• Staff of a supplier of medical equipment or supplies

• Staff of a billing service/clearinghouse

• Consultant or attorney

• Pharmacy

• Public health clinic

• Senior center/retirement community

• Manufacturer

• Clinical Laboratory

• Medicare Patient

• Administrative staff in a medical office

• Office or practice manager

• Professional association or trade group

• Provider of dental services

• Staff of a provider of dental services

• Other [open text box]

{Note: If ‘Provider of medical services’ or ‘Staff of a provider of medical services’ is selected, show 6a}

Q6a.* What is your Medicare enrollment type or the enrollment type of your practice or facility?

• Institutional Provider

• Clinic/Group Practice

• Physician

• Non-Physician Practitioner

• Home Health

• Hospice

• Skilled Nursing Facility

• Opioid Treatment Program

• Dentist or Dental Specialist

• Other [open text box]*

Q7.* If we have questions about your feedback, can we contact you?

• Yes, my email address is: (open text box)

• No

End of survey message:

If ‘Yes’ is selected for Q1, display:

Thanks for taking our survey.

If ‘No’ is selected for Q1, display:

Thanks for taking our survey. We’ll use your response to make your next experience better.

Embedded data to be collected:

• Physical location – based on visitors IP address

• Page Referrer – page the visitor was previously on

• Current Page URL

• Time Spent on Site – records both total time and time focused on site (when the webpage is opened as the front, “in-focus” window on the computer)

• Unique Visited Page Count – number of different pages’ user visited on the site

• Search term – captures the term the visitor searched to arrive to the website

• Recorded Site History – captures all the sites the visitor has visited that have the project code on the page

Pages to display survey:

Optional:

PRA Disclosure Statement

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 [0938-1459]. This information collection will be used on targeted CMS web pages to webpages to gather insight from visitors to deliver an improved user experience. The time required to complete this information collection is estimated to be [1 minute] per response, including the time to review instructions, search existing data resources, gather the data needed, to review and complete the information collection. This information collection is strictly voluntary and does not collect any personally identifiable information. CMS does not pledge confidentiality as no confidential information is being collected. 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.