Pre-Notification Communication Outpatient Clinician Letter

OMB No. 0938-1424

Expires xx/xx, 20xx

Appendix C.1 Data Collection Pre-Notification Communication

Outpatient Clinician Letter

OMB number: 0938-1424

Expiration Date: xx/xx/20xx

[FACILITY ADDRESS] XXXXX xx, 2022

Dear [OUTPATIENT CLINICIAN NAME],

The Centers for Medicare & Medicaid Services (CMS) is conducting a brief online survey to learn directly from you, our healthcare providers, how CMS quality improvement programs can best support the healthcare services you provide to Medicare beneficiaries. The survey will be conducted among physicians and clinicians as part of the CMS Quality Improvement Program. The survey results will be analyzed to compare feedback from physicians and clinicians that either did or did not receive assistance through the CMS Quality Improvement Program. Your feedback will help CMS better support all healthcare practitioners and will in no way influence any other relationship you have with CMS.

On [insert date] you will receive an email with a link to the survey. This survey should take no more than 15 minutes to complete, and all responses will be securely managed by Booz Allen Hamilton, our contractor conducting an independent evaluation of program satisfaction. We will be collecting responses from hundreds of healthcare providers across the nation. The aggregated results will not identify you or your organization and your responses will not in any way affect your relationship with CMS.

While your participation in this survey is voluntary, your responses directly contribute to the choices that CMS leadership makes on services that impact you, your work, and Medicare beneficiaries.

For verification that this is not a phishing attempt, you may visit https://qioprogram.org/survey (a CMS resource) for a verifying statement of the survey activity. If you have questions, please contact us at [email protected] or 877-934-2354. Thank you in advance for your participation in this important survey.

If you have a question for CMS about this survey, please contact my CMS lead staff person for this survey activity, Jeff Mokry at [email protected].

Sincerely,

[SIGNATURE]

Anita Monteiro, MBA, MSHCA, MA, BSN

Director, Quality Improvement and Innovation Group

CMS Center for Clinical Standards and Quality

7500 Security Boulevard, Baltimore, MD 21244

[email protected]

Pre-Launch (2-3 days prior)

Email subject line: CMS Survey Coming Soon

CMS will be issuing a survey to learn directly from you, our healthcare providers, to understand the support for Medicare beneficiaries to stay healthy in your community. In the next week, you will receive an email with a link to a survey where you will provide confidential feedback on CMS programs for physicians and clinicians.

The survey should take no more than 15 minutes to complete. Your voluntary and securely held responses will provide CMS with information on aspects of their assistance to providers that are going well and areas that require improvements. Only you can provide the necessary feedback on your experiences and observations.

For verification that this is not a phishing attempt, you may visit https://qioprogram.org/survey (a CMS resource) for a verifying statement of the survey activity. If you have questions or concerns, please contact us at [email protected] or 877-934-2354.

If you have a question for CMS about this survey, please contact my CMS lead staff person for this survey activity, Jeff Mokry at [email protected].

Thank you for your participation in the survey program.

Sincerely,

[SIGNATURE]

Anita Monteiro, MBA, MSHCA, MA, BSN

Director, Quality Improvement and Innovation Group

CMS Center for Clinical Standards and Quality

7500 Security Boulevard, Baltimore, MD 21244

[email protected]

Day of Survey email

Email subject line: Please respond to a 15-minute CMS survey

Please click here [Insert link] to respond to this brief survey. You are receiving this survey because you play an important role in the delivery of healthcare to Medicare beneficiaries in your community. This survey requires no more than 15 minutes of your time.

While your participation in the survey is voluntary, your responses directly contribute to the choices that CMS leadership makes on services that impact you, your work, and Medicare beneficiaries. All responses to the survey are held securely by a third-party. Only aggregated results will be made available to CMS.

Click the link above or point your browser to [Insert link]http://cfm_sakeholder_feedback_survey/ to complete the survey no later than [INSERT DATE].

For verification that this is not a phishing attempt, you may visit https://qioprogram.org/survey (a CMS resource) for a verifying statement of the survey activity. If you believe you are not the appropriate person to complete this survey, please forward this access to the clinician at your facility who most knowledgeable about quality improvement efforts. If you experience challenges accessing the survey, have questions, or would like to relay a concern, please contact us at [email protected] or 877-934-2354.

If you have a question for CMS about this survey, please contact my CMS lead staff person for this survey activity, Jeff Mokry at [email protected].

Sincerely,

[SIGNATURE]

Anita Monteiro, MBA, MSHCA, MA, BSN

Director, Quality Improvement and Innovation Group

CMS Center for Clinical Standards and Quality

7500 Security Boulevard, Baltimore, MD 21244

[email protected]

Post-deadline Survey Email

Email subject line: Please complete your CMS survey

According to our records, you have not completed the important CMS survey about the role of CMS assistance to help Medicare beneficiaries in your community to stay healthy.

Please click here [Insert link] to respond to this brief survey. You are receiving this survey because you play an important role in the delivery of healthcare to Medicare beneficiaries in your community. This survey requires no more than 15 minutes of your time.

While your participation in the survey is voluntary, your responses directly contribute to the choices that CMS leadership makes on services that impact you, your work, and Medicare beneficiaries. All responses to the survey are held securely by a third-party. Only aggregated results will be made available to CMS.

Click the link above or point your browser to [Insert link]http://cfm_sakeholder_feedback_survey/ to complete the survey no later than [INSERT DATE].

For verification that this is not a phishing attempt, you may visit https://qioprogram.org/survey (a CMS resource) for a verifying statement of the survey activity.

If you experience challenges accessing the survey, have questions, or would like to relay a concern, please contact us at [email protected] or 877-934-2354.

If you have a question for CMS about this survey, please contact my CMS lead staff person for this survey activity, Jeff Mokry at [email protected].

Sincerely,

[SIGNATURE]

Anita Monteiro, MBA, MSHCA, MA, BSN

Director, Quality Improvement and Innovation Group

CMS Center for Clinical Standards and Quality

7500 Security Boulevard, Baltimore, MD 21244

[email protected]