In-Center Hemodialysis CAHPS Survey: National Implementation

National Implementation of In-Center Hemodialysis CAHPS Survey (CMS-10105)

ICH _CL1_Sam_Nov2024_OMBRevised

In-Center Hemodialysis CAHPS Survey: National Implementation

OMB: 0938-0926

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[DATE]

[FIRST NAME] [LAST NAME]

[ADDRESS]

[CITY, STATE AND ZIP]

FAAMOLEMOLE TA’U MAI LE FAATINOGA O LE FAAMAMĀINA O LOU TOTO

Lau [FIRST NAME] [LAST NAME]:

O se suesuega tāua lenei mai le Medicare mo tagata o loo faamamā o latou toto. Matou te faamoemoe o le a e faaaluina se taimi e faasoa mai ai ni ou lagona i mea o e mātauina i le [FACILITY NAME]. O sou finagalo faaalia e fesoasoani le Medicare ia faaleleia atili le tulaga lelei aoao o le faatinoga o galuega mo le faamamāina o lou toto faapea ma isi, ma fesoasoani foi i isi e fai ai la latou filifiliga poo fea le nofoaga faamamā toto e fetaui mo latou.

E mafai ona e silafia nisi faamatalaga e uiga i le suesuega ma e tagai i le faanumeraina o le tulaga lelei o nofoaga faamamā toto ma le aufaigaluega i luga o le initaneti i le www.medicare.gov/care-compare i lalo o le provider type (itu’aiga o tausiga), o le “Dialysis facilities” (nofoaga faamamā toto). Mo fesili masani ma tali e uiga i le suesuega, e mafai foi ona e tagai i le https://ichcahps.org Shape2 ma kiliki i le faailoilo “DIALYSIS PATIENTS Click Here” (GASEGASE FAAMAMĀ TOTO Kiliki Iinei).

E tāua ou manatu. Atonu e talosagaina oe e faʻamaeʻa le suʻesuʻega e oʻo atu i le faalua i le tausaga ina ia mafai ai e Medicare ona malamalama pe faʻafefea ona suia aafiaga o tagata faamama toto i taimi. E tuu i lau faitalia pe e te fia auai, ma e puipuiamalu ou faamatalaga e tusa ai ma le tulafono. E leai se tasi e mafai ona faafesoota’ia lou suafa i au tali.

Faamolemole aua ne’i fesili atu i soo se tasi mai le [FACILITY NAME] mo se fesoasoani i lenei suesuega. Matou te fia iloa sou lava finagalo i le faatinoga o le faamamāina o lou toto. Faamolemole faafoi mai le suesuega i le teutusi o loo avatu ua uma ona totogi.

Mo nisi fesili e uiga i le suesuega, faamolemole e vili [VENDOR NAME], telefoni e lē totogia i le [VENDOR 800 NUMBER], [DAYS], i le va o le [HOURS AND TIME ZONE]. (For questions about this survey, or if you want to receive this survey in English, please call the survey manager at [VENDOR 800 NUMBER].)

Faafetai atu mo lau fesoasoani e faaleleia atili le faatinoga o le faamamāina o toto.

Ma le ava tele,

Vanessa S. Duran

Ta’ita’i

Penefiti o Fualaau ole Medicare ma le

C & D – Vaega o Faila Fa’amaumau

E tusa ai ma le Tulafono o le Faaitiitia o le Faaaogaina o Pepa o le 1995 (Paperwork Reduction Act of 1995), e le manaomia ai ni tagata e tali atu i se faamatalaga tuufaatasi sei vagana ua faaalia mai se numera faamaonia o se OMB (OMB) talafeagai. O le numera faamaonia o le OMB talafeagai mo lenei faamatalaga tuufaatasi o le 0938-0926. E maua mai i faamatalaga tuufaatasi faamaumauga faatusatusa mai nofoaga faamama toto e fesoasoani ai i tagata taitasi e filifili se nofoaga ma tausia lelei ai. O le taimi manaomia e faamaea ai lenei faamatalaga tuufaatasi e fuafua o le averesi e itiiti ifo i le 16 minute i le tali e tasi, e aofia ai ma le taimi e toe iloilo ai faatonuga, saili punaoa o faamaumauga o loo iai i le taimi nei, aoao faamaumauga moomia, e toe iloilo ma faamaea ai faamatalaga tuufaatasi. O lenei faamatalaga tuufaatasi e faatulafonoina ina ia agavaa ai nofoaga faamama toto i lalo o le 42 CFR §413.178(c)(iii) ina ia faamalie ai manaoga o le polokalame ma agavaa ai mo suesuega e tali atu ai. E mautinoa le teufaalilolilo o ou faamaumauga i lalo o le 5 U.S.C. 552a (Faiga E Puipuia Ai o le 1974). Afai e iai ni au faamatalaga e tusa ai ma le sao aiai o taimi faatusatusa po o se manatu e faaleleia ai lenei pepa, faamolemole tusi mai i le: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C1-2505, Baltimore, Maryland 21244-1850.

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleICH CAHPS Cover Letter 1 – Samoan
SubjectICH CAHPS
AuthorCenters for Medicare & Medicaid Services
File Modified0000-00-00
File Created2025-05-19

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