ICH/Home Dialysis Survey Cover Letter 1 for Mail and Mail-Phone

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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 in-center hemodialysis centers and staff online at
www.medicare.gov/care-compare under the provider type “Dialysis facilities.”
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.
If you have questions about this survey, please call RTI International, the organization working with Medicare,
(toll-free) at 1-866-245-8083 or send an email to [email protected] (Si tiene preguntas o desea recibir la
versión de la encuesta en español, por favor llámenos al número que aparece arriba o envíenos un correo
electrónico.)
Thank you for helping to improve dialysis care.
Sincerely,
Center of Medicare

We care about your dialysis
experience!

<<SID>>
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. This information collection produces
comparable data from dialysis facilities to help individuals choose a facility and improve care. The time required to complete this information
collection is estimated to average less than 11 minutes 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 mandatory for qualifying dialysis
facilities under 42 CFR §413.178(c)(iii) to meet program requirements and voluntary for survey respondents. Confidentiality is assured under 5
U.S.C. 552a (Privacy Act of 1974). 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 C1-25-05, Baltimore, Maryland 21244-1850.
****CMS Disclosure**** Please do not send applications, claims, payments, medical records or any documents containing sensitive
information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection
burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have
questions or concerns regarding where to submit your documents, please contact [email protected].