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

Status: Original and derived artifacts are available for this document.

Download: pdf

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]:
You recently received an invitation to complete a web survey from Medicare about your experiences with
[FACILITY NAME]. If you already completed this web survey, thank you! You do not need to do anything
else.
If you have not completed the web survey, this is a friendly reminder that we are very interested in learning
about your experiences! 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.
There are several ways to complete this survey:
1. Return this paper survey in the enclosed pre-paid envelope.
2. Type the website link below into the URL search bar at the top of your web browser and enter the access code
to ensure privacy.
Survey: https://Dialysis-Survey.rti.org
Access Code: «AccessCode»
3. Use your smartphone or tablet's camera to scan this QR code to access the survey.
Your voice matters. We know your time is valuable. Participation is voluntary, and your information is kept
private by law. No one can connect your name to your answers. 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.”
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]. (La encuesta también esta disponible
en español en el enlace personalizado que aparece arriba. Si tiene preguntas, llámenos al número que aparece
arriba o envíenos un correo electrónico.)
Thank you for helping to improve dialysis care.
Sincerely,

We care about your dialysis
experience!

Center for Medicare

<<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].