ICH/Home Dialysis Survey Email Invitation for Web-Mail-Phone

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Subject Line: Medicare would like your feedback about «Facility Name»
PLEASE TELL US ABOUT YOUR DIALYSIS CARE
(Vaya hacia abajo de la pantalla para ver este mensaje de correo electrónico en español)
Dear «FirstName» «LastName»:
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.
There are three ways to complete this survey on the web:
1. Click here to begin your survey. «EMBED UNIQUE WEB SURVEY URL»
2. Type https://Dialysis-Survey.rti.org into the URL search bar at the top of your web browser.
You will then be asked to enter the following access code: «AccessCode».

3. Use your smartphone or tablet's camera to scan this QR code to access the survey.
Your voice matters. 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.”
Please do not ask anyone from «facility name» for help with this survey. We are interested in
your own opinions about your dialysis care.
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].
Thank you for helping to improve dialysis care.
Sincerely,

Amy Hendershott
RTI International Project Director

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].