ICH/Home Dialysis Survey Mail Invite Letter for Web-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.
There are two ways to complete this survey on the web. If you have any problems, please see the helpful tips on
the back of this letter.
1. 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»
2. 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] (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>>

Helpful Tips
I don’t have a computer. Can I use another device to complete this survey?
Yes! You can use any device that connects to the Internet to complete this survey, including a computer,
smartphone, tablet, or other device.
Is the survey’s web link case sensitive?
The website link isn’t case sensitive, but you must include “https://” and the dash between dialysis and survey.
For example, you can type https://Dialysis-Survey.rti.org

or https://dialysis-survey.rti.org

and it will work.

I’m having trouble getting to the survey. How do I access the survey?
To access the survey by typing in the URL, follow these steps:
1. Type https://Dialysis-Survey.rti.org into the address bar at the top of your web browser (Microsoft
Edge, Google Chrome, Firefox, Safari, etc.), as shown below.

2. Press “Enter” on your keyboard to open the survey login page.
3. On the survey login page, enter the 6-digit access code listed on the front of this letter and click “Take
the Survey.”
NOTE: Typing the survey web link into a search engine (Google, Bing, etc.) will not take you to the Medicare
In-Center and Home Dialysis Survey.
To access the survey via the QR code, follow these steps:
1. Open the camera on your smartphone or tablet.
2. Point the camera at the code and tap the pop-up notification that appears on your screen.

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].