CMS-10399 Appendix G CMS Consent Forms

Appendix G
CONSENT FORMS
(1) AMERICAN INDIAN AND ALASKA NATIVE MEDICARE BENEFICIARY
SURVEY

(2) AMERICAN INDIAN AND ALASKA NATIVE HEALTH CARE PROVIDER
SURVEY

(3) AMERICAN INDIAN AND ALASKA NATIVE MEDICARE BENEFICIARY
INTERVIEW

(4) AMERICAN INDIAN AND ALASKA NATIVE MEDICARE BENEFICIARIES AND
FAMILY MEMBERS FOCUS GROUP
(5) AMERICAN INDIAN AND ALASKA NATIVE HEALTH CARE PROVIDER
INTERVIEW

Centers for Medicare and Medicaid Services
Analysis of Transportation Barriers to the Utilization of Medicare Services by
American Indian and Alaska Native Medicare Beneficiaries
CONSENT FORM FOR
AMERICAN INDIAN AND ALASKA NATIVE MEDICARE BENEFICIARY SURVEY
Purpose of Study
The Centers for Medicare and Medicaid Services (CMS) is an agency of the U.S. Department of Health and
Human Services with a mission to “ensure effective, up-to-date health coverage and to promote quality care
for beneficiaries.”
The Federal obligation to provide health services to American Indians and Alaska Natives is based upon a
unique historical government-to-government relationship established through treaties and affirmed over time
through laws, Executive Orders, and court decisions. Health services in particular were guaranteed in treaties
negotiated between tribes and the U.S. Government, and funding was specifically authorized by Congress in
The Snyder Act of 1921.
In the mid-1970s two laws were enacted that dramatically changed the face of Indian health care delivery. The
Indian Self Determination and Education Assistance Act of 1975 provided authority to federally recognized
tribes to take over and administer for themselves the Federal programs of the Indian Health Service (IHS)
designed to serve them, shifting the control and direction of health priorities to local tribal governments. The
other significant change was the enactment of the Indian Health Care Improvement Act of 1976, which
clarified Federal policy to “elevate the health status of Indians and Alaska Natives to the highest possible
level” and provided specific targets for this new policy, including health professional training, health facility
construction and modernization, and access to Medicaid and Medicare reimbursement for IHS and tribally
provided services. Despite the availability of Medicare coverage, significant barriers prevent American Indians
and Alaska Native beneficiaries from accessing care. One of the major barriers consistently mentioned is
transportation barriers to accessing Medicare services.
The purpose of this project is to collect information and analyze the transportation barriers experienced by
American Indian and Alaska Native Medicare beneficiaries and ultimately, to identify the solutions that could
help reduce this barrier and produce meaningful improvements in health outcomes for the beneficiaries.
Participation and Confidentiality
As part of the transportation barriers project we will be conducting one-on-one surveys with American Indian
and Alaska Native Medicare Beneficiaries. Your participation is entirely voluntary. You have the right to
refuse to answer any question that is asked and to refuse to participate further at any point in the project.
If you agree to participate in this project, you will take part in a 45 minute survey. Your responses will be
recorded either electronically on a computer or by hand on a written form. Your privacy is important to us.
We will make every effort to protect the confidentiality of your comments and responses. Your name will not
appear in any oral presentation or written report. Any information that you provide us will be combined with
other participants’ information; thus, you will not be identified. Electronic and written copies of the project
will be stored without personal identifiers in secure locations and will be destroyed at the close of the
evaluation. If you have any questions regarding this project or your participation, please contact Dr. Jeanette
Hassin, at Kauffman & associates, Inc. at (301) 588-6800 or jeanette.hassin@kauffmaninc.com.
Risks and Benefits
There are no known risks from taking part in this project. The main benefits of your participation in the
project include the enhancement of methods to best address AI/AN Medicare beneficiaries’ transportation

barriers to Medicare services. Finding out this kind of information will enable CMS to better address these
problems.
Participant Costs and Compensation
There is no cost to you to participate in this survey, interview, or focus group, with the exception of time. To
compensate you for your time, you will receive a $30 gift card.
Consent to Participate in Project
I have read and reviewed the above information about this project. I hereby consent and voluntarily agree to
participate in the transportation barriers project. By signing, I am not waiving any legal claims, rights, or
remedies.

___________________________
Participant’s Printed Name

___________________________
Participant’s Signature

Date

___________________________

___________________________

___________________

Interviewer’s Printed Name

Interviewer’s Signature

Date

According to the Paperwork Reduction Act of 1995, “no persons are required to respond to a collection of information
unless such collection displays a valid OMB control number.” The valid OMB control number for this information
collection is 0938-XXXX. The time required to complete this information collection is estimated to average 45
minutes per response, including the time to review instructions. If you have any comments concerning the
accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of
Health and Human Services, 200 Independence Ave., SW, Washington, DC, 20210. If you have comments or
concerns regarding the status of your individual submission of this form, write directly to: CMS, U.S.
Department of Health and Human Services, 7500 Security Blvd, Baltimore, MD, 21244-1850.

Centers for Medicare and Medicaid Services
Analysis of Transportation Barriers to the Utilization of Medicare Services by
American Indian and Alaska Native Medicare Beneficiaries
CONSENT FORM FOR AMERICAN INDIAN AND ALASKA NATIVE
HEALTH CARE PROVIDER SURVEY
Purpose of Study
The Centers for Medicare and Medicaid Services (CMS) is an agency of the U.S. Department of Health and
Human Services with a mission to “ensure effective, up-to-date health coverage and to promote quality care
for beneficiaries.”
The Federal obligation to provide health services to American Indians and Alaska Natives is based upon a
unique historical government-to-government relationship established through treaties and affirmed over time
through laws, Executive Orders, and court decisions. Health services in particular were guaranteed in treaties
negotiated between tribes and the U.S. Government, and funding was specifically authorized by Congress in
The Snyder Act of 1921.
In the mid-1970s two laws were enacted that dramatically changed the face of Indian health care delivery. The
Indian Self Determination and Education Assistance Act of 1975 provided authority to federally recognized
tribes to take over and administer for themselves the Federal programs of the Indian health Service (IHS)
designed to serve them, shifting the control and direction of health priorities to local tribal governments. The
other significant change was the enactment of the Indian Health Care Improvement Act of 1976, which
clarified Federal policy to “elevate the health status of Indians and Alaska Natives to the highest possible
level” and provided specific targets for this new policy, including health professional training, health facility
construction and modernization, and access to Medicaid and Medicare reimbursement for IHS and tribally
provided services. Despite the availability of Medicare coverage, significant barriers prevent American Indians
and Alaska Native beneficiaries from accessing care. One of the major barriers consistently mentioned is
transportation barriers to accessing Medicare services.
The purpose of this project is to collect information and analyze the transportation barriers experienced by
American Indian and Alaska Native Medicare beneficiaries and ultimately, to identify the solutions that could
help reduce this barrier and produce meaningful improvements in health outcomes for the beneficiaries.
Participation and Confidentiality
As part of the transportation barriers project we will be conducting surveys with health care providers. Your
participation is entirely voluntary. You have the right to refuse to answer any question that is asked and to
refuse to participate further at any point in the project.
If you agree to participate in this project, you will take part in a 30 minute survey. Your responses to this selfadministered survey will be recorded electronically, if you are doing it on-line or by hand, if you are
completing a hard copy. Your privacy is important to us. We will make every effort to protect the
confidentiality of your comments and responses. Your name will not appear in any oral presentation or
written report. Any information that you provide us will be combined with other participants’ information;
thus, you will not be identified. Electronic and written copies of the survey will be stored without personal
identifiers in secure locations and will be destroyed at the close of the project. If you have any questions
regarding this project or your participation, please contact Dr. Jeanette Hassin at Kauffman & Associates,
Inc. at (301) 588-6800 or jeanette.hassin@kauffmaninc.com.

Risks and Benefits
There are no known risks from taking part in this project. The main benefits of your participation in the
project include the enhancement of methods to best address AI/AN Medicare beneficiaries’ transportation
barriers to Medicare services. Finding out this kind of information will enable CMS to better address these
problems.
Participant Costs and Compensation
There is no cost to you to participate in this interview with the exception of time. To compensate you for
your time, you will receive a small gift.
Consent to Participate in Project
I have read and reviewed the above information about this project. I hereby consent and voluntarily agree to
participate in the transportation barriers project. By signing, I am not waiving any legal claims, rights, or
remedies.

___________________________
Participant’s Printed Name

___________________________
Participant’s Signature

Date

___________________________

___________________________

___________________

Interviewer’s Printed Name

Interviewer’s Signature

Date

According to the Paperwork Reduction Act of 1995, “no persons are required to respond to a collection of information
unless such collection displays a valid OMB control number.” The valid OMB control number for this information
collection is 0938-XXXX. The time required to complete this information collection is estimated to average 30
minutes per response, including the time to review instructions. If you have any comments concerning the
accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of
Health and Human Services, 200 Independence Ave., SW, Washington, DC, 20210. If you have comments or
concerns regarding the status of your individual submission of this form, write directly to: CMS, U.S.
Department of Health and Human Services, 7500 Security Blvd, Baltimore, MD, 21244-1850.

Centers for Medicare and Medicaid Services
Analysis of Transportation Barriers to the Utilization of Medicare Services by
American Indian and Alaska Native Medicare Beneficiaries
CONSENT FORM FOR AMERICAN INDIAN AND ALASKA NATIVE
MEDICARE BENEFICIARY INTERVIEW
Purpose of Study
The Centers for Medicare and Medicaid Services (CMS) is an agency of the U.S. Department of Health and
Human Services with a mission to “ensure effective, up-to-date health coverage and to promote quality care
for beneficiaries.”
The Federal obligation to provide health services to American Indians and Alaska Natives is based upon a
unique historical government-to-government relationship established through treaties and affirmed over time
through laws, Executive Orders, and court decisions. Health services in particular were guaranteed in treaties
negotiated between tribes and the U.S. Government, and funding was specifically authorized by Congress in
The Snyder Act of 1921.
In the mid-1970s two laws were enacted that dramatically changed the face of Indian health care delivery. The
Indian Self Determination and Education Assistance Act of 1975 provided authority to federally recognized
tribes to take over and administer for themselves the Federal programs of the Indian Health Service (IHS)
designed to serve them, shifting the control and direction of health priorities to local tribal governments. The
other significant change was the enactment of the Indian Health Care Improvement Act of 1976, which
clarified Federal policy to “elevate the health status of Indians and Alaska Natives to the highest possible
level” and provided specific targets for this new policy, including health professional training, health facility
construction and modernization, and access to Medicaid and Medicare reimbursement for IHS and tribally
provided services. Despite the availability of Medicare coverage, significant barriers prevent American Indians
and Alaska Native beneficiaries from accessing care. One of the major barriers consistently mentioned is
transportation barriers to accessing Medicare services.
The purpose of this project is to collect information and analyze the transportation barriers experienced by
American Indian and Alaska Native Medicare beneficiaries and ultimately, to identify the solutions that could
help reduce this barrier and produce meaningful improvements in health outcomes for the beneficiaries.
Participation and Confidentiality
As part of the transportation barriers project we will be conducting interviews with American Indian and
Alaska Native Medicare Beneficiaries. Your participation is entirely voluntary. You have the right to refuse to
answer any question that is asked and to refuse to participate further at any point in the project.
If you agree to participate in this project, you will take part in a 30 minute survey. Your responses will be
recorded either electronically on a computer or by hand on a written form. Your privacy is important to us.
We will make every effort to protect the confidentiality of your comments and responses. Your name will not
appear in any oral presentation or written report. Any information that you provide us will be combined with
other participants’ information; thus, you will not be identified. Electronic and written copies of the interview
will be stored without personal identifiers in secure locations and will be destroyed at the close of the project.
If you have any questions regarding this project or your participation, please contact Dr. Jeanette Hassin at
Kauffman & Associates, Inc. at (301) 588-6800 or jeanette.hassin@kauffmaninc.com.
Risks and Benefits
There are no known risks from taking part in this project. The main benefits of your participation in the
project include the enhancement of methods to best address AI/AN Medicare beneficiaries’ transportation

barriers to Medicare services. Finding out this kind of information will better enable CMS to better address
these problems.
Participant Costs and Compensation
There is no cost to you to participate in this interview with the exception of time. To compensate you for
your time, you will receive a $30 gift card.
Consent to Participate in Project
I have read and reviewed the above information about this project. I hereby consent and voluntarily agree to
participate in the transportation barriers project. By signing, I am not waiving any legal claims, rights, or
remedies.

___________________________
Participant’s Printed Name

___________________________
Participant’s Signature

Date

___________________________

___________________________

___________________

Interviewer’s Printed Name

Interviewer’s Signature

Date

According to the Paperwork Reduction Act of 1995, “no persons are required to respond to a collection of information
unless such collection displays a valid OMB control number.” The valid OMB control number for this information
collection is 0938-XXXX. The time required to complete this information collection is estimated to average 30
minutes per response, including the time to review instructions. If you have any comments concerning the
accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of
Health and Human Services, 200 Independence Ave., SW, Washington, DC, 20210. If you have comments or
concerns regarding the status of your individual submission of this form, write directly to: CMS, U.S.
Department of Health and Human Services, 7500 Security Blvd, Baltimore, MD, 21244-1850.

Centers for Medicare and Medicaid Services
Analysis of Transportation Barriers to the Utilization of Medicare Services by
American Indian and Alaska Native Medicare Beneficiaries
CONSENT FORM FOR AMERICAN INDIAN AND ALASKA NATIVE
MEDICARE BENEFICIARIES AND FAMILY MEMBERS FOCUS GROUP
Purpose of Study
The Centers for Medicare and Medicaid Services (CMS) is an agency of the U.S. Department of Health and
Human Services with a mission to “ensure effective, up-to-date health coverage and to promote quality care
for beneficiaries.”
The Federal obligation to provide health services to American Indians and Alaska Natives is based upon a
unique historical government-to-government relationship established through treaties and affirmed over time
through laws, Executive Orders, and court decisions. Health services in particular were guaranteed in treaties
negotiated between tribes and the U.S. Government, and funding was specifically authorized by Congress in
The Snyder Act of 1921.
In the mid-1970s two laws were enacted that dramatically changed the face of Indian health care delivery. The
Indian Self Determination and Education Assistance Act of 1975 provided authority to federally recognized
tribes to take over and administer for themselves the Federal programs of the Indian health Service (IHS)
designed to serve them, shifting the control and direction of health priorities to local tribal governments. The
other significant change was the enactment of the Indian Health Care Improvement Act of 1976, which
clarified Federal policy to “elevate the health status of Indians and Alaska Natives to the highest possible
level” and provided specific targets for this new policy, including health professional training, health facility
construction and modernization, and access to Medicaid and Medicare reimbursement for IHS and tribally
provided services. Despite the availability of Medicare coverage, significant barriers prevent American Indians
and Alaska Native beneficiaries from accessing care. One of the major barriers consistently mentioned is
transportation barriers to accessing Medicare services.
The purpose of this project is to collect information and analyze the transportation barriers experienced by
American Indian and Alaska Native Medicare beneficiaries and ultimately, to identify the solutions that could
help reduce this barrier and produce meaningful improvements in health outcomes for the beneficiaries.
Participation and Confidentiality
As part of the transportation barriers project we will be conducting focus groups with American Indian and
Alaska Native Medicare Beneficiaries and Family Members. Your participation is entirely voluntary. You have
the right to refuse to answer any question that is asked and to refuse to participate further at any point in the
project.
If you agree to participate in this project, you will take part in a 90 minute focus group. Your responses will
be recorded and written notes will be taken. Your privacy is important to us. We will make every effort to
protect the confidentiality of your comments and responses. Your name will not appear in any oral
presentation or written report. Any information that you provide us will be combined with other participants’
information; thus, you will not be identified. Electronic and written copies of the focus group will be stored
without personal identifiers in secure locations and will be destroyed at the close of the project. If you have
any questions regarding this project or your participation, please contact Dr. Jeanette Hassin at Kauffman &
Associates, Inc.AI at (301) 588-6800 or jeanette.hassin@kauffmaninc.com.

Risks and Benefits
There are no known risks from taking part in this project. The main benefits of your participation in the
project include the enhancement of methods to best address AI/AN Medicare beneficiaries’ transportation
barriers to Medicare services. Finding out this kind of information will better enable CMS to better address
these problems.
Participant Costs and Compensation
There is no cost to you to participate in this focus group, with the exception of time. To compensate you for
your time, you will receive a $30 gift card.
Consent to Participate in Project
I have read and reviewed the above information about this project. I hereby consent and voluntarily agree to
participate in the transportation barriers project. By signing, I am not waiving any legal claims, rights, or
remedies.

___________________________
Participant’s Printed Name

___________________________
Participant’s Signature

Date

___________________________

___________________________

___________________

Interviewer’s Printed Name

Interviewer’s Signature

Date

According to the Paperwork Reduction Act of 1995, “no persons are required to respond to a collection of information
unless such collection displays a valid OMB control number.” The valid OMB control number for this information
collection is 0938-XXXX. The time required to complete this information collection is estimated to average 90
minutes per response, including the time to review instructions, and complete the demographic survey. If you have
any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form,
please write to: U.S. Department of Health and Human Services, 200 Independence Ave., SW, Washington, DC,
20210. If you have comments or concerns regarding the status of your individual submission of this form,
write directly to: CMS, U.S. Department of Health and Human Services, 7500 Security Blvd, Baltimore, MD,
21244-1850.

Centers for Medicare and Medicaid Services
Analysis of Transportation Barriers to the Utilization of Medicare Services by
American Indian and Alaska Native Medicare Beneficiaries
CONSENT FORM FOR AMERICAN INDIAN AND ALASKA NATIVE
HEALTH CARE PROVIDER INTERVIEW
Purpose of Study
The Centers for Medicare and Medicaid Services (CMS) is an agency of the U.S. Department of Health and
Human Services with a mission to “ensure effective, up-to-date health coverage and to promote quality care
for beneficiaries.”
The Federal obligation to provide health services to American Indians and Alaska Natives is based upon a
unique historical government-to-government relationship established through treaties and affirmed over time
through laws, Executive Orders, and court decisions. Health services in particular were guaranteed in treaties
negotiated between tribes and the U.S. Government, and funding was specifically authorized by Congress in
The Snyder Act of 1921.
In the mid-1970s two laws were enacted that dramatically changed the face of Indian health care delivery. The
Indian Self Determination and Education Assistance Act of 1975 provided authority to federally recognized
tribes to take over and administer for themselves the Federal programs of the Indian Health Service (IHS)
designed to serve them, shifting the control and direction of health priorities to local tribal governments. The
other significant change was the enactment of the Indian Health Care Improvement Act of 1976, which
clarified Federal policy to “elevate the health status of Indians and Alaska Natives to the highest possible
level” and provided specific targets for this new policy, including health professional training, health facility
construction and modernization, and access to Medicaid and Medicare reimbursement for IHS and tribally
provided services. Despite the availability of Medicare coverage, significant barriers prevent American Indians
and Alaska Native beneficiaries from accessing care. One of the major barriers consistently mentioned is
transportation barriers to accessing Medicare services.
The purpose of this project is to collect information and analyze the transportation barriers experienced by
American Indian and Alaska Native Medicare beneficiaries and ultimately, to identify the solutions that could
help reduce this barrier and produce meaningful improvements in health outcomes for the beneficiaries.
Participation and Confidentiality
As part of the transportation barriers project we will be conducting one-on-one interviews with health care
providers. Your participation is entirely voluntary. You have the right to refuse to answer any question that is
asked and to refuse to participate further at any point in the project.
If you agree to participate in this project, you will take part in a 30 minute interview. Your responses will be
recorded either electronically on a computer or by hand on a written form. Your privacy is important to us.
We will make every effort to protect the confidentiality of your comments and responses. Your name will not
appear in any oral presentation or written report. Any information that you provide us will be combined with
other participants’ information; thus, you will not be identified. Electronic and written copies of the interview
will be stored without personal identifiers in secure locations and will be destroyed at the close of the project.
If you have any questions regarding this project or your participation, please contact Dr. Jeanette Hassin at
Kauffman & associates, Inc. at (301) 588-6800 or jeanette.hassin@kauffmaninc.com.

Risks and Benefits
There are no known risks from taking part in this project. The main benefits of your participation in the
project include the enhancement of methods to best address AI/AN Medicare beneficiaries’ transportation
barriers to Medicare services. Finding out this kind of information will better enable CMS to better address
these problems.
Participant Costs and Compensation
There is no cost to you to participate in this interview with the exception of time. To compensate you for
your time, you will receive a small gift.
Consent to Participate in Project
I have read and reviewed the above information about this project. I hereby consent and voluntarily agree to
participate in the transportation barriers project. By signing, I am not waiving any legal claims, rights, or
remedies.

___________________________
Participant’s Printed Name

___________________________
Participant’s Signature

Date

___________________________

___________________________

___________________

Interviewer’s Printed Name

Interviewer’s Signature

Date

According to the Paperwork Reduction Act of 1995, “no persons are required to respond to a collection of information
unless such collection displays a valid OMB control number.” The valid OMB control number for this information
collection is 0938-XXXX. The time required to complete this information collection is estimated to average 30
minutes per response, including the time to review instructions. If you have any comments concerning the
accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of
Health and Human Services, 200 Independence Ave., SW, Washington, DC, 20210. If you have comments or
concerns regarding the status of your individual submission of this form, write directly to: CMS, U.S.
Department of Health and Human Services, 7500 Security Blvd, Baltimore, MD, 21244-1850.