Medicare Beneficiary and Family-Centered Satisfaction Survey

< Date>

<BENEFICIARY/REP FULL NAME>

<ADDRESS>

<CITY STATE ZIP>

Enclosed is the Medicare survey you requested

We spoke with you a few days ago to ask about about your experience with Medicare’s {complaint review/appeal} process. Enclosed is the survey you requested. Your responses to this survey are important and will help us make improvements in providing Medicare services to you and other people with Medicare.

What to do next

Please fill out and return the survey in the envelope that was sent with the survey.

Get help & more information

For help with or questions about this survey, call the survey helpline at 1-800-XXX-XXXX or send an email to XXX@XXXXXXXXXX.XXX.

THANK YOU for taking your time to help improve Medicare services.

Sincerely,

<Insert Signature>

<INSERT NAME >
Director, Quality Improvement & Innovation Group