Pre-Notification Letter_Version 2.0

1979 Marcus Avenue, Suite 105 • Lake Success, NY 11042-1072
Phone: 516-209-5253 • Fax: 516-326-7805 • ncc@ncc.esrd.net
www.esrdncc.org • www.kcercoalition.com

[Click Here to Select a Date]
[Recipient Name]
[Recipient Street Address, City, ST ZIP Code]
[Recipient Email]

Dear [Recipient],
I’m contacting you because you recently agreed to complete a survey regarding a grievance you filed
with [Network Name] on or around [Completion Date]. This survey is very important to Medicare,
because Medicare oversees both the dialysis facilities and the End Stage Renal Disease (ESRD)
Networks. Medicare has authorized my office to work with ESRD patients to learn more about how
ERSD patients feel they are treated by an ESRD Network when filing a grievance. Medicare believes it
is vital to partner with ESRD patients to understand the quality of service provided to ESRD patients by
an ESRD Network when trying to resolve a difficult situation.
The survey is being conducted by the Subcontractor Name. This group is not connected with the
government, the ESRD Networks, or your dialysis center. This will help to ensure everything you say is
private. It’s very important that you feel comfortable sharing anything with the surveyor good or bad
about the way you felt [Network Name] explained the grievance process and treated you while trying to
resolve your grievance. The information you provide will be summed up with information from other
ESRD patients before being given to Medicare to assist the Network program to improve the way they
work with patients on grievances. If you decide not to participate in the survey it will not affect your
Medicare benefits, nor will anything you say during the interview.
Please let us know when will be a good time to speak with you about your experience with [Network
Name]. You can call (XXX) XXX-XXXX to schedule an appointment between mm/dd/yyyy and
mm/dd/yyyy [between 9:00 am and 7:00 pm local time]. The survey isn’t long and will take only
approximately 15 minutes to complete by phone.
Thank you so much for your time and effort. It is truly appreciated. Medicare needs ESRD patients like
you to help make the things we do for all ESRD patients better.
If you have any questions about the survey process, please contact CMS Representative, Medicare, at
(XXX)XXX-XXXX or email at XXXXXXXX.XXXX@cms.hhs.gov
Warm regards,

End Stage Renal Disease NCC