CMS-10721 CMS-10721.Final Persistent Website Feedback Survey

Persistent Website Feedback:

* denotes a response is required

Please select your Medicare Contract:

• Jurisdiction A Durable Medical Equipment Supplier (DME Providers from CT, DC, DE, MA, MD, ME, NH, NJ, NY, PA, RI, VT)

• Jurisdiction D Durable Medical Equipment Supplier (DME Providers from AK, AS, AZ, CA, GU, HI, ID, IA, KS, MO, MT, ND, NE, NV, N. Mariana Islands, OR, SD, UT, WA, WY)

• Jurisdiction E (A/B Providers from AS, CA, GU, HI, NV, N. Mariana Islands) 

• Jurisdiction F (A/B Providers from AK, AZ, ID, MT, ND, OR, SD, UT, WA, WY) 

• Jurisdiction 15 (A/B Providers from KY, OH) 

• Jurisdiction 15 (HH+H Providers from CO, DC, DE, IA, KS, MD, MO, MT, ND, NE, PA, SD, UT, VA, WV, WY) 

• Jurisdiction B Durable Medical Equipment Supplier (DME Providers from IL, IN, KY, MI, MN, OH, WI)

• Jurisdiction C Durable Medical Equipment Supplier (DME Providers from AL, AR, CO, FL, GA, LA, MS, NC, NM, OK, PR, SC, TN, TX, VA, VI, WV)

• Jurisdiction 5 (A/B Providers from IA, KS, MO, NE) 

• Jurisdiction 8 (A/B Providers from IN, MI) 

• Jurisdiction L (A/B Providers from DC, DE, MD, NJ, PA) 

• Jurisdiction H (A/B Providers from AR, CO, LA, MS, NM, OK, TX) 

• Jurisdiction RRB (Part B Nationwide) 

• Jurisdiction J (A/B Providers from AL, GA, TN) 

• Jurisdiction M (A/B Providers from NC, SC, VA, WV) 

• Jurisdiction M (HH+H Providers from AL, AK, FL, GA, IL, IN, KY, LA, MS, NC, NM, OH, OK, SC, TN, TX) 

• Jurisdiction K (A/B Providers from CT, MA, ME, NH, NY, RI, VT) 

• Jurisdiction K (HH+H Providers from CT, MA, ME, NH, RI, VT) 

• Jurisdiction 6 (A/B Providers from IL, MN, WI) 

• Jurisdiction 6 (HH+H Providers from AK, AS, AZ, CA, GU, HI, ID, MI, MN, NJ, NV, NY, N. Mariana Islands, OR, PR, VI, WA, WI)

• Jurisdiction N (A/B Providers from FL, PR, VI)

{Notes:

• This question is only presented to a survey respondent when a Medicare Administrative Contractor (MAC) is not able to pass embedded data to Qualtrics that identifies the specific jurisdiction for which the survey respondent is providing feedback.

• The answer choices represent the universe of MAC jurisdictions. However, the list will be filtered based on the jurisdictional contracts and the services offered by a particular MAC. For example, a survey respondent will only see the choices Jurisdiction K or Jurisdiction 6 if they are visiting the website of the contractor responsible for those jurisdictions.}

     

Q1*. What is your feedback about?

• Information on this page

• A technical issue

• Other [open text box]*

Q2*. What would you like to share with us?

[Open text box]

Q3*. Overall, how satisfied or dissatisfied are you with this page?

• Extremely satisfied

• Somewhat satisfied

• Neither satisfied nor dissatisfied

• Somewhat dissatisfied

• Extremely dissatisfied

Q4*. Which best describes you?

• Provider of medical services

• Supplier of medical equipment or supplies

• Staff of a provider of medical services

• Staff of a supplier of medical equipment or supplies

• Staff of a billing service/clearinghouse

• Consultant or attorney

• Other [open text box]*

{Notes:

1. If ‘Provider of medical services’ or ‘Staff of a provider of medical services’ is selected, show question 4a

2. If any other answer choice is selected, show Question 5}

     Q4a.* What is your Medicare enrollment type or the enrollment type of your practice or facility?

• Institutional Provider

• Clinic/Group Practice

• Physician

• Non-Physician Practitioner

• Home Health

• Hospice

• Other (please specify)

{Notes:

This question only shows if ‘Provider of medical services’ or ‘Staff of a provider of medical services’ is selected in Question 4}

Q5*. Can we follow up with you about your feedback?

• Yes

• No

{Note:

1. If “No” is selected, end survey and show appropriate End of Survey message listed below

2. If “Yes” is selected, show Question 6}

Q6*. Please provide the following contact information:

Name: 

Work Email: 

Custom End of Survey Messages

• If “Somewhat dissatisfied” or “Extremely dissatisfied” is selected in Question 3 then the following response is provided:

Thank you for taking our survey. We’re sorry you didn’t have a positive experience on our website, and we appreciate the time you took to share your feedback with us. We’ll be working to address your concerns.

• If “Neither satisfied nor dissatisfied” is selected in Question 3 then the following response is provided:

Thank you for taking our survey. We appreciate the time you took to share your experience with us.

• If “Somewhat satisfied” or “Extremely satisfied” is selected in Question 3 then the following response is provided:

Thank you for taking our survey. We're happy that you had a positive experience on our website, and we appreciate the time you took to share your feedback with us.

PRA Disclosure Statement will be added as a link to the bottom of the survey. (OMB control number and expiration date will be added when survey is approved).

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-XXXX.  The expiration date is (XX/XX/XXXX). The time required to complete this information collection is estimated to average 3 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.  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 C4-26-05, 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 about the survey please contact MCE@cms.hhs.gov.