[HOSPICE OR VENDOR LETTERHEAD] 
[SAMPLED CAREGIVER NAME] 
[ADDRESS] 
[CITY, STATE ZIP] 
 
Dear [SAMPLED CAREGIVER NAME]: 
 
[HOSPICE NAME] is conducting a survey about the hospice services that patients and their families receive. You were selected for this survey because you were identified as the caregiver of [DECEDENT NAME]. We realize this may be a difficult time for you, but we hope that you will help us learn about
the quality of care that you and your family member or friend received from the hospice.
 
Questions [NOTE THE QUESTION NUMBERS] in the enclosed survey are part of a national initiative sponsored by the United States Department of Health and Human Services (HHS) to measure the quality of care in hospices. The Centers for Medicare & Medicaid Services (CMS), which is part of HHS, is conducting this survey to improve hospice care. CMS pays for most of the hospice care in the U.S. It is CMS’s responsibility to ensure that hospice patients and their family members and friends get high quality care. One of the ways they can fulfill this responsibility is to find out directly from you about
the hospice care your family member or friend received. Your participation is voluntary and will not affect any health care or benefits you receive.
 
We hope that you will take the time to complete the survey. After you have completed the survey, please return it in the pre-paid envelope. Your answers will be combined with other respondents and may be shared with the hospice for purposes of quality improvement. [OPTIONAL: You may notice a number
on the survey. This number is used to let us know if you returned your survey so we don’t have to send you reminders.]
 
If you have any questions about the enclosed survey, please call the toll-free number 1-800-xxx-xxxx.
 
Thank you for helping to improve hospice care for all consumers.
 
Sincerely,
[HOSPICE ADMINISTRATOR]
[HOSPICE NAME
 
 
Note: CMS says the draft is pending OMB approval.