Survey Vendor Authorization Form

Hospice agencies must authorize an approved CAHPS Hospice Survey vendor to submit data on their behalf for the administration of the CAHPS Hospice Survey.

In order to authorize a survey vendor or switch to a new vendor, a hospice representative must complete the CAHPS Hospice Survey Vendor Authorization Form and submit it to the RAND Corporation one calendar quarter (90 days) prior to the first time data will be submitted to the CAHPS Hospice Survey Data Warehouse by that vendor.

If a hospice wishes to change CAHPS Hospice Survey vendors, it may do so ONLY at the beginning of a calendar quarter.

The individual who completes this form for the hospice will be considered the CAHPS Hospice Survey Administrator for that hospice.

Please note, when completing the CAHPS Hospice Survey Vendor Authorization Form pertaining to multiple hospice agencies, it is appropriate to attach a list to the form (signed and dated by the CAHPS Hospice Survey Administrator) of all the applicable hospices (hospice names and CMS Certification Numbers [CCNs]). Please check the box on the form indicating that a separate document is attached and indicate the number of hospice names and CCNs listed on the separate sheet.

Click here to download the CAHPS Hospice Survey Vendor Authorization Form. Please type in the required fields to complete the form, save the completed form, and print the completed form. The completed form must be signed and dated in the presence of a notary public, notarized, and sent to the RAND Corporation.

Send the completed form to:

RAND Corporation
ATTN: Survey Research Group - Data Reduction
CAHPS Hospice Survey
1776 Main Street
Santa Monica, CA 90401
Phone: 310-393-0411, extension 5599

Note: After submission of the CAHPS Hospice Survey Vendor Authorization Form, no further action is required by the hospice to notify CMS of their survey vendor selection. The RAND Corporation communicates to CMS which hospice agencies have authorized a survey vendor to administer the CAHPS Hospice Survey on their behalf. The RAND Corporation notifies vendors of hospices who have authorized them for data collection. Vendors cannot submit data for hospices that have not authorized them.