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 submit the CAHPS Hospice Survey Vendor Authorization Form  one calendar quarter (90 days) prior to the first time data will be submitted to the CAHPS Hospice Survey Data Warehouse by that vendor.

Approved Survey Vendors may be located at: Approved Vendor List

Calendar Quarter Caregivers are Surveyed: Corresponding to Patient Deaths: Vendor Authorization Form MUST be Submitted by:
Q4 2023 January-March 2024 October-December 2023 January 31, 2024
Q1 2024 April-June 2024 January-March 2024 April 30, 2024
Q2 2024 July-September 2024 April-June 2024 July 31, 2024
Q3 2024 October-December 2024 July-September 2024 October 31, 2024

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

If the quarter you are trying to authorize is not listed in the table above or the form below, you must contact the CAHPS Hospice Survey Project Team at hospicecahpssurvey@hsag.com. Do not submit the form for an incorrect quarter as it will delay your organization's data submission.

The individual who completes the CAHPS Hospice Survey Vendor Authorization Form for the hospice will be considered the CAHPS Hospice Survey Administrator for that hospice.

Please note that a separate CAHPS Hospice Survey Vendor Authorization Form must be submited for each hospice CCN. 

Please type in the required fields to complete the form, print the completed form for your records, and submit the form.

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.

1. Hospice Information
CCN is required. The first position must be an alphanumeric. Only the first position can be alphanumeric. Cannot have any hyphens. The third position must be a 1. Too few characters. Must be 6 characters Too many characters. Must be 6 characters
Hospice Name is required.
2. Survey Vendor Information
Indicate if there is no prior vendor or it's a change of survey vendor:
No Prior Vendor *
Change Survey Vendor *
Vendor selection is required.
Name of Old Survey Vendor(De-authorizing) is required. The name of the new survey vendor cannot be the same name as the old survey vendor. Please select another value for the name of the new survey vendor.
LAST Calendar Quarter for Old Survey Vendor is required.

Checkbox is required.
Checkbox is required.
Name of New Survey Vendor (Authorizing) is required. The name of the new survey vendor cannot be the same name as the old survey vendor. Please select another value for the name of the new survey vendor.
Start Calendar Quarter for Vendor Authorizing is required.

3. General Information
Hospice Administrator First Name is required.
Hospice Administrator Last Name is required.
Title is required.
Phone Number is required.
Email is required.
Hospice Mailing Address is required.
City is required.
State is required.
ZipCode is required.
Hospice Point of Contact for the CAHPS Hospice Survey Project Team (if different from administrator):
4. Acknowledgement
By signing this form, the below mentioned Authorized Hospice Administrator acknowledges and accepts the role and all of the responsibilities of the CAHPS Hospice Survey Administrator.

In this role the Authorized Hospice Administrator will be responsible for:
1) Authorizing the below mentioned survey vendor to collect data as part of the CAHPS Hospice Survey and to submit data to CMS on behalf of the hospice.
2) Notifying CMS and the RAND Corporation immediately if the hospice de-authorizes a survey vendor by completing a new Vendor Authorization Form.
3) Designating an individual within the hospice organization to serve as the main point of contact with the CAHPS Hospice Survey Project Team.
4) Notifying the CAHPS Hospice Survey Project Team if my role as the CAHPS Hospice Survey Administrator for the hospice will no longer be valid and identifying my successor by submitting a new Vendor Authorization Form.
Checkbox is required.
By signing this form, I authorize the below mentioned CAHPS Hospice Survey vendor to collect data for the hospice I represent as part of the CAHPS Hospice Survey and to submit data to CMS on behalf of the hospice.

Authorized Hospice Administrator Name is required.
Checkbox is required.

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Note: Please print completed Survey Vendor Authorization form before submitting.