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

• A quarter is based on the calendar year (CY) and will correspond to the month of patient death. For example, Quarter 1 2024 begins with January 2024 patient deaths (caregivers to be surveyed April 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 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.

• This person must attest that they are authorized to submit the CAHPS Hospice Survey Authorization Form on behalf of their hospice.
• Hospices may also designate an additional individual within the hospice organization to serve as the main point of contact with the CAHPS Hospice Survey Project Team.
  

Please note that a separate CAHPS Hospice Survey Vendor Authorization Form must be submitted 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.

• The CAHPS Hospice Survey Administrator will receive an automated email to confirm the form has been received.
• 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.

Unique Report ID : 6187

1. Hospice Information

CCN (Must be 6-characters, no hyphens) * 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 * 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 No Prior Vendor *

ChangeOfVendor Change Survey Vendor *

UpdatingAdministratorOnly Updating Administrator only *

Vendor selection is required.

Name of Old Survey Vendor (De-authorizing)* Select 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 * Select LAST Calendar Quarter for Old Survey Vendor is required.

The LAST month my Old Survey Vendor will survey the caregivers of our patients

Corresponding with patient deaths in

We have notified the old vendor of this change.* Checkbox is required.

We confirm the old vendor will stop surveying caregivers as of the above quarter.* Checkbox is required.

Name of New Survey Vendor (Authorizing)* Select 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 * Select Start Calendar Quarter for Vendor Authorizing is required.

The FIRST month my New Survey Vendor will survey the caregivers of our patients

Corresponding with patient deaths in

3. General Information

Hospice Administrator First Name * Hospice Administrator First Name is required.

Hospice Administrator Last Name * Hospice Administrator Last Name is required.

Title * Title is required.

Phone Number * Phone Number is required.

Phone Extension

Email * Email is required.

Mailing Address* Hospice Mailing Address is required.

City* City is required.

State* State is required.

Zip Code* ZipCode is required.

Hospice Point of Contact for the CAHPS Hospice Survey Project Team (if different from administrator):

First Name

Last Name

Phone Number

Phone Extension

Email

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.

By checking this box, I certify that the below mentioned Authorized Hospice Administrator is authorized to complete this form on behalf of this hospice agency.* 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.

CCN

Hospice Name

The FIRST month my New Survey Vendor will survey the caregivers of our patients

Name of Survey Vendor

Authorized Hospice Administrator Name * Authorized Hospice Administrator Name is required.

Authorized Administrator Signature

Date

By checking this box, you agree that your electronic signature is the equivalent of your manual signature on this agreement.* Checkbox is required.

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

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