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Hospital Data Quality Reporting Authorization Forms

QualityNet Security Administrator Registration Form

To authorize a QualityNet Security Administrator for your facility, please go to www.qualitynet.org, select the "My QualityNet" tab, and then select "Begin the Registration Process," and follow the information from there. Once the forms are complete, mail the original forms to Robin Harrison, 1020 West 4th Street, Suite 200, Little Rock, AR, 72201.  If you have any questions or need any assistance, contact Robin Harrison at (501)212-8720 or rharrison@afmc.org

Vendor Transmission

Hospital Authorization for Vendor Transmission to the QIO Clinical Warehouse
Print the form below if your hospital will be transmitting data through a third party vendor (i.e. ORYX vendor or other vendor). Hospitals must contact their vendors to notify them of this information. Complete and mail original form to:
Attention: Robin Harrison
AFMC
1020 West 4th Street, Suite 200
Little Rock, AR  72201
SEND ORIGINALS.
 Download Authorization Form(PDF)

Hospital Quality Alliance (HQA) Initiative Forms:

Pledge (Sign Up) for HQA:

To sign up for HQA, hospitals must complete the Pledge of Participation form for the Hospital Quality Alliance and fax it to the AHA. To make changes later, either submit a new form or have the hospital CEO/administrator initial and date changes made on the original form; then fax to the AHA. (Please also fax a copy of the pledge form to AFMC in Little Rock, attn: Robin Davis, at 501-375-5705, so that electronic flags may be set.)

Obtain the pledge form from qualitynet.org or contact AFMC at 877-375-5700 and ask for a member of the hospital team.

Please mail original form to:

Attention: Robin Harrison
AFMC
1020 West 4th Street, Suite 200
Little Rock, AR  72201
SEND ORIGINALS.

Withholding Data in the HQA:

Hospitals have 30 days to preview data that will be posted to www.cms.hhs.gov. During this time period a hospital may elect to withhold certain measure(s) by completing a Request for Withholding Data from Public Reporting form. The hospital's data for measure(s) that were withheld for that reporting period would be posted for the next reporting period unless the hospital withholds again or withdraws from HQA. (To obtain the withholding form click link below. Fax copy of completed form to Robin Davis at 501-375-5705.)

Obtain form from qualitynet.org or contact AFMC at 877-375-5700 and ask for a member of the hospital team.

Please mail original form to:

Attention: Robin Harrison
AFMC
1020 West 4th Street, Suite 200
Little Rock, AR  72201
SEND ORIGINALS.

Withdrawal of Participation from HQA:

A hospital has 30 days to preview data that will be posted to public Web sites. During this time period a hospital may elect to completely withdraw from the HQA by completing a Withdrawal of Participation in the Hospital Quality Alliance form.
Obtain form from qualitynet.org or contact AFMC at 877-375-5700 and ask for a member of the hospital team. Fax the completed form to: Robin Davis AFMC – Little Rock, at 501-375-5705. If the hospital chooses to pledge again at a later date, administrators must complete another pledge form

Please note that for an acute PPS hospital to receive the full market basket update for Hospital Inpatient Quality Reporting (IQR), you must report the required quality measure set.

Please mail original form to:
Attention: Robin Harrison
AFMC
1020 West 4th Street, Suite 200
Little Rock, AR  72201
SEND ORIGINALS.

Obtain form from www.qualitynet.org or contact AFMC at 877-375-5700 and ask for a member of the hospital team.

Hospital Inpatient Data Validation Appeal Form

Hospital to complete the Part One form when the overall reliability is <75 (across all cases) and decides to appeal data elements. Complete the information identifying data elements to consider for appeal. Hospital to submit the completed Part One form to the local QIO no later than 10 business days after the validation results posted date.
Click here for Validation Appeal Form (PDF)