Form #1 Form #1 Registration Form and Data Submission

Registration Form

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CAHPS Health Plan Survey Registration Request Form
Complete the information below. The CAHPS Database will review your request and will send you an e-mail with the
information to access the 2009 CAHPS Health Plan Survey Data Submission System.

* Required Item

*Organization Name:
*First Name:
*Last Name:
Title/Position:
*Address 1 (No P.O. Box allowed):
Address 2: (No P.O. Box allowed):
*City:
*State:
*Zip Code:
*Telephone number:
Fax number:

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)

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Ext.

*Email address:

*Identify your role as a participant
Sponsor (Organization that receives the sponsor report)
Coalition
Vendor
Please list the name(s) of the sponsor organization you are representing:

Health Plan but not a Sponsor (Submitting data for a sponsor and does not receive a report)

https://ncbd.cahps.org/plancahps/Registration.asp (1 of 2) [11/4/2009 3:37:42 PM]

Registration Form

As a Health Plan are you submitting data on behalf of :
Sponsor Organization
Please list the name of the sponsor(s):

Coalition
Please list the name of the coalition(s):

Other Organization
Please list the name of the other organization(s):

Additional Information about your role as a participant:

*Are you the primary contact?
Yes
No
First Name:
Last Name:
Telephone number:

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)

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Ext.

* Has your organization previously participated in the CAHPS Health Plan Survey?
Yes
No
* Do you submit data to NCQA?
Yes
No

Register

https://ncbd.cahps.org/plancahps/Registration.asp (2 of 2) [11/4/2009 3:37:42 PM]

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