CMS-10450 Appendix G: Vendor Renewal Form

DRAFT

The Consumer Assessment of Healthcare Providers and Systems (CAHPS) for the Merit-based Incentive Payment System (MIPS) Survey

2018 Survey Administration Renewal Participation Form
for Survey Vendors

^{This participation form is to be completed by those organizations conditionally re-approved to administer the Consumer Assessment of Healthcare Providers and Systems (CAHPS) for the Merit-based Incentive Payment System (MIPS) Survey for the 2018 survey administration period.}

^{Please note that if your organization is re-approved to be a survey vendor for the CAHPS for MIPS Survey, all staff and all of your subcontractors must conduct all of your business in the United States.}

^{ALL VENDOR APPLICATIONS AND CVs ARE DUE BY [TBD] AT 5:00 PM (EDT).}

I. General Participation Application Information

^{Fill this part in with your organization’s basic information.}

APPLICANT ORGANIZATION
1a. ORGANIZATION NAME Click here to enter text.
1b. MAILING ADDRESS 1 Click here to enter text.
1c. MAILING ADDRESS 2 Click here to enter text.
1d. CITY Click here to enter text.					1e. STATE Click here.	1f. ZIP CODE Click here to enter text.
1g. TELEPHONE AND FAX (area code, number and extension)						1h. WEB SITE
TEL	Click here to enter text.	EXT	Click here.	FAX	Click here to enter text.	Click here to enter text.

Applicant Contact Person
2a. PRIMARY CONTACT PERSON
First Name Click here to enter text.				Middle Initial Click here to enter text.		Last Name Click here to enter text.
2b. TITLE Click here to enter text.					2c. DEGREE (e.g., RN, MD, PhD) Click here to enter text.
2d. MAILING ADDRESS 1 Click here to enter text.
2e. MAILING ADDRESS 2 Click here to enter text.
2f. CITY Click here to enter text.				2g. STATE Click here to enter text.		2h. ZIP CODE Click here to enter text.
2i. Telephone and fax (area code, number and extension)						2j. EMAIL ADDRESS Click here to enter text.
TEL	Click here to enter text.	EXT	Click here.	FAX	Click here to enter text.

List of Physical Location(s) Where Survey Vendor Conducts Survey Administration Activities
ACTIVITY	ADDRESS
Click here to enter text.	Click here to enter text.
Click here to enter text.	Click here to enter text.
Click here to enter text.	Click here to enter text.

CMS-Sponsored and CAHPS Survey Experience
1. Have you been approved as a vendor to implement CMS or CAHPS surveys other than CAHPS for MIPS in the past five years?	Yes No
If Yes, please provide the name of the survey(s) for which you have been approved as a vendor.
Click here to enter text.
2. Have you been a subcontractor to an approved vendor for CMS or CAHPS surveys other than CAHPS for MIPS in the past five years?	Yes No
If Yes, please provide the name of the survey vendor(s) and the survey(s) for which you have been a subcontractor.
Click here to enter text.
CMS will consider prior experience, as either a survey vendor or subcontractor, on CMS or CAHPS surveys when reviewing your organization’s CAHPS for MIPS Survey Renewal Participation Form.

II. List of Key Project Staff (Include CV for any staff changes from the 2017 administration period)

List of Key Project Staff
Project Staff Name	Role	Email	Telephone
Click here to enter text.	Project Manager	Click here to enter text.	Click here to enter text.
Click here to enter text.	Mail Survey Supervisor	Click here to enter text.	Click here to enter text.
Click here to enter text.	Telephone Survey Supervisor	Click here to enter text.	Click here to enter text.
Click here to enter text.	Programmer/Developer	Click here to enter text.	Click here to enter text.

III. List of Subcontractors

Check here if you currently do not use subcontractors. Go to Section IV.

LIST OF SUBCONTRACTORS (add more lines if necessary or include as a separate attachment).

Subcontractor Name and Experience

Subcontractor Organization Name, Address and Telephone Number: Click here to enter text.	Role in 2018 CAHPS for MIPS Survey Administration: Click here to enter text.
Number of years this subcontractor has worked with your organization: Click here to enter text.
Number of years conducting surveys: Click here to enter text.
Number of years in business: Click here to enter text.
Survey Experience Related to 2018 CAHPS for MIPS Survey Administration Role: Click here to enter text. General Survey Experience: Click here to enter text.
Subcontractor Organization Name, Address and Telephone Number: Click here to enter text.	Role in 2018 CAHPS for MIPS Survey Administration: Click here to enter text.
Number of years this subcontractor has worked with your organization: Click here to enter text.
Number of years conducting surveys: Click here to enter text.
Number of years in business: Click here to enter text.
Survey Experience Related to 2018 CAHPS for MIPS Survey Administration Role: Click here to enter text. General Survey Experience: Click here to enter text.

^{Include additional subcontractor sections as needed.}

IV. Rules of Participation

Any organization participating in the CAHPS for MIPS Survey must adhere to the following Rules of Participation. To be eligible, the organization must:

1. Take part in a teleconference with the CAHPS for MIPS Survey Project Team to talk about your organization’s relevant survey experience, organizational survey capability and capacity, quality control procedures, and role of subcontractors (if applicable).

2. Take part in and successfully complete CAHPS for MIPS Survey Training(s). Your organization’s Project Manager, Mail Survey Supervisor and Telephone Survey Supervisor must attend training for your organization. Your organization’s Programmer/Developer or the Programmer/Developer’s Supervisor is strongly encouraged to attend training. Your organization’s subcontractors that have key roles in administering the CAHPS for MIPS Survey are required to attend training.

3. Review and follow the CAHPS for MIPS Survey Quality Assurance Guidelines and policy updates.

4. Attest to the accuracy of your organization’s data collection (as determined by CMS), following guidelines in the most current version of the CAHPS for MIPS Survey Quality Assurance Guidelines.

5. Write and send a CAHPS for MIPS Survey Quality Assurance Plan (QAP) by due date. Also, send in materials relevant to the survey administration (as determined by CMS), including mailing materials (e.g., cover letters, envelopes, and questionnaires) and telephone scripts.

6. Participate and cooperate (including subcontractors) in all oversight activities conducted by the CAHPS for MIPS Survey Project Team.

7. Send in an interim CAHPS for MIPS Survey data file to CMS.

8. Acknowledge that review of and agreement with the Rules of Participation is necessary for participation and public reporting of results by CMS’ Medicare Compare Website.

V. Applicant Organization Qualification and Acceptance:

I certify that: I have reviewed and agree to meet the Rules of Participation for participating in the CAHPS for MIPS Survey. The statements herein are true, complete and accurate to the best of my knowledge, and I accept the obligation to comply with the CAHPS for MIPS Survey Minimum Survey Vendor Business Requirements.

AUTHORIZED REPRESENTATIVE: Name: Title: Organization: Date:

^{Submit this form via email to TBD.}

^{For assistance, please contact the CAHPS for MIPS Survey Project Team by telephone at TBD or email at TBD.}

^{According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1222. The time required to complete this information collection is estimated to average 10 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.}

OMB No. 0938-1222

Expiration Date: XX/XX/XXXX

1

July 2017